Fibromyalgia and Chronic Fatigue Syndrome
Fibromyalgia and Chronic fatigue syndrome are linked by a viral etiology. Chronic fatigue syndrome is the current name for a disorder characterized by debilitating fatigue and a variety of associated physical, constitutional, and neuropsychological complaints. (See table 1) The medical literature of the past three centuries informs us that this is not a new type of syndrome. Those diagnosed with ailments such as the vapors, neurasthenia, effort syndrome, epidemic neuromyasthenia, myalgic encephalomyelitis, multiple chemical sensitivity syndrome, chronic candidiasis, chronic mononucleosis, chronic Epstein-Barr viral infection, and post viral fatigue syndrome, probably all had what we now call chronic fatigue syndrome. U. S. Centers for Disease Control and Prevention (CDC) developed in 1988, and revised in 1998 a case definition based predominantly on symptoms after excluding all other causes. (See table 2)
Patients with chronic fatigue syndrome are twice as likely to be women and are generally 25 to 45 years old, although cases in childhood and the elderly have been reported. Most cases of chronic fatigue syndrome occur sporadically, but over 30 clusters of similar illness have been reported. The most famous of such "outbreaks" occurred in Los Angeles County Hospital in 1934; in Akureyri, Iceland, in 1948; in the Royal Free Hospital, London, in 1955; in Punta Gorda, Florida, in 1956; and in Incline Village, Nevada, and surrounding communities in 1985. (1) While these clustered cases suggest a common environmental or infectious cause, none yet has been identified. The CDC considered and dismissed the viral origin of chronic fatigue syndrome because a trial of the drug Acylovir was not effective. In my view this was shortsighted, as the drug was poorly absorbed and blood levels were too low to kill the virus. Newer antivirals with higher absorption levels are effective in DNA viral control.
Having chronic fatigue syndrome often appears to be associated with the increased risk of developing other physical health problems, as suggested by the results of a study of identical and fraternal twins. The study results were published in the January 2001 issue of the Journal of General Internal Medicine. The author, Leslie A. Aaron, Ph.D., and MPH, of the Department of Medicine at the University of Washington, stated, "Patients with chronic fatigue may present a complex clinical picture that poses diagnostic and management challenge."
In the study, 127 pairs of twins, in which one twin had chronic fatigue for least six months while the other did not suffer from chronic fatigue, were screened. The researchers chose to compare twins using a co-twin study design because this method matches twins with regard to nearly identical early environment and genetics.
Study participants with chronic fatigue had higher rates of several physical conditions -- most notably fibromyalgia, irritable bowel syndrome, chronic pelvic pain, multiple chemical sensitivities, and temporomandibular disorder -- than did their twins.
The largest disparities between twins were noted in the cases of fibromyalgia and irritable bowel syndrome. Seventy percent of those with chronic fatigue also had fibromyalgia, compared with only 10 percent of their twins; and 50 percent of those with chronic fatigue also had irritable bowel syndrome, compared with five percent of their twins. (2) This facet of the syndrome suggests a food component.
So how do we know if we have chronic fatigue syndrome? The diagnosis can be complicated. The Centers for Disease Control has established certain criteria for diagnosing chronic fatigue syndrome (3):
- Fatigue that is persistent relapsing or debilitating; does not improve with bed rest; and reduces or impairs average daily activity level by more than 50 percent for at least six months. The patient has no previous history of fatigue.
- The patient has four or more of the following symptoms, which must have persisted or recurred during six or more consecutive months and predated the fatigue: short-term memory or concentration problems, sore throat, multiple joint pain without joint swelling or redness, muscle pain, headaches of a new type, pattern or severity, non-refreshing sleep, post-exertional malaise lasting more than 24 hours. In addition, a number of minor symptoms may also appear: poor sleep, acheness, brain fog, increased thirst, bowel disorders, recurrent infections, and exhaustion after minimal exertion.
Identifying fibromyalgia without a diagnosis of chronic fatigue would mean the patient probably does not have fibromyalgia. Now if it is fibromyalgia, it is a very debilitating disorder.
Fibromyalgia, an associated disease of chronic fatigue, is a commonly encountered disorder characterized by widespread musculoskeletal pain, stiffness, paresthesia, nonrestorative sleep, and easy fatigability along with multiple tender points that are widely and symmetrically distributed. Fibromyalgia affects predominantly women. The prevalence of fibromyalgia in the general population, as reported in the 1990 American College of Rheumatology classification criteria, recently was 3.4 percent in women and 0.5 percent in men. It is most prevalent in women aged 50 and older. Although not common, fibromyalgia also occurs in children. In the general population the prevalence increased with age, being 7.4 percent in women between the ages of 70 and 79 years. However, the reported prevalence of fibromyalgia in some rheumatology clinics has been as high as 20 percent. This is probably a more realistic percentage. Several causative mechanisms for fibromyalgia have been postulated: sleep disturbance, low levels of serotonin, or lower levels of somatomedin C, which causes lower levels of growth hormone. Inflammation of muscles has not been found. Many patients with fibromyalgia have psychological abnormalities, the most common being depression, anxiety, somatization, hypochondriases, and a high prevalence of sexual and physical abuse and eating disorders. (4)
The characteristic feature on physical examination is a demonstration of specific tender points, which are exclusively more tender or painful than adjacent areas. The American College of Rheumatology criteria for fibromyalgia define 18 tender points. (See table 3) These points of tenderness are remarkably constant in location.
