Chronic viral presence in CFS/ME
(By Dr Sarah Myhill and Craig Robinson)
We know that many cases of CFS/ME are triggered by Epstein Barr Virus (EBV). EBV is otherwise known as glandular fever or mononucleosis. This virus seems particularly pernicious and is also good at switching on autoimmunity and I suspect, also, allergy.
EBV, like polio, is a gut virus. Before vaccination, polio was a common childhood infection and a small proportion of those infected developed paralysis. A small proportion also developed post-polio syndrome (a chronic fatigue syndrome with other neurological deficits). 90-95% of people who contracted polio experienced no symptoms.
However if one survives full blown polio, then this may confer cross-immunity to other gut viruses such as EBV. This is not achieved by polio vaccination. What this means in practice is that our epidemics of polio have been replaced by epidemics of EBV.
It has been estimated that 25% of the population will suffer EBV infection with its much greater risk of CFS/ME. A test developed recently (VirScan - reported in New Scientist 13 June 2015 – please see here -New Scientist Article on VirScan ) allowed researchers to detect every virus to which subjects had ever been exposed - ie their viral footprint. On average subjects had a footprint of 10 viruses, but EBV was one of the most common. Some authorities state that 95% of the world's population have been exposed to, and carry antibodies to, the virus – please see American Family Physician - Common Questions About Infectious Mononucleosis. Indeed we know that EBV is so pathogenic because of its ability to evade the host’s immune system. EBV is associated not just with CFS but also with cancer and auto-immunity.
General symptoms of inflammation include recurrent ‘flu-like symptoms with fever, malaise (feeling ill), enlarged tender lymph nodes, flitting joint and muscle pain and sore throat. This chronic inflammation amounts to “civil war” in the body and is greatly demanding of energy and raw materials. There will usually be additional symptoms of poor energy delivery such as fatigue and foggy brain.
Dr Martin Lerner has shown that patients with CFS, triggered by EBV, can be greatly improved by taking the antiviral valacyclovir. Please see - Valacyclovir in the treatment of post viral fatigue syndrome .Indeed he reckons that EBV is causally associated with 81% of cases of CFS/ME. This can now be treated relatively cheaply with valacyclovir. Lerner found that a proportion of cases are also associated with cytomegalovirus (CMV – which has only some sensitivity to valacyclovir) and human herpes virus HHV-6 (which is also susceptible to valacyclovir).
The idea here is a simple numbers and sensitivity game – if one can reduce the numbers of EBV and other herpes’ viruses that are present in the body AND combine this with the nutritional interventions to improve immune function then one can switch off the EBV driven pathology. Note that EBV is human herpesvirus 4 - HHV-4. Now that valacyclovir (Valtrex) has come out of patent, treatment is a more realistic possibility. Valaciclovir is very safe. Please see- Wikipedia Article on Valaciclovir for possibly side effects. Side effects of most drugs occur because of nutritional deficiencies. By simply taking the Basic Package of nutritional supplements, this will render any side effects highly unlikely. Please see Nutritional Supplements - what everybody should be taking all the time even if nothing is wrong. Examples of this effect in action include the anti-fungals, which can be liver toxic - in my 30 plus years of clinical practice I have never seen abnormal liver function tests in patients, who have been prescribed these drugs, who have additionally been taking nutritional supplements.
However for long term high dose therapy, it is wise to monitor renal function. The key test is serum creatinine. This is routinely available on the NHS but can also be done on a TDL TINY – ie a DIY blood test on a few drops of blood. This I can supply directly, the result comes to me and I can forward it on. The cost of this test is £25 if you order through my website. Please see Category: Tests webpage for details of how to order TDL TINY tests and search for "Creatinine" on the TDL list of tests.
Dr Lerner states: "The one concern is that valacyclovir is excreted by the glomerulus and so can cause acyclovir stones (note valacyclovir is a pro-drug and converted in the liver to acyclovir). This will not occur if the patient drinks at least six 8-ounce glasses of water daily"
The dose of valtrex is 1 gram (1,000mgs) x 4 daily (increase by 50% for patients over 12 stone ie 1,500mgs x 4 daily, 50% less than this if under 9 stone ie 750mgs x 4 daily). It can be taken with or without food.
Criteria for initiating treatment with valacyclovir
The following criteria must be met:
- A clear history of a virally induced CFS.
- Recurrent virus like symptoms as above.
- The Basic Package of treatment must be put in place (this is to put the immune system in the best possible shape to kick out EBV, and protect the body against any possible drug toxicity). Please see Pacing, Sleep, Supplements and Diet sections of Stage 2 of CFS Checklist - start off and check your treatment regime here
- IgG Viral antibody titres to demonstrate past exposure to EBV. The level of antibody may be important - -a high titre suggests that the body is reacting “allergically” to EBV. I think this is what Dr Lerner means when he refers to “non-permissive” EBV infection. This test may be useful to monitor response to treatment because if successful I would expect antibody titres to fall. In some cases, I would also recommend measuring antibodies to CMV and HHV-6, again to help monitor future response. It may be that by using Valtrex to reduce the load of EBV and HHV-6 we put the immune system into a better state to allow it to deal with CMV, which has only some sensitivity to Valtrex. Viral antibody studies can be done at The Doctors Laboratory - see Category:Tests webpage In the first place, please request The Doctors Laboratory test for “Epstein-Barr Virus Antibodies IgG”. Once I have the results of this test, I can decide upon treatment or the need for further tests.
- Exclude co-infections – such as Lyme or babesia. Dr Martin Lerner found that if patients additionally had co-infections then they did not respond to the anti- viral regime. To diagnose co-infections please see Lyme Disease and other Co-infections. Having said that, my guess is that this is not quite as important as Dr Lerner states. The reason is that many of my patients do very well simply on the regimes advocated - ie improve diet, nutritional status etc and the body is well able to get rid of these co-infections itself. Furthermore I have now seen about 8 Elispot results (as at June 2015) and only one has been mildly positive.
- Check creatinine before starting treatment then again at the end of the first month of treatment, then after 3 months, then every six months whilst treatment continues.
- A “Herxheimer” response with a worsening of symptoms and a worsening energy score (as measured by the validated Energy Index Point Score® (EIPS®)) continuing for two to six weeks after treatment began was a good prognostic omen per Dr Lerner’s experience. Again per Dr Lerner’s studies, an increasing energy score and decreasing symptoms were apparent at the fifth to sixth month of continuing with valacyclovir.
- After six months and/or in parallel with symptoms reduce the dose of valacyclovir.
For me to prescribe
- You need to be a patient of mine.
- We need to do all the above.
- I must write to and inform your GP.
- Category:Tests - relevant Epstein-Barr Virus Antibodies IgG test as noted above
- Valacyclovir in the treatment of post viral fatigue syndrome
- Lyme Disease and other Co-infections
- Nutritional Supplements - what everybody should be taking all the time even if nothing is wrong
- CFS Checklist - start off and check your treatment regime here
- New Scientist Article on VirScan
- American Family Physician - Common Questions About Infectious Mononucleosis
- Wikipedia Article on Valaciclovir
- Dr Lerner CFS Foundation
- Lerner, A. Martin et al (2010). "An update on the management of glandular fever (infectious mononucleosis) and its sequelae caused by Epstein–Barr virus (HHV-4): new and emerging treatment strategies." Virus adaptation and treatment 2: 135 – 145.
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