News on Medicine

A few new treatments offer hope for Chronic Fatigue.:

#1. we all know that Vitamin B12 IM -up to 3cc every 72 hours works well for Fatigue. But now A Mixture of B12 & Oxytocin a Drug used to help in - -the delivery room in OB, Helps stimulate the same side of the Brain as B12 does. The mixture of these to Drugs given Intramuscularly at an apx Dosage of B12 between 1 & 3cc & Oxytocin 1ml/10U Helps a large % of CFIDS sufferers.My self ( & i have tried the mixture) Did not help much, but others it has. Each Must be drawn up in a separate syringe- but your Doctor should know this.

#2.Vitamin C Given IV piggyback about every 5 to 10 days.

#3. Gamaglobulin Ask your Doctor about this & the coarse of treatment. It has done wonders for those who have used it Im told.

#4. Thalidomide Just ask your Doctor about this reject from the 1960,s. IT is coming back & ( AND MAY BE OUR BEST BET YET I THINK ) it May help slow the Virus ability to reproduce.

#5. Oxycontin This Strong Pain Medicine is a good choice because it is a 12 hour time released form of Percodan so theirs - - no ups & downs / highs & lows / peaks & valleys / as there is in short acting Narcotics that only last a few hours. Oxycontin comes in strengths of 10mg 20mg & 40mg tablets. Just one dose every 12 hours & it should control your pain - - adequately, That is after you titrate up to the dose that's right for you. (UP DATED 11/6/97.

#6. Seratonin Uptake Inhibitors Like Paxil, Prozak, and many others, Can help you better deal with the everyday- -Ups & downs of the stress of handling CFIDS. One catch though, It takes about a month for your body to adjust- -To the medicine, and some work better than others so you may need to try different brands until you find the right one. After you get through that rough few weeks you may find that this Medicine is a GOD/SENT. Talk with your MD about- -Getting on one.

By: Jenifer Joseph, ABC.NEWS.com

April 8 - Jan Murphy committed suicide last summer because she could no longer live with a disease that many doctors still don't believe exists. She had fibromyalgia, a chronic pain condition that made cool breeze on her skin feel like fire and caused every part of her body to ache. After CT scans and MRIs showed no medical reason for her pain, Murphy turned to Dr. Jack Kevorkian for a final solution.

"When you start hearing there is no hope, no treatment, and no cure, over and over, you lose your will to fight," Murphy wrote in a eulogy that was read at her funeral. "What most people saw of me was a shell of what was going on inside."

What exactly was going on with Murphy and other fibromyalgia patients has long been a controversial matter in the medical profession. Many doctors thought that fibromyalgia was a mental health problem, with no physical cause. Until five years ago, grassroots fibromyalgia groups were virtually chased out of medical conferences when they tried to spread the word about the syndrome. Now, researchers at the University of Alabama have uncovered proof that what patients like Murphy experience isn't a psychological disorder, but rather is caused by abnormalities in the brain and central nervous system.

Sensory Alarms Stuck
The researchers found that fibromyalgia patients have significantly less blood flow to the parts of their brains that deal with pain. And compared to healthy people, they also have twice the level of a brain chemical called Substance P, which helps nervous system cells communicate with each other about painful stimuli. Elevated P levels may actually produce the higher levels of pain throughout the body.

Dr. Laurence Bradley, a pain management specialist who led the research, presented his findings at a National Institutes of Health conference on pain and gender today. About 90 percent of fibromyalgia sufferers are women, though researchers don't know why. "It's like a burglar alarm which normally goes off in the body in response to certain kinds of signals," Bradley explains. "But in patients with fibromyalgia, benign signals are making them go off as well." Bradley, who estimates that 8 percent of all women suffer from fibromyalgia, says his research is comforting to those who thought their symptoms meant they were "crazy." "It was easy for doctors to attribute the pain to psychological disorders," says Bradley, who is also a psychiatrist. "That perception is beginning to change now that we can show distinctly different brain function that is not evident in patients with depression."

Treatments elusive now that the cause of fibromyalgia seems clearer, scientists are searching for better ways to treat the symptoms. One research team is investigating whether antidepressant drugs increase cerebral blood flow. Another is looking at injecting toxins into precise places in the spine to block debilitating pain without causing the numbing side effects of narcotic drugs.

