Chronic Fatigue & Fibromyalgia: a medical overview

Chronic fatigue syndrome (CFS) and Fibromyalgia (FM) are debilitating and complex disorders characterized by persistent fatigue and widespread pains not improved by bed rest and worsened by physical or mental activity. Sufferers often function at a substantially lower level of activity and it is hypothesized that genetics and physical and emotional stressors may contribute to the development of the illness.

PATIENT’S HISTORY – REVIEW ‘POINTERS’

FM: chronic fatigue and low energy; chronic, widespread pains and aches; depression; memory and concentration problems; sleep disturbances; stiffness & muscle twitching; headaches; tenderness of at least 11 of 18 specific anatomical sites; intolerance to cold temperatures.

CFS: Prior infection during which they are tired and “run down” but the fatigue continues after the person has recovered from the illness. Cognitive difficulties including dysnomia or verbal dyslexia; postexertional fatigue; fatigue after sleep; depression; headaches; muscle aches; sore throat; mild fever.

COMMON FINDINGS

FM

–          An impaired ability to activate the hypothalamic-pituitary portion of the hypothalamic-pituitary-adrenal (HPA) axis as well as the sympathoadrenal system (eg. reduced ACTH and epinephrine responses to hypoglycemia)(1).

–          Abnormality in circadian rhythm of hormonal profiles and cytokines; deficiency of serotonin, melatonin, cortisol and cytokines which are fully regulated by circadian rhythm (2).

CFS

–          HPA axis dysregulation (hypocortisolism and dysregulation of glucocorticoid signaling) (3).

–          Often either follows a viral infection (EBV) or a period of stress and immune dysfunction with slightly increased parameters of inflammation and pro-inflammatory cytokines (4,6).

 

TEST RECOMMENDATIONS

Saliva Testing:

–          DHEA-S & Cortisol – DHEA levels are raised in CFS and correlate with the degree of self-reported disability. The right and left adrenal gland bodies have also been found to be reduced by over 50% in CFS patients indicative of significant adrenal atrophy (11).

Hair Analysis:

–          Heavy Metal toxicity/Essential Mineral depletion – chronic mercury toxicity presents similarly to CFS and it has been shown that serum magnesium and zinc levels may play an important role in the pathophysiology of FM (12, 13).

Food Sensitivity:

–          There is emerging evidence to suggest that adverse reactions to foods or food components may be associated with disturbances (leaky gut) that may play a role in each of these disorders (5, 8).

TREATMENT

–          CoQ10: Persons with CFS have been found to have significantly lower than normal Plasma CoQ10 levels and persons with very low CoQ10 suffering significantly more from concentration and memory disturbances (7). The findings that lower CoQ10 is an independent predictor of chronic heart failure (CHF) and mortality due to CHF explains the  findings that the mean age of CFS patients dying from CHF is 25 years younger than the age of those dying from CHF in the general population (7).

–          Magnesium and Melatonin: Patients with CFS and FM show evidence of circadian rhythm disturbances  shown to be directly related to magnesium status (9). Exogenous magnesium (Mg) has been found to increase the activity of serotonin N-acetyltransferase -an enzyme in the pathway for melatonin synthesis. In vivo studies have found a significant decrease in plasma melatonin levels of Mg-deficient animals when compared to Mg-adequate animals (10).

–          D-Ribose: At a dose of 5 g tid in CFS and FM patients, D-ribose resulted in significant improvements in energy,  sleep,  mental clarity, pain intensity, and well-being (15).

–          Fish Oils and Curcumin: Anti-inflammatory agents that reduce the production of Cox-2 and iNOS have been found to improve CFS symptoms(6). EPA/DHA and Curcumin show synergistic anti-inflammatory as well as anti-oxidative stress effects (14).

–          Other Adrenal Support: Adaptogenic herbs, adrenal glandulars, licorice extract, Vitamin C, B-complex.

 

 

REFERENCES:

