Chronic Fatigue is Common in Boulder, here are some ideas from the desk of Dr. Steve Parcell

CHRONIC FATIGUE SYNDROME 

Although newly defined and currently popular, CFS is not a new disease at all. References to a similar condition in the medical literature go back as far as
the 1860s. In the past, chronic fatigue syndrome has been known by a variety of names including, among many others:

•   chronic mononucleosis-like syndrome or chronic EBV syndrome
•   Yuppie flu
•   postviral fatigue syndrome
•   post-infectious neuromyasthenia
•   chronic fatigue and immune dysfunction syndrome (CFIDS)
•   Iceland disease
•   Royal Free Hospital disease

In addition, symptoms of chronic fatigue syndrome mirror symptoms of neurasthenia, a condition first described in 1869.Although a definitive cause of CFS has not been determined, one of the most persuasive hypotheses is that various triggering events, such as stress or a viral infection, may lead to the chronic expression of cytokines and then to CFS.

Physical or emotional stress, which is commonly reported in CFS patients, activates the hypothalamic-pituitary-adrenal axis, or HPA axis, leading to increased release of cortisol and other hormones. Long-term activation of this axis may lead to adrenal fatigue/exhaustion. Cortisol and corticotrophin-releasing hormone (CRH), which are also produced during the activation of the HPA axis, influence the immune system and many other body systems. They may also affect several aspects of behavior.  Recent studies revealed that CFS patients often produce lower levels of cortisol than do healthy controls. Cortisol suppresses inflammation and cellular immune activation, and reduced levels may allow the immune system to run in an overactive state, increasing inflammation and immune cell activation.

Disturbances in the autonomic regulation of blood pressure and pulse (neurally mediated hypotension, or autonomic dysfunction) are common in CFS patients. Many CFS patients experience lightheadedness or worsened fatigue when they stand for prolonged periods or when in warm places, such as in a hot shower. Adrenal dysfunction has three stages. The third stage (stage 3) denotes low levels of adrenal hormones and has fatigue as its primary symptom. Adrenal fatigue/exhaustion (Non-Addison’s hypoadrenia) can, if left untreated, lead to fibromyalgia and CFS. There can be considerable overlap in symtomology between adrenal exhaustion and CFS. Adrenal fatigue and adrenal exhaustion are often used interchangeably.Adrenal fatigue should be suspected when a collection of signs and symptoms are seen:

Signs and Symptoms of Adrenal Exhaustion

Sugar cravings	Stimulant use	Hypoglycemia	Allergies	Joint pain
Frequent colds	Unrested in AM	Postexertional malaise	Fear, anxiety, depression
Decreased mental fcn (concentration, memory)	Feeling dragged out (everything feels like a chore)	Salt cravings	Poor wound healing	Difficulty getting up in AM
Decreased sex drive	Decreased ability to handle stress	Increased time to recover from illness	Dizziness	PMS chocolate cravings
Can not skip meals or SX get worse	Irritability	Feels better after the evening meal	Low BP	Orthostatic hypotension

Causes (stresses add up):

Poor diet	Alcohol	Caffeine (chronic use)	Toxic metals	Lack of sleep
Overwork	Perfectionism	Lack of recreation	Unhappy marriage or work	Single parent
Death of close friend or family	Severe emotional or physical trauma	Loss of stable job	Chemical exposure	Change in financial status
Respiratory infections	University	HX of acute or prolonged stress or trauma

DIAGNOSIS

Adrenal fatigue is diagnosed when lab testing; questionnaire results, and history reveal adrenal hypo-function. A patient will be classified as having CFS if he or she meets the following two criteria:

• Unexplained fatigue that is not due to ongoing exertion, other medical conditions, is not relieved by rest, and results in a substantial reduction in previous levels of activity, and…
• Four or more of the following symptoms are concurrently present for six weeks or more:
  • impaired memory or concentration
  • sore throat
  • tender cervical or axillary lymph nodes
  • muscle pain
  • multi-joint pain
  • new headaches
  • unrefreshing sleep
  • post-exertional malaise