Meanwhile, gassroots groups like the Fibromyalgia Network will continue to pursue funding for more research into the condition. "It feels like being run over by a Mack truck," says network manager Steve Thorn, whose wife has fibromyalgia. "It's a terrible thing to live with. It doesn't go away." Jan Murphy, for one, wasn't willing to wait. "Please do not think of this as suicide," she wrote, "but as a self-deliverance from a life that became too unbearable to live."

Symptoms of FM Syndrome:

• All-over chronic body pain
• Trouble sleeping
• Stiffness
• Severe fatigue
• Memory loss
• Headaches
• Nausea

CDC

Complete text of revised case definition for Chronic Fatigue Syndrome by the Center for Disease Control.

CFS may run in families

Science Writer Leigh Dayton writes in the Sydney Morning Herald-Daily News that there is new evidence from Britain and Australia suggesting the CFS runs in families.

Chronic Fatigue, Sarcoidosis, and ACE

What is Sarcoidosis and why is ACE of interest to Chronic Fatigue sufferers?

Fact Sheet
What Is NIAID Doing About CFS?
Chronic Fatigue Syndrome Resources for Patients

CFS: Information for Physicians National Institute of Allergy and Infectious Diseases (NIAID) online information

FAQ - Roger Burns

Long document with lots of comprehensive information from Roger Burns on behalf of the CFS Internet Group.

Guidelines for Doctors

Breakdown of the progression of CFS. Covers the physical, psychological, social and work environment of sufferers.
Patricia Fennell, CSW, is the founder of Albany Health Management Associates in Albany NY.

Have I got Chronic Fatigue Syndrome?

On-line brochure written by Dr Livingstone, Little Surgery, Stamford, UK. Covers all the basics in easy to understand language.

Medicine for the Public - CFS

Moira's Canberra Fibromyalgia and Chronic Fatigue
Syndrome Page

Perspectives on Diagnosing Chronic Fatigue Syndrome

Four physicians across the country discuss their procedures for diagnosing chronic fatigue. Good reading for those who have never seen a doctor for a diagnosis.

Questions And Answers Relating To The Diagnosis Of
CFIDS

Newly diagnosed or just suspect that you might be a PWC? Here is a good place to start learning more about CFS.

Scientific Workshop Summary:

Site for Osteopathy and Accupuncture discusses CFS, FMS and disorders that can mimic them.
Tell me what my physician should know.
Still searching for a CFS diagnosis? Recent doctor change? Here is a good starting point to review with your physician.

10 Years After First Report, Mystery Lingers

Myalgic Encephalomyelitis: Is the name given to an unknown virus that Infects & Inhibits the Auto Immune System & Neuro Muscular System Of those who have been Diagnosed with (Fibromyalgia)- (CFIDS)- & (IVN). This Disease can lay Dormant in an individual, or be contracted through unknown, causes, ways, or even possibly Hereditary Factors. The Method of transmission (again) is only speculatory to infection. For instance, A husband may get it & his wife may not, but his child or neighbor may become Infected. & Visa Versa. You might get CFIDS & not progress to Fibro- & your Immune system may fight it off, or you might progress to the Fibro- stage, & even in rare cases progress to Severe Fibromyalgia or Severe- Myalgic Encephalomyelitis. Severe Myalgic Encephalomyelitis is Characterized by the Virus Mutating To the point of irreversible, Muscle-Nerve-&-Fibrous Tissue Degeneration.

In the late stages of this Retro Virus known as Severe ME, can be found Changes in the Blood Chemistry similar to that of MS & ALS Pt's especially the CPKmm & the CPKmb, The markers that point to the probable cause of the unpredictable chest pain & muscle pain in which so many Pt's have. This CPK fluctuation in the mm differential can climb in the thousands, & is hard to track due to the transient nature of the virus. That is to say that in fibro & CFIDS, the virus runs around attacking different Body systems, until that particular system fights it off & It moves on to another (or other) systems to attack.

In Severe ME the body has no longer the ability to fight off the virus, & as a Result the body system (lets say Neuro) sustains irreversible damage. This can happen to the muscular system, or any other organ or system under attack. The chart above shows what course the virus might take in its attack on the Human Body. This Analogy of the ME Virus is not taken from text or Published Articles- But from Pt's own experiences & my tracking of this disease over a period of years. I am a Nurse & a Scientist, & a casualty of this terrible disease, with Severe ME.

