Tuesday, April 15, 2014

Chronic Fatigue Syndrome after Swine Flu Vaccination

I may look cute, but I'm really a pathogenic gammaretrovirus.
Two case studies concerning ME/CFS recently appeared in the British Medical Journal. They are of interest because in both of these cases, CFS (as stated by the authors) was triggered by a vaccine.

Flu vaccines contain attenuated viruses, the theory being that the virus in its weakened state will not produce the illness, but will merely generate antibodies to resist it. However, in these two cases, both women developed long-lasting symptoms that did not resolve.

The obvious conclusion one can draw from these cases is that the women suffered from an immune system impairment before receiving the vaccine. But, if that were true, they would have shown symptoms after previous viral infections.

Another consideration is that viruses can recombine to form new viruses. For example, in mice, the spleen focus-forming virus (SFFV) genetic envelope can recombine with an endogenous retrovirus to form a new pathogenic virus. (Hoatlin et al)

Given the number of people who report having a flu-like illness just before falling ill with ME/CFS, it is not too great a leap to propose that the disease itself may be the result of recombinant viral genes. This was how XMRV was created, and there is no reason why other viruses - for example, one that produces PEM, mitochondrial impairment, neurological injury, and immune dysfunction - can't do the same.

There is a real possibility that in their haste to discredit XMRV's role in the pathogenesis of ME/CFS, scientists may have thrown the baby out with the bathwater.
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Should influenza vaccination be mandatory for healthcare workers?

By Sean Lynch and Dr. Mike Jefferys. British Medical Journal March 21, 2014

We report two cases of Chronic Fatigue Syndrome (CFS) after Swine Flu vaccination.

CLINICAL BACKGROUND CASE ONE

Mrs A was a 52 year old married lady of Caucasian background, working in a profession allied to medicine in a Devon hospital. At the time of vaccination she had no known health problems. Routine vaccination for swine flu was recommended by Occupational Health in January 2010.

Stiffness and pain developed in all her joints 2 days after immunisation and she needed time off work. Her current symptoms then developed over the following two weeks. She noticed impaired concentration and pronounced fatigue. Fatigue was brought on by minor degrees of activity, was not fully relieved by rest and had associated post-exercise myalgia. She described her muscles feeling weak, leaden and aching. Other principal symptoms were that she had a struggle to get her breath and at times lost her voice. She also described difficulty in gripping things. She was housebound for two months after the onset.

There was a minor car accident a few months before the onset of these symptoms without any major physical or psychological injury. At the onset of her symptoms she was on Hormone Replacement Therapy, (as she was menopausal) which was stable and without adverse effects. She had been referred for ENT investigation of dysphonia eight years before, thought to be post-viral. No fatigue syndrome was documented then. ENT investigations and blood tests (including thyroid function) were normal and after speech therapy she made a full recovery.

Past medical and surgical history was otherwise negative as was psychiatric, drug and alcohol and forensic history. She did not smoke or use alcohol. Positive aspects of the family history were that her mother had depression when she was younger and Mrs A’s older sister has a history of chronic fatigue syndrome.

She was investigated in respiratory medicine and ENT, but no serious pathology of the ENT, cardiovascular or respiratory systems was found and no preceding viral illness was implicated. Dysphonia was again diagnosed and possible dysfunctional breathing (but with normal saturation). She had speech therapy and physiotherapy. A phased return to work was arranged (on reduced hours), but she could not maintain this and was signed off sick by her general practitioner. 15 months after the onset of her complaints she was referred by her general practitioner to the local CFS/ME service. At this time fatigue was her principal complaint and respiratory and vocal symptoms were less prominent.

Investigations as per NICE guidelines for CFS (1) were performed by her general practitioner before referral and were unremarkable. She was assessed and discussed by the multidisciplinary CFS/ME team and her notes thoroughly reviewed before a diagnosis of chronic fatigue syndrome was made conforming to criteria as per NICE guidelines (1). No current or lifetime psychiatric diagnoses were detected and her fatigue was of definite onset, severe, persistent and medically unexplained.

