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The question of which infection, if any, is the cause of CFS and fibromyalgia has been both the Holy Grail and bane of CFS/Fibromyalgia researchers. Literally dozens of infections have been implicated, with virtually all of them failing to have reliable testing available to confirm the infection. Because of this, taking a good clinical history, and looking for the response to treatment, continues to be the best approach.

So which infection is the cause of CFS and fibromyalgia? The simple answer? It is not a specific infection, but rather the immune dysfunction. This allows many opportunistic infections, i.e. infections that cannot survive in a healthy immune system, to cause problems.

Our impression is that the body shows many areas of immune dysfunction, including the inability to turn off the immune system even after certain common viral infections have been eliminated. This contributes to overactivity, followed by exhaustion, of the immune system, resulting in multiple “hitchhiker” infections being present.

It is not necessary to treat every infection, but some do need to be addressed. The most important? Candida overgrowth. There is no test that I find reliable for this, but I will treat most people who have CFS and fibromyalgia with six weeks of the medication Diflucan 200 mg a day, combined with a low sugar diet and a weaker antifungal (such as berberine or nystatin) to decrease the risk of developing resistant strains of Candida.

Symptoms that suggest Candida overgrowth include nasal congestion, sinusitis, and/or symptoms of irritable bowel syndrome (gas, bloating, diarrhea, or constipation). In addition, I find that about 15 percent of people with CFS/ FMS benefit from being treated with an extended course of antibiotics, most often doxycycline or Zithromax. Symptoms that suggest that a course of treatment with antibiotics should be tried include:

  1. A fever over 98.6°F—even 99°F—and/or,
  2. Chronic lung congestion,
  3. Recurrent scalp sores which scab,
  4. A history of bad reactions to several different antibiotics (people misinterpret the die-off reaction as being an allergic reaction),
  5. A history of your CFS/FMS transiently improving in the past when given an antibiotic, in which case I will give an extended course of the antibiotic which helped,
  6. Severe vertigo—this is when you feel like you or the room is spinning in a circle and is not to be confused with the disequilibrium experienced by the majority of people with CFS/FMS, and/or,
  7. Severe night sweats that persist after addressing the Candida and hormonal deficiencies.

Many antibiotic sensitive infections, including Lyme disease, can be involved. Unfortunately, the lab tests available for these are unreliable, and I do not consider any of the Lyme tests to be especially helpful. If chronic diarrhea is present, I will do stool testing for Clostridium difficile. This infection was present in 22 percent of people with CFS/FMS in our initial study, and standard lab testing will show if it is present. Treatment is pretty straightforward. I will also use compounded nose sprays for six weeks to treat possible toxin producing nasal staph infections.

For those with chronic flulike symptoms, or the onset of CFS/FMS after an acute flulike illness, I will consider antivirals. If the CMV or HHV-6 IgG blood level is over 4, I consider the antiviral Valcyte combined with Celebrex. Otherwise, using a combination of Famvir 500 mg twice a day plus Celebrex 200 mg twice a day for six months may be helpful.

In addition, I will treat all parasites found on stool testing– even those that are considered unimportant (the medical term is “nonpathogenic”). In the presence of immune dysfunction, all parasites should be treated. Most standard labs do not know how to do proper stool parasite testing, and I will do these stool tests at Genova, DiagnosTechs, or Doctors Data.

Upcoming articles will discuss the treatment of each major category of infections in depth. These include:

  1. antibiotic sensitive infections, including post Lyme syndrome/chronic Lyme disease
  2. Candida overgrowth (including the treatment of chronic sinusitis and irritable bowel syndrome)
  3. chronic viral reactivation
  4. other infections
  5. research and clinical experience showing the presence of IgG 1 & 3 subset antibody deficiencies, and a marked clinical improvement from intravenous gamma globulin in a significant percent of severe and refractory cases of CFS/FMS

We will also discuss how to test for and eliminate food allergies, while getting rid of their underlying causes so they do not come back. For starters, be sure that the Candida overgrowth is addressed. The Candida organisms are very large, often overwhelming the immune system, and also cause “leaky gut,” which can put another major strain on the immune system while triggering food allergies. Addressing adrenal fatigue is also important. Interestingly, common symptoms of severe adrenal fatigue include flulike symptoms with recurrent sore throats, as well as irritability when hungry. The latter has spawned the new term “Hangry.”

In addition to treating the infections, augmenting immune function can be very helpful. Most important? A simple lowcost mineral called zinc, 20 mg a day for four months. Zinc is arguably the most important nutrient for immune function, and is routinely low when chronic infections or inflammation are present, as these cause large zinc losses in the urine. After supplementing for the four months, make sure your multivitamin has 15 mg of zinc in it. Taking the zinc will not result in a dramatic clinical response on its own, as often occurs from treating the infections directly, but it will set the stage to allow your immune system to recover. A number of other treatments can also augment immune function, including a good probiotic (caution-many are not).

Jacob E Teitelbaum, MD

Jacob Teitelbaum, MD, is a board certified internist and Medical Director of the national Fibromyalgia and Fatigue Centers and Chronicity. He is author of the popular free iPhone application "Cures A-Z," and author of the best-selling books

Dr. Teitelbaum knows CFS/fibromyalgia as an insider — he contracted CFS when he was in medical school and had to drop out for a year to recover. In the ensuing 25 years, he has dedicated his career to finding effective treatments.