I was a hard working Nurse & Paramedic for over 16 years & My Hobbies for over 30 years were Body Building, Martial Arts Instructor, Aerobics, Gymnastics & Running. I had CFIDS for 5 years, Then Fibro for 1 year, and now for the past 2 &1/2 years Severe ME. 2&1/2 years ago I could still Bench Press @ least 300 pounds- Today I am wheel chair & crutches Bound. Can hardly lift a cup of coffee without dropping it from either- to week or shaking to much. I also require around the clock Nursing care. We have charted all my blood tests, Medications & other tests. And have found no other disease present. Also followed CPK tests weekly for 6 months along with sed rate & liver functions All are either slightly abnormal, or grossly abnormal

MYALGIC ENCEPHALOMYELITIS
This name has been used in scientific literature since 1956, although not as broadly as CFS, and has been widely accepted in most of the world outside of the U.S. This term is listed in the World Health Organization's classification of diseases. However, many scientists nowadays consider this name inaccurate and they discourage its broader use, since the "-it is" portion refers to inflammation of the brain, which is not sufficiently supported by medical evidence. The recent British Royal Colleges' Report recommends against using this name and recommends using CFS instead. Yet that report has been criticized by the journal Lancet as being biased towards psychiatric views.

MYALGIC ENCEPHALOPATHY
This new alternative has been discussed by several scientists recently. It allows use of the familiar term "M.E." yet omits "-itis" to which many scientists object (see above). This name has not been in use by scientists or patients. In addition, while "encephalopathy" means "brain disease" to American doctors, it has a much more serious connotation to British physicians, and there could be objections based on lack of scientific evidence for this term as well.

FDA approves Trinity Biotech EBV markers

WESTPORT, Jun 02 (Reuters) - Trinity Biotech, based in Dublin, Ireland, said on Monday that the Food and Drug Administration approved the company's two markers for detecting Epstein Barr Virus. In a press release posted on Business Wire, Trinity said that enzyme immunoassays detect the presence of virus antibodies, EBNA-1 IgM and EA-D IgG, associated with acute and chronic infection, respectively. Carter Wallace's Wampole Laboratories will distribute the markers in the US. Trinity Biotech CEO Ronan O'Caoimh said that the company now has over 80 FDA-approved test kits.

Cytotoxic T-Cell Therapy Shows Promise In EBV-Positive Hodgkin's Disease

Wed, 29 Apr 1998 12:53:01 GMT
By Nancy Ehrlich
WESTPORT, Apr 29 (Reuters) - Epstein-Barr virus (EBV)-specific cytotoxic T lymphocytes drawn from patients with EBV-positive Hodgkin's disease can be expanded in vitro and reinfused as treatment during relapse. In the April 15th issue of Blood, Dr. Cliona M. Rooney, presently at Texas Children's Hospital in Houston, Texas, describes the approach she developed to treat this disease with colleagues at St. Jude's Children's Research Hospital and the University of Tennessee College of Medicine, both in Memphis, Tennessee.

Dr. Rooney and her colleagues explain that EBV-positive immunoblastic lymphoma cells are often EBV-antigen positive and may therefore be vulnerable to treatment with virus-specific cytotoxic T lymphocytes. However, the researchers add, the immune effects of Hodgkin's disease likely prevent the generation or proper function of EBV-specific cytotoxic T lymphocytes. In the study reported this month, the investigators attempted to determine whether or not autologous EBV-specific cytotoxic T lymphocytes could be expanded ex vivo, "...in the absence of in vivo immunosuppressive effects." According to the article, Dr. Rooney's team was able to generate cytotoxic T lymphocyte cell lines from 9 of 13 patients with Hodgkin's disease. Five of the 9 had active disease, and 4 were in remission. "Although these lines had an abnormal pattern of expansion comparable to EBV-specific [cytotoxic T lymphocytes] generated from normal donors, their phenotype was normal except for reduced expression of the zeta chain of the T-cell receptor," the authors report.