Both individual and group treatment was offered by occupational therapists in the CFS/ME service (based on current NICE guidelines). Despite the intervention, her severe fatigue has persisted and she has not been able to return to work.

CASE TWO

Mrs B is a 46 year old married lady of Caucasian background. She was employed as a specialist nurse within a Devon Hospital and had no preceding health problems before this episode. She had a flu-like illness at the time of the Swine flu pandemic in Winter of 2009, with shortness of breath, low energy and chest infection (treated with antibiotics). Her symptoms lasted six to eight weeks with this illness, but she made an unremarkable recovery. She had no physical complaints before she was given the combined swine flu and influenza vaccination at work in October 2012. The routine vaccination for swine flu was recommended by the Occupational Health Department.

2-3 days after the vaccination she became extremely lethargic with low energy, not relieved by resting and pains in her leg muscles and areas of tenderness over her knees and thighs. She also described clear post-exercise myalgia. She had sharp occipital headaches (not relieved by painkillers) and ringing in her ears, which was worse under stress. She also described pins and needles and twitching in her arms and legs and hands (like a vibration). These symptoms were worse on the left side of her body. In addition, she described difficulties with short term memory and concentration and difficulties with word-finding (using the wrong word or forgetting common words).

She was investigated in primary care and in view of a family history of multiple sclerosis was seen by a local neurologist and also had a second opinion from a Professor of Neurology at a local University hospital.

Stiffness and pain developed in all her joints 2 days after immunisation and she needed time off work. Her current symptoms then developed over the following two weeks. She noticed impaired concentration and pronounced fatigue. Fatigue was brought on by minor degrees of activity, was not fully relieved by rest and had associated post-exercise myalgia. She described her muscles feeling weak, leaden and aching. Other principal symptoms were that she had a struggle to get her breath and at times lost her voice. She also described difficulty in gripping things. She was housebound for two months after the onset.

Past medical and surgical history was a history of a right sided wrist injury many years before and a regional pain syndrome managed by an orthopaedic surgeon and Pain management service with reasonable recover. Otherwise history was negative as was drug and alcohol and forensic history. She did not smoke and her use alcohol was sparing and well under safe recommended limits. Positive aspects of the family history were that her non-identical sister who is two years younger has been diagnosed with MS. Her mother had renal disease during pregnancy which has persisted since then. Her maternal grandfather had the onset of Parkinson’s disease in his fifties.

Psychiatric history was of a period of mild reactive depression/adjustment disorder after divorce 6 years before the present illness, for which she received brief counselling. There was no other history of note, history of self-harm, or other psychiatric contact. She had a difficult bereavement when her infant son died in hospital 15 years earlier.

She was on no prescribed medication at the time of assessment. She had bought multivitamins, magnesium and evening primrose oil. She has been mostly housebound since this episode and cannot usually get out of the house without aid. She had severe difficulties in a range of physical activities, needing to use a stick or wheelchair for mobility and needing help from her husband with daily household tasks and at times showering and dressing. She had difficulties also in a range of cognitive tasks, such as reading, conversation, taking in new information, remembering appointments. Mental state examination revealed some anxiety and irritability and edginess and one panic attach (2-3 days before the assessment). Her mood was normal and reactive with no negative thought content or thoughts of self-harm. Her sleep has been unrefreshing and disturbed and her appetite decreased (but no weight change). There were no other somatic complaints.

Investigations as per NICE guidelines for CFS (1) were performed by her general practitioner before referral and were unremarkable. She was assessed and discussed by the multidisciplinary CFS/ME team and her notes thoroughly reviewed before a diagnosis of chronic fatigue syndrome was made conforming to criteria as per NICE guidelines (1). No current or lifetime psychiatric diagnoses were detected and her fatigue was of definite onset, severe, persistent and medically unexplained.

