From Fatigued to Fantastic Newsletter
Vol. 3, No. 3 (2000)--Vol 4, No. 1 (2001)

Fighting Those Persistent Infections in CFIDS
By Jacob Teitelbaum, M.D. 

		Medical science has known for quite some time that Chronic Fatigue Syndrome is associated with changes in the body’s immune system.  In fact, the acronym “CFIDS” stands for “Chronic Fatigue And Immune Dysfunction Syndrome.”  This can result in your having several different and unusual infections at one time.  Many of these infections need to be treated directly.  Other infections will go away on their own as your immune (defense) system comes back “on line” by using our treatment protocol.  In this article, I’ll discuss some of the more common, yet not usually thought of (in “regular” medicine), infections.    

What Kind Of Infections Am I Most At Risk For?

		Although CFIDS of sudden onset often seems to be triggered by viral infections (e.g., EBV, HHV-6, CMV), those infections, I suspect, are “simmering” or no longer active in many cases.  However, the body acts as if they are. This may result in elevated interferon levels.  I suspect this was what triggered my CFIDS.
		The body produces interferon to fight viral infections.  When a cancer or hepatitis patient is injected with interferon, the patient becomes achy, fatigued and brain-fogged.  An under-active adrenal can also cause interferon levels to become elevated.  Because of this elevation, it is more accurate to say that the body’s immune system is not functioning properly, than to say that it is underactive.  Indeed, in many ways, the immune system may be in overdrive and soon exhaust itself.  The immune system malfunctions in many other ways, too, including decreasing the effectiveness of the body’s “natural killer” cells, which are an important defense mechanism.
		Many other recurrent or unusual infections can also occur because of your malfunctioning immune system.  Chronic sinus, bladder, prostate and respiratory infections are common and are often treated with repeated courses of antibiotics.  The large amount of antibiotics introduced into the system can cause a secondary yeast over-growth as it changes the natural balance between the bowel’s healthy bacteria and yeast.  The original immune dysfunction also contributes to the yeast overgrowth.  Although it is controversial, a theory held by many physicians is that chronic overgrowth of yeast due to overuse of antibiotics is a potential and strong trigger for chronic fatigue, fibromyalgia and further immune dysfunction.  What makes the theory controversial is that no definitive tests exist to distinguish fungal overgrowth from normal fungal levels.  Also, many of the symptoms ascribed to yeast overgrowth can also come from the many other problems present in chronic fatigue syndrome and fibromyalgia.  On the other hand, most doctors who try treating yeast in at least three or four CFS patients see how well it works and keep using it. 
		CFIDS patients also frequently have bowel parasite infections.  Bowel parasites can cause severe allergic or sensitivity reactions, which in turn can trigger fibromyalgia and fatigue.  Often, a patient will finally recover from long-standing and disabling fatigue within a week or two after beginning treatment for bowel parasites.
		Many other CFS/FMS patients are left with disabling fatigue after a bout with viral infections such as polio, HHV-6, CMV, or EB viral infections.  This fatigue also usually responds to the treatments discussed in this newsletter.  In addition, infections with unusual organisms such as Rickettsia (e.g., Lymes Disease), chlamydia, and mycoplasma may also be problematic. 

Yeast Overgrowth

		Everyone’s immune system has strong spots, as well as weak spots. Some people never get colds but have frequent bouts with athlete’s foot or other skin fungal infections.  Others never get fungal infections but tend to get colds.  Many people seem to have a diminished ability to fight off fungal infections.
		Fungi are very complex organisms. Fungal overgrowth may suppress the body’s immune system.  The host body may also develop allergic reactions to components of the yeast.
		This allergic reaction was suggested in a study which connects Candida Albicans with Allergic Skin Dermatitis (Eczema).  This study was published in The Journal of Clinical Experimental Allergy back in 1993 (Vol. 23, pp. 332-339).  It found that there is a significant correlation between the body having antibodies to Candida and Allergic Dermatitis/Eczema.  In addition, we have found that unexplained rashes that have lasted for many years often clear up with antifungal treatment as well!  Many physicians feel that yeast overgrowth causes a generalized suppression of the immune system.  In other words, once the yeast gets the upper hand, it sets up a cycle that further suppresses your body’s defenses.  Interestingly, a recent Mayo Clinic study showed that most cases of chronic sinusitis seem to be associated with a reaction to yeast in the sinuses - something I proposed years ago.  None the less, as I already noted, this theory is controversial. Yeast are normal members of our body’s “zoo.”  They live in balance with bacteria - some of which are helpful and healthy and some of which are detrimental and unhealthy.  The problems begin when this harmonious balance shifts and the yeast begin to overgrow.  
		As noted above, many things can prompt yeast to overgrow.  One of the most common causes is frequent antibiotic use.  When the good bacteria in the bowel are killed off by antibiotics (along with the bad bacteria) the yeast no longer have competition and begin to overgrow.  The body is often able to rebalance itself after one or several courses of antibiotics, but after repeated or long-term courses - and especially if the body has an underlying immune dysfunction - the yeast can get the upper hand.  
		Other factors are also important.  Studies have shown that animals who are sleep deprived and/or have increased sugar intake develop bowel yeast overgrowth.  Many physicians feel that eating sugar stimulates yeast overgrowth in people, as well.  Sugar is food for yeast.  Yeast ferment sugar in order to grow and multiply.  Yeast overgrowth due to sugar overuse also seems to cause immune suppression, which facilitates bacterial infections, which then requires even more antibiotic use.  Poor sleep also results in marked suppression of your immune function.