Reduced expression of the zeta chain is a recognized T-cell abnormality in Hodgkin's disease, they add. The researchers then infused labeled cells from these cell lines into three patients with multiply relapsed disease. The cytotoxic T lymphocytes "...persisted for more than 13 weeks postinfusion and retained their potent antiviral effects in vivo," they report. "Many barriers remain to prevent the successful therapy of EBV-positive Hodgkin's disease using virus-specific [cytotoxic T lymphocytes]," according to Dr. Rooney and her associates. "Nonetheless, our demonstration that it is possible to generate EBV-specific [cytotoxic T lymphocytes] from patients with advanced Hodgkin's disease, that these cells survive and function in vivo, and that [cytotoxic T-cell therapy] may be directed to the subdominant viral epitopes expressed by Hodgkin's cells, provides reason to hope that such...therapy will become a useful adjunct to conventional treatments for EBV-positive Hodgkin's disease."

Blood 1998;91:2925-2934. Copyright 1998 Reuters Limited. All rights reserved. Republication or redistribution of Reuters content is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.

Cognitive, Physical Disability Linked In Patients With Chronic Fatigue Syndrome.
Fri, 10 Apr 1998 12:53:02 GMT WESTPORT, Apr 10 (Reuters) - There may be an association between functional disability and neuropsychological impairment in patients with chronic fatigue syndrome, according to researchers in New Jersey and North Carolina. The investigators assessed neuropsychologic impairment and functional disability in 53 patients with chronic fatigue syndrome and 32 healthy controls, none of whom exercised regularly. Lead author, Dr. Christopher Christodoulou of the University of Medicine and Dentistry of New Jersey-New Jersey Medical School and his team report in the April 6th issue of the Journal of Neurology, Neurosurgery and Psychiatry that "...patients with chronic fatigue syndrome who perform worse on neuropsychological testing are also more likely to display greater functional disability in their daily activities." Specifically, patients who failed tests of list acquisition and free recall had significantly more days of general inactivity than those who passed the test. Although this is the first study to show a relationship between cognitive function and physical impairment in patients with chronic fatigue syndrome, similar associations have been observed in patients with HIV, multiple sclerosis, Alzheimer's disease and stroke, Dr. Christodoulou and others say. Neither cognitive impairment nor physical disability correlated with the presence of psychiatric symptoms or depression, according to the report.

Co-author Dr. John DeLuca, of the Kessler Institute for Rehabilitation in West Orange, New Jersey, told Reuters Health that the data provide a "strong suggestion" that cognitive impairment in patients with chronic fatigue syndrome "...could cause significant functional disability." He said, "It is important for physicians and health professionals to realize that [chronic fatigue syndrome] patients have real cognitive problems and that these problems can have real consequences for their everyday activities." J Neurol Neurosurg Psychiatry 1998;64:431-434. Copyright 1998 Reuters Limited. All rights reserved. Republication or redistribution of Reuters content is expressly prohibited without the prior written consent of Reuters. Reuters shall not be liable for any errors or delays in the content, or for any actions taken in reliance thereon.

New Chronic Fatigue Drug Available in U.S. and Canada
PHILADELPHIA, June 26, 1997 -- Five clinical sites across the United States have received approval to participate in the FDA-approved Ampligen(R) treatment protocol for patients with Chronic Fatigue Syndrome (CFS). Ampligen, developed by HemispheRx Biopharma, Inc., is a new drug under development for potential restoration of physical and cognitive functions of patients with CFS. This is the first specific FDA approval for treatment with cost recovery for this disorder. An estimated 500,000-to-2,000,000 patients in the U.S. suffer from CFS. This first approval for treatment with cost recovery means that patients reimburse the cost of the drug, allowing the company to recover a portion of the research, development and manufacturing costs associated with its development to date. Patients also absorb the cost of twice weekly drug infusion and lab tests. The treatment program in the U.S. initially will be directed towards the most severely disabled patients who are expected to be treated for 24 weeks followed by medical evaluation and reassessment. Simultaneously, sales of Ampligen have also begun in Montreal and Vancouver under the Canadian Emergency Drug Release Program. The approval in Canada covers patients in all stages of the disease, where the CFS patient population is estimated at more than 100,000.