1. Gail K Adler, et al. Reduced hypothalamic-pituitary and sympathoadrenal responses to hypoglycemia in women with fibromyalgia syndrome. AM J Med. 1999; 106 (5): 534-543.
2. Mahdi AA, Fatima G, Das SK, Verma NS. Abnormality of circadian rhythm of serum melatonin and other biochemical parameters in fibromyalgia syndrome. Indian J Biochem Biophys. 2011; 48(2): 82-7.
3. Jason L. et al. Increased HDAC in association with decreased plasma cortisol in older adults with chronic fatigue syndrome. Brain Behav Immun. 2011; Apr 28.
4. Bansal AS, Bradley AS, Bishop KN, Kiani-Alikhan S, Ford B. Chronic fatigue syndrome, the immune system and viral infection. Brain Behav Immun. 2011; Jul 2.
5. Bellanti, Joseph A et al. Are Attention Deficit Hyperactivity Disorder and Chronic Fatigue Syndrome Allergy Related? What is Fibromyalgia? Allergy Asthma Proc. 2005; 26(1):19-28.
6. Maes M, Mihaylova I, Kubera M, Bosmans E. Not in the mind but in the cell: increased production of cyclo-oxygenase-2 and inducible NO synthase in chronic fatigue syndrome. Neuro Endocrinol Lett. 2007; 28(4):463-9.
7. Maes M, et al. Coenzyme Q10 deficiency in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is related to fatigue, autonomic and neurocognitive symptoms and is another risk factor explaining the early mortality in ME/CFS due to cardiovascular disorder. Neuro Endocrinol Lett. 2009;30(4):470-6.
8. Maes M. Inflammatory and oxidative and nitrosative stress pathways underpinning chronic fatigue, somatization and psychosomatic symptoms. Curr Opin Psychiatry. 2009 Jan;22(1):75-83.
9. Durlach J, Pagès N, Bac P, Bara M, Guiet-Bara A. Magnesium depletion with hypo- or hyper- function of the biological clock may be involved in chronopathological forms of asthma. Magnes Res. 2005 Mar;18(1):19-34.
10. Billyard AJ, Eggett DL, Franz KB. Dietary magnesium deficiency decreases plasma melatonin in rats. Magnes Res. 2006 Sep;19(3):157-61.
11. Scott LV, Teh J, Reznek R, Martin A, Sohaib A, Dinan TG. Small adrenal glands in chronic fatigue syndrome: a preliminary computer tomography study. Psychoneuroendocrinology. 1999 Oct;24(7):759-68.
12. Wojcik DP, Godfrey ME, Christie D, Haley BE. Mercury toxicity presenting as chronic fatigue, memory impairment and depression: diagnosis, treatment, susceptibility, and outcomes in a New Zealand general practice setting (1994-2006). Neuro Endocrinol Lett. 2006 Aug;27(4):415-23.
13. Sendur OF, Tastaban E, Turan Y, Ulman C. The relationship between serum trace element levels and clinical parameters in patients with fibromyalgia. Rheumatol Int. 2008 Sep;28(11):1117-21.
14. Saw CL, Huang Y, Kong AN. Synergistic anti-inflammatory effects of low doses of curcumin in combination with polyunsaturated fatty acids: docosahexaenoic acid or eicosapentaenoic acid. Biochem Pharmacol. 2010 Feb 1;79(3):421-30.
15. Teitelbaum JE, Johnson C, St Cyr J. The use of D-ribose in chronic fatigue syndrome and fibromyalgia: a pilot study. J Altern Complement Med. 2006 Nov;12(9):857-62.
16. Rossini M, et al. Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol.2007 Mar-Apr;25(2):182-8.
17. Maes M, et al. Coenzyme Q10 deficiency in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is related to fatigue, autonomic and neurocognitive symptoms and is another risk factor explaining the early mortality in ME/CFS due to cardiovascular disorder. Neuro Endocrinol Lett. 2009;30(4):470-6.
18. Maes M. Inflammatory and oxidative and nitrosative stress pathways underpinning chronic fatigue, somatization and psychosomatic symptoms. Curr Opin Psychiatry. 2009 Jan;22(1):75-83.
19. Durlach J, Pagès N, Bac P, Bara M, Guiet-Bara A. Magnesium depletion with hypo- or hyper- function of the biological clock may be involved in chronopathological forms of asthma. Magnes Res. 2005 Mar;18(1):19-34.
20. Billyard AJ, Eggett DL, Franz KB. Dietary magnesium deficiency decreases plasma melatonin in rats. Magnes Res. 2006 Sep;19(3):157-61.
21. Scott LV, Teh J, Reznek R, Martin A, Sohaib A, Dinan TG. Small adrenal glands in chronic fatigue syndrome: a preliminary computer tomography study. Psychoneuroendocrinology. 1999 Oct;24(7):759-68.
22. Wojcik DP, Godfrey ME, Christie D, Haley BE. Mercury toxicity presenting as chronic fatigue, memory impairment and depression: diagnosis, treatment, susceptibility, and outcomes in a New Zealand general practice setting (1994-2006). Neuro Endocrinol Lett. 2006 Aug;27(4):415-23.
23. Sendur OF, Tastaban E, Turan Y, Ulman C. The relationship between serum trace element levels and clinical parameters in patients with fibromyalgia. Rheumatol Int. 2008 Sep;28(11):1117-21.
24. Saw CL, Huang Y, Kong AN. Synergistic anti-inflammatory effects of low doses of curcumin in combination with polyunsaturated fatty acids: docosahexaenoic acid or eicosapentaenoic acid. Biochem Pharmacol. 2010 Feb 1;79(3):421-30.
25. Teitelbaum JE, Johnson C, St Cyr J. The use of D-ribose in chronic fatigue syndrome and fibromyalgia: a pilot study. J Altern Complement Med. 2006 Nov;12(9):857-62.
26. Rossini M, et al. Double-blind, multicenter trial comparing acetyl l-carnitine with placebo in the treatment of fibromyalgia patients. Clin Exp Rheumatol. 2007 Mar-Apr;25(2):182-8.