TESTING

• RNase L (Elastase expression assay) This test distinguishes between CFS, Fibromyalgia and depression and identifies those who will respond well to antiviral or immune therapies. Viral infection results in the secretion of chemicals (called cytokines) including interferons. Interferons control the way cells respond to a virus through an enzymatic antiviral defense pathway called the RNase L pathway. When active, RNase L inhibits viral replication. When overactive it can have detrimental effects on the body by degrading cellular as well as viral RNA. An increase in the activity of this pathway is associated with a lower state of health in CFS. Those with CFS also have a unique, smaller form of this enzyme and a ratio of LMW RNase L to normal RNase L can be calculated.
• Perforin expression assay (Natural Killer cell activation)
• CD57+/CD3- absolute cell count
• Soluble CD14 serum level
• C4a serum level
• Red Blood Cell magnesium
• Blood or Salivary cortisol, sex hormones DHEA. If cortisol is very low or high at night this can interfere with sleep. Nighttime saliva cortisol may be used if nighttime waking is a problem. Low sex hormone levels may contribute to fatigue.
• ACTH stimulation test. This test checks how the adrenal glands respond to a certain hormone. The hormone is called adrenocorticotrophic hormone, also known as ACTH. ACTH is made in the pituitary gland and travels through the bloodstream to the adrenal glands. ACTH stimulates the adrenal gland to release cortisol. Cortisol levels in the bloodstream are measured before and after an injection of ACTH into the blood or muscle. A blood sample is taken from a vein on the forearm or hand. All 3 criteria must be met for a ‘Normal response’:
• Lyme disease PCR. Chronic lyme disease may be a cause of  fatigue.
• CBC, Chem: Rules out anemia, liver, kidney and a number metabolic disturbances
• Sed rate
• Thyroid panel (Ft3, Ft4, Rt3, Ab etc)
• Immunologic tests: Relates to immunodeficiency  associated with fatigue.
• Electrocardiogram: heart problems are a cause of fatigue.
• HIV testing
• Antinuclear antibody
• Neuroadrenal test: Measures a number of adrenal hormones as well as neurotransmitters that regulate mood and energy
• Urinalysis: Rules out a number of possible other causes of fatigue.
• Blood and urine heavy metals: Lead, arsenic and mercury can all cause fatigue. A surprising number of patients have elevated levels and do not know it.

PHYSICAL EXAM

• Othostatatic hypotension test: Positive if BP drops when patient stands after lying down for 10 min. Normally BP will rise 10-20 mmHg and heart rate should increase as well. Rule out dehydration.
• Iris contraction (Hippus test): + if  miosis  not sustained. Pupil remains dilated despite light (do for at least 40 sec).
• Sergent’s white line: Stroke abdomen with dull object, making a mark 6” long. Positive when line stays white for more than 10 seconds and may stay white for 2 min or more.