As in the United States, patients on the treatment may also absorb additional costs associated with drug infusion and medical oversight. The five sites approved in the United States are New York City, Charlotte, NC, Houston, TX, Charleston-area, SC, Philadelphia-area, PA and San Francisco Bay/Reno, NV area. All sites have received or are awaiting confirmation from their local Review Boards or Ethics Committees that they may begin treating patients with Ampligen. Treatment will begin as soon as customary baseline lab tests, scheduled over two weeks, are completed. In addition to the five approved sites, an additional twelve sites are under consideration for approval to treat CFS patients with Ampligen. CFS, also known as Chronic Fatigue Immune Dysfunction (CFIDS), or Myalgic Encephalomyelitis (ME), is a serious and complex illness that affects a vast number of different body systems. It is generally characterized by disabling fatigue, problems with concentration and memory, flu-like symptoms, pain in the joints and muscles, sleep disorders, etc. As a result, the Centers for Disease Control (CDC) has assigned the disorder to its priority one list of "new and reemerging infectious diseases" in the U.S. Hemispherx is a biopharmaceutical company engaged in the manufacture and global clinical development of new drug entities in the nucleic acid (NA) class for chronic viral disease and disorders of the immune system. The Company is working with regulatory agencies, physicians and patients to help ensure that epidemic diseases are prevented, managed and cured with maximum benefit and minimum costs to patients and society.

This press release contains statements of a forward-looking nature regarding future events. These statements are only predictions and actual events may differ materially. Please refer to documents that Hemispherx files from time to time with the Securities and Exchange Commission for a discussion of certain factors that could cause actual results to differ materially from those contained in the forward-looking statements. More information on: Hemispherx, Ampligen

Scientists Uncover Marker Of Autoimmune Disease Activity

September 16, 1998
UT Southwestern Medical Center at Dallas/MedscapeWire DALLAS -- UT Southwestern Medical Center at Dallas researchers have uncovered what they believe is a marker of autoimmune disease activity in patients with lupus and rheumatoid arthritis, which may one day enable doctors and patients to predict disease flare-ups. In today's issue of the Journal of Clinical Investigation, Dr. Mark Siegelman, associate professor of pathology at UT Southwestern, and colleagues described the correlation of disease flare-ups in pediatric patients with lupus and rheumatoid arthritis with the level of activated CD44 (the marker) in circulating blood. The activated form of CD44, a cell surface molecule induced on a small subpopulation of white blood cells called T-lymphocytes (T-cells) during immune reactions, was measurable only in patients who were experiencing an exacerbation of their condition.

Dr. Pila Estess, UT Southwestern assistant professor of pathology and a co-author of the study, envisions the day when patients with autoimmune diseases or their physicians will be able to monitor blood levels for activated CD44 much the same way that diabetes patients monitor their blood-sugar levels. "T-cells are thought to be the cells that start and perpetuate autoimmune disease," said Siegelman. "In our study, every time there was an exacerbation, there was another wave in the blood of T-cells with activated CD44 on their surface. The implication is that these cells may initiate the autoimmune exacerbations." Activated CD44 T-cells have the ability to bind to a specific molecule called hyaluronan (HA) induced on the inner surface of the blood vessels near or in the inflammatory site. These particular T-cells repeatedly bind to HA as they roll along the blood vessel wall. The result of this "rolling" is a slowing down of the T-cells so that they can bind more firmly to other adhesion molecules and move out through the blood vessel to the site of inflammation, where they cause further injury. Previous work by these investigators showed that in mice the migration of T-cells into an inflammatory site (extravasation) was dependent on this interaction of CD44 with HA (Science 278:672, 1997). They proposed that in humans activated CD44 initiates extravasation of T-cells at sites of inflammation. This paper supports that proposal by clearly showing that circulating blood only from patients with disease flare-ups contains activated CD44 T-cells that undergo "rolling." "There has never been a reliable cell surface marker that correlates with an autoimmune exacerbation,* said Siegelman. "Regarding therapeutic treatment, if these are truly the T-cells that enter the tissue and initiate damage, you should be able to intervene in the disease process by directly getting in the way of the CD44-HA interaction, thereby preventing injury. Currently we are trying to design molecules that block the CD44-HA connection."