Both individual and group treatment was offered by occupational therapists in the CFS/ME service (based on current NICE guidelines). Despite the intervention, her severe fatigue has persisted and she has not been able to return to work.

DISCUSSION

During the previous pandemic of Swine Flu, possible complications of vaccination were reported (e.g. Guillain-Barre Syndrome, multiple sclerosis), but remain controversial (2,3). The recent vaccination programme for Swine Flu was introduced rapidly to deal with the serious public health threat of the pandemic and the UK Government rolled out this programme first for at risk groups and also for health staff.

Potential risks of immunisation causing aberrant immune responses have been suggested in some cases of chronic fatigue syndrome, but causality remains unclear (4). Chronic fatigue syndrome has also been reported in confirmed sufferers of swine flu (5), but we are not aware of any published case reports of chronic fatigue syndrome with onset after Swine Flu vaccination. Factors associated with the onset of chronic fatigue syndrome are difficult to assess, but there did not appear to be any other obvious triggers in Mrs. A’s case.

A definite causal relationship between vaccination and chronic fatigue syndrome is not claimed here, all that has been established is a possible temporal relationship. By its definition, Chronic Fatigue Syndrome, needs to be present for at least four months or six months (depending on the case definition), which highlights the case for longer post-vaccination surveillance if this possible adverse outcome is to be considered.

CONFLICTS OF INTEREST

We are not aware of any competing commercial, clinical or academic conflicts of interests.
Written permission has been given for us to report the case by the patient concerned. To protect their confidentiality certain details have not been mentioned in this report.

Sean Lynch MBChB FRCPsych PhD MBA DIC *
Consultant Psychiatrist, Wonford House Hospital, Exeter and Honorary Associate Professor, Peninsula College of Medicine and Dentistry
Corresponding author, assessed patient and prepared body of case report

Dr. Mike Jefferys BSc MBBCh FRCP
Consultant Physician, Royal Devon and Exeter Hospital NHS Foundation Trust
Reviewed medical notes to confirm diagnosis and contributed to development of case report

Dawn Cutts SROT MBAOT
Head Occupational Therapist, CFS/ME Service (North and East Devon), Arlington Centre, Exeter Community Hospital, Whipton, Exeter, Devon
Involvement with patient treatment and contributed to case report

Jessica Guy BSc(Hon) Occ. Therapy
Specialist Senior Occupational Therapist, CFS/ME Service (North and East Devon), Arlington Centre, Exeter Community Hospital, Whipton, Exeter, Devon
Involvement with patient treatment and contributed to case report

Abby Burton BSc (Hon) Occ. Therapy
Senior Occupational Therapist, CFS/ME Service (North and East Devon), Arlington Centre, , Exeter Community Hospital, Whipton, Exeter, Devon
Involvement with patient treatment and contributed to case report

Acknowledgement: We are grateful for the administrative support and help in preparing the report from Julie Lawry, service administrator.

REFERENCES

1. Chronic fatigue syndrome / Myalgic encephalomyelitis (or encephalopathy): diagnosis and management in adults and children Clinical guidelines, CG53 – Issued: August 2007 NICE

2. KE Nelson . Invited commentary: influenza vaccine and Guillain-Barre syndrome–is there a risk? Am J Epidemiol. 2012 Jun 1;175(11):1129-32.

3. LT Kurland , CA Molgaard , EM Kurland , WC Wiederholt , JW Kirkpatrick . Swine flu vaccine and multiple sclerosis JAMA. 1984 May 25;251(20):2672-5.

4. OD Ortega-Hernandez , Y Shoenfeld . Infection, vaccination, and autoantibodies in chronic fatigue syndrome, cause or coincidence? Ann N Y Acad Sci. 2009 Sep;1173:600-9.

5. R Vallings. A case of chronic fatigue syndrome triggered by influenza H1N1 (swine influenza). J Clin Pathol. 2010 Feb;63(2):184-5.

1 comment:

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