TREATMENTS

• Exercise: Everyone, for physical and emotional well-being, requires an appropriate amount of physical activity. Patients with CFS are no exception. In general, we advise patients with CFS to pace themselves carefully and encourage them to avoid unusual physical or emotional stress. The paced activity can be counter-productive if it increases fatigue or pain. A regular, manageable daily routine helps avoid the “push-crash” phenomenon characterized by overexertion during periods of better health, followed by a relapse of symptoms perhaps initiated by the excessive activity. Adrenal fatigue patients benefit most from weight training.
• Massage therapy, acupuncture, chiropractic, cranial-sacral, massage, self-hypnosis, and therapeutic touch. These modalities may contribute to feeling better, but they are most effective when combined with patient-generated activity, such as aquatic therapy, light exercise (adapted to personal capabilities), and stretching. Some patients may tolerate activities such as yoga and tai chi that require more energy.
• Lifestyle
  • Make a list with good for me in one column and bad for me in the other
  • Identify factors that “take energy away “and minimize them
    • People
    • Environments
    • Tasks
    • Situations
  • Rest and relax as much as possible
  • Improve your sleep: there are several reasons people with hypoadrenia have sleep problems. If you wake between 1:00 and 3:00 AM your liver may be lacking the glycogen reserves needed to keep blood sugar stable during the night. Blood sugar is normally low during the early morning hours but your glucose levels may get so low that hypoglycemic symptoms result (anxiety, panic, nightmares or restlessness). We may use nighttime cortisol testing because abnormally high or low cortisol can cause similar symptoms.
    • Go to bed before 10:30 and sleep until 9:00 when possible
    • Get some type of physical exercise everyday
    • Do light yoga or stretching before bed
    • Avoid caffeine especially after 12:00 PM
    • Do not work on the computer after 8:00 PM
    • Melatoni1-3 mg 30 min before bed
    • 1 tsp of inositol powder
    • Have a nutritious (protein, fat, carb) light snack before bed if hypoglycemic
    • Various sedative herbs (valerian, hops, chamomile, ashwanganda)
    • Always sleep in a quiet dark room. A while noise generator may be helpful
    • Kavinace and Travacor are very helpful
• Food
  • Eat breakfast before 10:00 AM
  • Always eat lunch
  • Avoid sugary snacks, avoid alcohol
  • Eliminate all foods you are allergic, addicted or sensitive to
  • 30-40% vegetables, 30-40% whole grains, 10-29% animal foods, 5-10% fruits, 10-15% beans, seeds and nuts
  • Eat plenty of sea salt (only if blood pressure is below 140/80)
  • Eat good quality protein (organic meat, fish, fowl, eggs, dairy)
  • Low glycemic carbs only. Avoid white flour, sugar, pastries, cookies. Unrefined grains are OK (brown rice, barley, buckwheat, whole oats, millet, quinoa, amaranth)
  • Fats and oils should be supplied by raw nuts and seeds, organic butter, olive oil, fish oil and flax oils. Avoid deep fried foods and all hydrogenated oils. Store nuts and oils in the refrigerator. Cook with oil under low heat only.
  • Fruit should be low glycemic (apples, mango, plums, pears, kiwi, cherries)
  • 6-8 servings of colorful, organically grown vegetables per day (soups are great a great way to get your veggies)
    • Adrenal recovery soup
      • 16 ox green beans
      • 1 cup chopped celery
      • 1 zucchini sliced
      • 1 medium onion chopped
      • 1 cup tomato juice
      • 1 cup filtered water
      • 2 tsp raw honey
      • 1 tsp Paprika
      • 1 cup chicken broth
      • Pepper to taste
      • 1-2 tpsp miso added at the end
• Drink
  • Herbal teas
  • Green tea
  • Water
  • Water with a pinch of sea salt
  • Avoid fruit juice and soft drinks
  • Fresh or canned vegetable juices
  • No more than one cup of coffee per day is permitted

HORMONE THERAPY

• Low dose hydrocortisone therapy: This is stronger than adrenal gland extract and very effective in restoring normal cortisol levels. Take it with food if it causes an acid stomach. Do not take over 4 tablets a day without discussing the risks with your physician. Take Calcium if on Cortef. If taken too late in the day, Cortef can keep you up at night. You can double the dose for up to 1 to 3 weeks (to maximum 7 tablets a day), during periods of severe stress (e.g., infections – see or call your doctor for the infection and let him/her know you’re raising the dose). If routinely taking over 4 tablets a day (at your doctor’s direction), wear a “Med- Alert bracelet” that says “on chronic Cortisol treatment.” After 9-18 months, you can try to wean off the Cortef (decrease by ½ tablet a day each 2 weeks) if you feel OK (or no worse) without it.
  • 5 mg or 10 mg in AM before breakfast
  • 5 mg before lunch
  • 1 mg before bed
• DHEA 25, 50, 75, 100 mg (check PSA before and/or after 3 months)
• Pregnelolone 25 mg, 50 mg/day. Pregnenolone is the basic precursor, or starting raw material, for the production of all the human steroid hormones, including DHEA, progesterone, estrogen, testosterone, cortisol and aldosterone. But pregnenolone is not itself steroid hormone.
• Natural progesterone 20, 30 mg applied as a cream to the skin.
• < > gel, patches.High dose vitamin C for chronic viral infections
• Myers cocktail; a nutrient cocktail given for ten weeks once a week.