Fibromyalgia may be triggered by emotional stress, medical illness, surgery, hypothyroidism, and trauma. It has appeared in some patients with human immunodeficiency virus (HIV) infection, parvovirus, B19 infection, or Lyme disease.
Disorders commonly associated with fibromyalgia include irritable bowel syndrome, irritable bladder, headaches (including migraine headaches), dysmenorrhea, premenstrual syndrome, restless leg syndrome, temporomandibular joint pain and sicca syndrome. (5)
Results of joint and muscle examinations are normal in fibromyalgia patients, and there are no laboratory abnormalities. Fibromyalgia may occur in patients with rheumatoid arthritis, other connective tissue diseases, or other medical illnesses.
Fibromyalgia and chronic fatigue syndrome have many similarities. Both are associated with fatigue, abnormal sleep, musculoskeletal pain, and psychiatric conditions. Patients with chronic fatigue syndrome, however, are more likely to have symptoms suggesting viral illness.
Hundreds, if not thousands, of articles have been written trying to explain the causes of fibromyalgia and chronic fatigue syndrome. Unbelievably, in this age of advanced science, no one has a clue as to the causes of this disease or what the cure might be. Originally, fibromyalgia was thought to be a psychiatric illness, but more recently, research has shown that there are physical changes in individuals with fibromyalgia and chronic fatigue that indicate a viral illness.
Fibromyalgia is a very debilitating disorder. The pain can be so severe that people are being treated with narcotics and morphine. Such things as overexertion, changes in climate or weather, stress, anxiety, and mood swings can contribute to these symptoms and cause severe pain. Some patients lose their jobs and their families.
Fibromyalgia is really a result of chronic fatigue syndrome. The symptoms frequently associated with fibromyalgia can also include: tender sore areas of the body (shoulders, back of neck, lower back, and hips, shins, elbows, knees, and joint pain.), chronic fatigue, inability to sleep, chronic aches of the body and face, headaches, irritable bowel syndrome, interstitial cystitis, neurological symptoms, numbness and tingling sensations, chest wall pain, sensitivity to cold, anxiety and or depression, memory and concentration difficulties, and inability to accomplish everyday tasks.
Let us look to see what the patient experiences by visiting her doctor. The patient makes the initial visit to the doctor's office. The doctor prescribes a pain reliever for comfort and relief then schedules her back in a couple of weeks. It has been a couple of weeks and the patient is still feeling the same. -- Lousy. The pain relievers and the flu medicine are just not working so again she visits the doctor. The patient is nearing the end of the medication, feels awful and by now is quite worried and depressed. At this stage, the doctor normally will refer the patient to someone else or will start running routine lab tests on the patient.
For a doctor to diagnose fibromyalgia a patient must have the symptoms for least three months. Given that it has only been a couple of weeks, the doctor probably prescribes something stronger like antibiotics, figuring that the patient has some virus or a really bad case of the flu. He gives her one refill and tells her to come back if it does not clear up in a few more of weeks. It does not.
Fibromyalgia is hard to diagnose because there is no blood test or x-ray to detect it. Tests are performed to rule out other disorders. Moreover, to complicate matters even further, most doctors have limited knowledge about the disorder. In addition, there are so many other ailments that are associated with fibromyalgia and some of them are likely to be present along with fibromyalgia. Therefore many doctors may misdiagnose the patient as having: rheumatoid arthritis, depression, adrenal insufficiency, allergies, hypothyroidism, nasal congestion and sinuses, sleep disorders, chronic fatigue syndrome, cervical and low back degenerative disease, or Lyme disease.
Most common treatments include anti-depressants such as Prozac, Paxil or pain medications Ultram and Celebrex. Alternative medicine includes chiropractic, massage therapy, acupuncture, hypnosis, achieving normal and adequate amounts of sleep, medications to improve sleeping and relieve muscle pain, stress maintenance, low impact exercise and stretching, vitamins and minerals, diet manipulation, identifying and eliminating allergic foods, no caffeine or alcohol, drinking lots of water, learning about the disorder, and counseling.