PATIENTS REPORT IMPROVEMENT WITH EXPERIMENTAL TREATMENT FOR CHRONIC FATIGUE SYNDROME
But treatment causes potentially dangerous suppression of adrenal system CHICAGO-Low-dose hydrocortisone may be an ffective treatment for chronic fatigue syndrome (CFS), but patients experience a potentially dangerous side effect, according to an article in the September 23/30 issue of The Journal of the American Medical Association (JAMA). Robin McKenzie, M.D., of the National Institutes of Health in Bethesda, Md., and colleagues studied the effect of low-dose hydrocortisone as a treatment for CFS. Participants who received low-dose hydrocortisone reported feeling better than participants who only received a placebo treatment. The study used a wellness score that rated overall health using a scale with zero representing the worst the participant had ever felt and 100 representing the best they had ever felt. As the researchers report: "The percentages of patients recording improvement of at least 5, 10 or 15 points on the wellness scale were greater for hydrocortisone than placebo recipients (5 points, 53 percent vs. 29 percent; 10 points, 33 percent vs. 14 percent; and 15 points, 20 percent vs. 6 percent). " They add: "The mean improvement on treatment in the hydrocortisone group was 6.3 points, being higher than the mean improvement of 1.7 points for the placebo group." Although these results were promising, the study also found that patients who received hydrocortisone experienced significant adrenal suppression. It was previously believed that low doses of corticosteroids were relatively safe and would not cause this type of suppression. As the researchers note: "Although steps were taken to avert serious or potentially life-threatening adrenal insufficiency in the face of emergent stress, the fact that it could happen with less cautious widespread use precludes the present regimen of hydrocortisone or comparable doses of other systemic corticosteroids as acceptable choices for the prolonged treatment of chronic fatigue syndrome."

The researchers have been exploring the possible connection between the endocrine system (especially the hypothalamic -pituitary adrenal axis) and CFS. Corticosteroid hormones are an important part of making nutrients and energy available to the body. The adrenal glands are the source of natural production of corticosteroid hormones, such as cortisol, commonly known as hydrocortisone. The researchers tested the amount of hydrocortisone in patients with CFS and found that they had on average about 30 percent less hydrocortisone than healthy controls. This led the researchers to consider low-dose supplementation with hydrocortisone to possibly correct the imbalance. The researchers used the more complex 1988 Centers for Disease Control and Prevention criteria to define the cases to be included in the study. The 1988 case definition requires debilitating fatigue and eight or more of eleven signs and symptoms occurring for at least 6 months. The patients also met the 1994 CDC criteria. The eight symptoms are memory or concentration complaints, sore throat, tender lymph nodes, muscle pain, multi-joint pain, a new pattern of headaches, unrefreshing sleep, and malaise after exertion that lasts more than 24 hours. The researchers conclude that though this is the first study, to their knowledge, to show an improvement in CFS due to a drug treatment, the low-dose hydrocortisone treatment probably is not viable in a clinical setting. The researchers note: "What little improvement might be attributable to hydrocortisone treatment (JAMA. 1998;280:1061-1066)

Editorial: The Nature of Chronic Fatigue In an accompanying editorial, David H. P. Streeten, M.B., D.Phil., of the State University of New York Health Science Center in Syracuse, N.Y., writes: "Perhaps the most reasonable conclusion from the evidence to date is that chronic fatigue may have a variety of causes and pathogeneses. In patients with chronic fatigue syndrome, the cause might include dysfunction of the hypothalamic-pituitary adrenal axis and hypocortisolism [under production of hydrocortisone] or ... an infectious agent." The author adds: "Further studies are needed to unravel the pathophysiologic mechanism of chronic fatigue and to find therapies to effectively ameliorate the debilitating symptoms that accompany this complex disorder."

(JAMA. 1998;280:1094-1095)

Fibromyalgia in Hepatitis C Virus Infection Another Infectious Disease Relationship

Dan Buskila, MD; Alla Shnaider, MD; Lily Neumann, PhD; Doron Zilberman, MD; Nir Hilzenrat, MD; Emanuel Sikuler, MD Background: Fibromyalgia syndrome (FS) is a common disorder of diffuse pain in the muscles or joints accompanied by tenderness at specific tender points and a constellation of related symptoms. The potential role of infections in the pathogenesis of FS has only recently been investigated.