DIETARY SUPPLEMENTS

• Mitochondrial support: CoQ10 100, 200 mg/ Lipoic acid 100 mg and L-Carnitine:
• Magnesium Glycinate 75mg/Malic Acid 300mg (Fibrocare) – 2 tablets 3 x a day for 8 months, then 2 tablets a day (less if diarrhea is a problem. Start with 1 to 2 a day and slowly work up as able without getting uncomfortable diarrhea. You can take up to 10 a day for constipation. Taking it with food may lessen diarrhea. If pain or fatigue recurs on lowering the dose, increase it. Taken at bedtime, it helps sleep.
• Fish oil. A team of researchers at Hammersmith Hospital, London, scanned the brains of sufferers of Chronic Fatigue Syndrome , and found “gaps” indicative of deficiencies in omega 3 fatty acids that were not present in non-sufferers. They have been backed by similar findings in Scotland and Japan. They found that when sufferers were later treated with fish oil supplements the “gaps” in the brain closed and they started to feel better.
• B12 injections:
• TAAT: Targeted Amino Acid therapy or TAAT is very effective at balancing the neurohormones and neurotransmitters that regulate mood and energy.
• Colloidal silver Argentyn 23. Take 2 tbsp. by mouth in the morning, 1 tbsp. before lunch, and 1 tbsp. 20 minutes before dinner. Silver should be taken on an empty stomach (at least 10 minutes before eating or drinking).If you get a “die-off” reaction (flaring of symptoms) as the infection is killed, lower the dose to 1 tsp. a day and increase more slowly. Although the higher dose can be taken safely for at least a year, 1 tsp. a day is good maintenance dose after the infection resolves.
• Olive Leaf – 500mg – 3 to 4 capsules 3 times a da y for 10 to 14 days for respiratory infections or 3 to 4 capsules, 3 times a day for 6-24 weeks for chronic infections (e.g., HHV-6, Epstein Barr, etc).
• ImmunotiX 3-6. Take one per day. A very strong immune stimulant. Do not take if you have autoimmune disease.
• Adrenal specific support
  • Vitamin C (as mixed mineral ascorbates) to bowel tolerance. Day one 500 mg every hour until bowel movements become loose (its best to do this at home on a weekend). Once you have achieved this level reduce this by 500 mg. This is your body’s maximum level (commonly 2-4 grams per day). The more severe and chronic your illness the more Vitamin C you may require.
  • Pantothenic acid 1,500 mg/day. Needed for adrenal hormone synthesis and found in high quantities ion the adrenal glands.
  • Pyridoxine 50 mg. Also needed for adrenal hormone synthesis.
  • Vitamin E (mixed tocopherols) 800 iu/day.
  • Niacin 25 mg/day.
  • Ultraplex 4-6 day.
  • Calcium /Magnesium citrate or glycinate 2:1 ratio or 1:1 ration supplying at least 400 mg/day of magnesium. Take after 8:00 PM for best absorption. Magnesium is depleted during chronic stress and is often deficient.
  • Adrenal gland extracts 6-12 tablets/day. Since the late 1890s, physicians have treated symptoms of adrenal cortex insufficiency with adrenal cortex extract (ACE), taken from the adrenal glands of animals. This treatment was found to be very effective for reversing hypoglycemia, chronic fatigue, alcoholism, allergies, arthritis and certain types of schizophrenia. In 1968, Dr. John Tintera published his book Hypoadrenocorticism, documenting the successes he had as a practitioner using adrenal cortex extract. For forty years, Physicians’ Desk Reference recorded no adverse effects from ACE.