The downfall of taking certain medications is that it may treat the symptom it is designed for, but the same time, it may cause another ailment. For example, Prozac, the most commonly used medication for treating depression, causes fatigue and insomnia.
After 20 plus years of treating patients with fibromyalgia and chronic fatigue syndrome it is my belief that using symptomatic drugs only masks the problem. Antiviral tests must be run to make the proper diagnosis and food sensitivities tested. Antiviral drug therapy and elimination diets must be followed for the patient to have significant improvement or to actually get well.
"The New Fibromyalgia Remedy: Stop Your Pain Now with an Anti-Viral Drug Regimen" by Daniel C. Dantini, MD.
Treatment is now the question. Given all the preceding information, how can you develop an approach to the problem of fibromyalgia and chronic fatigue in your office? Over the past 20 years I have refined an approach, which gets consistent and dramatic results.
- First of all, you have been taught to take a good medical history. The hallmark complaints should center around the fatigue, night sweats, memory impairment, sleep disturbances, muscle and joint aches and pains without obvious joint deformity or swelling. Psychological problems of depression, irritability, and mood swings will also be evident.
- The physical exam should demonstrate muscle and joint tenderness. (See table 3) The muscle and joint pain will be migratory. Fixed joint or muscle pain will be more often a mechanical problem related to nerve root compression in the spine or arthritic involvement of the joints. Joints are not swollen or deformed as in arthritic disease. You'll occasionally find enlarged lymph nodes in the neck, axilla, and groin area in the early stages.
- An ENT exam should reveal thick mucus in the nose and a particular red blush of the anterior tonsillar pillar. This is a good way to follow a patient's progress.
- SMA-24 and a CBC with sed rate and C-reactive protein are usually normal; otherwise, consider collagen vascular disease.
- A viral panel consisting of Epstein Barr, Cytomegalic virus, herpes I, II, VI, and Para-virus should be ordered. A fourfold increase in antibody titer over normal should be considered positive for that virus
- Multi-pathway complement antigen testing completes the laboratory workup for your patient. The immune system is in overdrive attempting to rid itself of the virus but is unable to get the job done. Every patient I see with chronic fatigue and fibromyalgia has food sensitivities. Tests for delayed food sensitivities must always be done. A RAST test for IgE allergy is effective for immediate reactions, but rarely pinpoints the food sensitivities that are identified by the complement antigen test. Food avoidance and a good rotation diet should be strictly monitored on a weekly basis. Vitamins, supplements, immune stimulants, and digestive aids have been found to speed up the healing process but are not effective stand-alone treatments.
In summary, fibromyalgia and chronic fatigue are related diseases, which involve a primary viral infection, followed by an exaggerated immunological response, which can lead to immune responses and autoimmune disease. There are two things that must be done to treat these conditions thoroughly; test for delayed food sensitivities, and be tested for a complete viral panel. Drugs will need to be administered to treat the viruses. To learn more please call us.
1.4.5 Harrison's Principles of Internal Medicine 14th edition on CD-ROM, 1999
Copyright© 1998 McGraw-Hill.
2. Journal of General Internal Medicine, January 2001
3. Centers for Disease Control, 1998
Table 1. Approximate percentage of patients with the chronic fatigue syndrome reporting specific symptoms:
|Tender lymph nodes||80|
SOURCE: S.E. Straus: the chronic mononucleosis syndrome.
Journal of infectious diseases 157:405, 1988
Table 2. Revised CDC criteria for chronic fatigue syndrome
A case of chronic fatigue syndrome is defined by the presence of:
- Clinically evaluated, unexplained, persistent or relapsing fatigue that is of a new board definite onset; is not the result of ongoing exertion: is not alleviated by rest; and results is substantial reduction of previous levels of occupational, educational, social, or personal activities; and
Four or more of the following symptoms that persist or recur during six or more
consecutive months of illness and that do not predate the fatigue:
- Self-reported impairment in short-term memory or concentration
- Sore throat
- Tender cervical or auxiliary lymph nodes
- Muscle pain
- Multi-joint pain without redness or joint swelling
- Headaches, a new pattern or severity
- Unrefreshing sleep
- Post-exertional malaise lasting more than 24hours
SOURCE: Adapted from Fukuda et al.
- Tender points in fibromyalgia.
- Sub occipital muscle insertion at base of skull;
- anterior aspect of intertransverse process spaces at C5-7;
- midpoint of upper border of trapezius muscle;
- above scapular spine near medial border of scapula;
- second costochondral junction; lateral epicondyle;
- upper outer quadrant of buttocks;
- posterior aspect of trochanteric prominence;
- medial fat pad of knee (all bilateral).
SOURCE: From the brochure "Fibromyalgia," Arthritis Information, Advise and Guidance, Disease Series. The Arthritis Foundation.