Objectives: To evaluate the prevalence of FS and to assess tenderness thresholds in patients infected with hepatitis C virus (HCV).

Methods: The study included 90 patients with HCV, 128 healthy, anti-HCV-negative controls, and 32 patients with non-HCV-related cirrhosis. Tenderness was measured by manual palpation (18 tender points) and with a dolorimeter. Fibromyalgia syndrome was diagnosed according to the 1990 American College of Rheumatology criteria. Results: The diagnosis of FS was established in 14 patients (16%) with HCV, in 1 patient (3%)with -HCV-related cirrhosis, and in none of thehealthy controls (P<.001). Thirteen of the HCV- positive patients with FS were women. The patients with HCV had significantly (P<.01) more tender points (mean [±SD] 3.6±5.3) than the healthy controls (0.1±0.5) and the patients with non-HCV-related cirrhosis (1.2±2.7). Specifically, the patients with cirrhosis were most tender on both tenderness measures owing to the high proportion of women in this group. Patients with FS were significantlymore tender than those without FS: their dolorimetry thresholds were 2.9 kg vs 6.0 kg (P<.001). Conclusions: A high prevalence of FS was observed in patients infected with HCV, especially women. Recognizing FS in patients with HCV will prevent misinterpretation of FS symptoms as part of the liver disease and will enable the physician to reassure the patient about these symptoms and to alleviate them.

Arch Intern Med. 1997;157:2497-2500

18 Tender Points and the "18-Wheeler" Sign: Clues to the Diagnosis of Fibromyalgia

To the Editor.-A common question asked by rheumatologists of their patients is, "How do you feel in the morning?" This question may refer to morning stiffness from inflammatory joint disease or restoration from the night's sleep in fibromyalgia. Fibromyalgia is common (2% to 5% of the population in a recent study[1]) and underdiagnosed as a cause of chronic fatigue, achiness, cognitive dysfunction, and irritability.[2] Approximately 2 years ago, one of us (L.H.S.) noted that fibromyalgia patients often responded to this question with the answer, "I feel like I was hit by a Mack truck"; some did not specify the truck manufacturer, and others substituted bus or train. We determined the frequency and specificity of this finding, which could be referred to as the "18-wheeler" sign, as a clue in the diagnosis of fibromyalgia.

All patients seen in initial consultation at The Lyme Disease Center and The Lupus Clinic at Robert Wood Johnson Medical School, New Brunswick, NJ, were asked, "How do you feel when you wake up in the morning?"-no patients were provided any leading hints as to a desired response. Patients seen were then categorized as having Fibromyalgia (meeting the American College of Rheumatology 1990 criteria for the diagnosis of fibromyalgia, which includes the presence of at least 11 of 18 defined tender points[2]) or a syndrome resembling fibromyalgia (not having a sufficient number of tender points to satisfy the criteria but having chronic fatigue, historical evidence of sleep disturbance, and cognitive dysfunction) or another rheumatologic syndrome (including systemic lupus, anticardiolipin antibody syndrome, rheumatoid arthritis, polymyalgia rheumatica, osteoarthritis, psoriatic arthritis, and Reiter syndrome). From September 22, 1995, through November 20, 1996, we saw 93 patients with fibromyalgia, 77 with a fibromyalgialike syndrome, and 202 patients with other rheumatologic diseases or no definable abnormalities (eg, asymptomatic patients referred for evaluation of an isolated positive antinuclear antibody test or positive anti-Borrelia burgdorferi antibody assay). In this group of 372 patients, 42 (45%) of the 93 in the fibromyalgia group, 29 (38%) of the 77 in the fibromyalgialike group, and 18 (9%) of the 202 in the other group were referred for evaluation of Lyme disease or "chronic Lyme disease."[3] Although the primary focus of the evaluation of these patients was not chronic fatigue syndrome, for persons with a history of the syndrome, physical examination focused on the presence of fever or chills, sore throat, painful or nontender adenopathy, muscle pain or weakness, headache, arthralgia, and the rapidity with which the main symptom complex had developed. No patient was explicitly diagnosed as having chronic fatigue syndrome according to the Centers for Disease Control and Prevention definition then in use.[4]

The "18-wheeler" sign was present in 30 (42%) of 93 patients in the fibromyalgia group, including a patient with underlying lupus in whom fibromyalgia had not been suspected; none of the patients in the other 2 groups had a positive "18-wheeler" sign. None of the 77 patients with fibromyalgialike disorder or the 202 patients with other rheumatologic disorders had a positive "18-wheeler" sign (P<.001; Fisher exact test).

Further studies will be needed to determine if this historical feature is present in other conditions associated with chronic fatigue, eg, chronic fatigue syndrome, cancer, or hypothyroidism. Given that patients with chronic fatigue syndrome commonly satisfy criteria for the diagnosis of fibromyalgia (and vice versa), it is quite likely that the "18-wheeler" sign will be present in some patients with chronic fatigue syndrome. Nonetheless, as a clinical marker of fibromyalgia (whether or not in conjunction with chronic fatigue syndrome), the "18-wheeler" sign appears to be a specific, although not very sensitive, historical marker for the clinical entity fibromyalgia and may be useful in suggesting consideration of fibromyalgia.

Leonard H. Sigal, MD
David J. Chang, MD
Victor Sloan, MD
UMDNJ-Robert Wood Johnson Medical School
New Brunswick, NJ

References
1. Wolfe F, Ross K, Anderson J, Russell IJ, Hebert L. The prevalence of fibromyalgia in the general population. Arthritis Rheum. 1995;38:19-28.

2. Wolfe F, Smythe HA, Yunus MB, et al. The American College of Rheumatology 1990 criteria for the classification of fibromyalgia. Arthritis Rheum. 1990;33:160-172.

3. Sigal LH. Summary of the first one hundred patients seen at a Lyme disease referral center. Am J Med. 1990;88:577-581.

4. Holmes GP, Kaplan JE, Gantz NM, et al. Chronic fatigue syndrome: a working case definition. Ann Intern Med. 1988;108:387-389.

(JAMA. 1998; 279:434)

DEATH & DYING: Fibromyalgia, CFIDS & Myalgic Encephalomyelitis There are many pt who have died from this terrible & devastating disease- that many of you did not know about.There have been deaths from suicide- unexplained causes, or from conditions that have arose after being diagnosed with (Fifro/ME). People who have AIDS, Do not die of AIDS, They die of AIDS related complexes Or (ARC). Diseases that have arose as a cause of the AIDS virus. Unlike pt's that have died of AIDS, I would like to say that we have a better chance, but some of us, Again (SOME) of us do not. It just takes a little longer for (some) of us to end up with a ME related complex. For instance you may get Pneumonia from being bed bound & on Narcotics, & not doing your (turn cough & deep breathing) exercising. Or lets say your pain gets to great & with (Bad short term memory impairment) that most of us have, You take to much medicine! or maybe to many pain killers, & OD.? Well that is some of the explainable ways that People have died from this disease. But what about those who Died from other reasons while being affected by this (PAINFUL DEVILISH BUG) What About Them? Do we know who they are? Do we know there Names? Well the Government does not know them either! & Won't help us with this disease untill somebody Famous, or in Government, dies from one of the many complications of this Virus. Well, what do we do? Well heroes one thing we can do! Lets find out who did die from a FIBRO/CFIDS/ME/IVN related complex & start letting People know! IF YOU KNOW OF A FAMILY MEMBER, OR A NEIGHBOR, OR SOME ONE THAT HAD THE VIRUS & IS NO LONGER WITH US, PLEASE FIND OUT THE DETAILS OF WHAT HAPPENED, & HOW THE VIRUS TOOK THEIR LIVES, & LET ME KNOW. Even if you don't know their Names, but know they had the virus & did die, find out the details & send me an email of what their symptoms were & the probable cause of death, so we can keep track of such occurrences & start informing the Public & GET ON THE GOVERNMENTS BACK & GET SOME HELP FOR ALL OF US WHO SUFFER. Please send me an email, & weather you want it posted or not!

Latest Article: Fibromyalgia / Chronic Fatigue News

News on Medicine A few new treatments offer hope for Chronic Fatigue.: #1. we all know that Vitamin B12 IM -up to 3cc every 72 hours works well for Fatigue. But now A Mixture of B12 & Oxytocin a Drug used to help in - -the delivery room in OB, Helps stimulate the same side of the Brain as B12 does. The mixture of these to Drugs given...