How Does One Know If They Have Yeast?

		There are no definitive tests for yeast overgrowth that will distinguish yeast overgrowth from normal yeast growth in the body.  There is one test which may be useful, though.  This is a Urine Tartaric Acid test done by The Great Plains Lab in Kansas City, Missouri, run by William Shaw, Ph.D.  Tartaric Acid is a waste product of yeast growth.  In fermenting wine, for example, it is critical to remove the Tartaric Acid.  Otherwise, the wine could be toxic to people.  Dr. Shaw has found elevations in Urine Tartaric Acid that decrease with antifungal treatment in both CFIDS/FMS patients and autistic children.  Interestingly, both these illnesses often improve with antifungals (specifically, Sporanox or Diflucan, plus Nystatin).  Dr. Shaw likes to use the Urine Tartaric Acid to decide when to treat yeast overgrowth and to follow-up the effectiveness of treatment.
		In my experience, however, using Dr. Crook’s Yeast Questionnaire (available in my book, From Fatigued To Fantastic!) is still the most reliable way to tell if a person is at risk of yeast overgrowth.  If the symptom score is over 140 points, I recommend treatment.  In addition, anyone who has been on recurrent or long-term antibiotic use (especially Tetracycline for acne) or anyone who intermittently has painful sores in different parts of the mouth that last for about ten days at a time and who has CFIDS/FMS, should be treated with antifungals.  Bowel symptoms are some of the more overt symptoms that are caused by yeast and I feel that most people who have “spastic colon” have yeast overgrowth or parasites.

How Is Yeast Treated?

		A number of very effective methods can be utilized to take care of a yeast problem.  Primary among the methods is to avoid sugar and other sweets.  One can enjoy one or two pieces of fruit a day, but should not consume concentrated sugars such as juices, corn syrup, jellies, pastry, candy or honey.  Stay far away from soft drinks, which have ten to twelve teaspoons of sugar in every twelve ounces.  This amount of sugar has been shown to markedly suppress immune function for several hours.  Be pre-pared to have withdrawal symptoms for about one week when sugar is cut out of the diet.  Several excellent books have been written on the yeast controversy and offer additional methods to try.  One of the best books is The Yeast Connection and the Woman by William Crook, M.D., a physician who has done a spectacular job advancing the understanding of CFIDS/FMS.
		Many patients have found that acidophilus (that is, milk bacteria, a healthy bacteria for the bowel) helps restore balance in the bowel. Acidophilus is found in yogurt with live and active yogurt cultures.  Indeed, one cup of yogurt a day can markedly diminish the frequency of recurrent vaginal yeast infections.  Acidophilus is also available in capsule form.  Although many claims are made for one type of acidophilus being better than the other, I’m not sure this is so.  I usually recommend 3 to 6 billion units a day (1 unit = 1 bacteria) on an empty stomach.  If on antibiotics (not antifungals), take the acidophilus at least 3 to 6 hours away from the antibiotic dose.  
		Nystatin, an antifungal medication, has also been helpful in the treatment of yeast overgrowth. Unfortunately, some fungi seem to be resistant to Nystatin.  In addition, Nystatin is poorly absorbed, which means that it has little impact on the yeast outside of the bowel.  Other anti-fungal medications, such as Diflucan and Sporanox, seem to be effective systemically (throughout the body) but they have two main drawbacks.  First, they are expensive, costing more than $450 to $900 for a two-month course.  Second, any effective anti-fungal can initially make the symptoms of yeast infection worse.  Although uncommon, Sporanox and Diflucan can also cause liver inflammation (as can Advil and Tylenol).  If you are taking Sporanox or Diflucan for more than 6 to 12 weeks, I would consider intermittently checking liver blood tests (ALT and AST).  If you have preexisting active liver disease, be cautious in using (or don’t use) Sporanox or Diflucan.  I strongly recommend taking Lipoic Acid (a natural supplement which protects and helps heal the liver), 200mg a day, whenever you take Sporanox or Diflucan.  I also strongly recommend Lipoic Acid for anyone with active liver disease (e.g., hepatitis) at doses up to 1000mg to 3000mg a day as it may prevent and/or treat cirrhosis.

Natural Yeast Treatments

		Below, I have summarized the nonprescription part of the treatment checklist that I use in my office.
	1.	Avoiding sweets is still the single most important thing.  Using Stevia as a sweetener is a wonderful substitute.  Stevia is a safe, natural remedy and you can use all you want.  There are even cookbooks for using Stevia (available from my office or 800-4STEVIA).  A new natural sweetner, Sweet Balance, also tastes good and is 12 times as sweet as sugar.  It is a natural product from the Lo Han fruit and appears to be safe.  Although it is 70% sugar (fructose), you only need a small amount.  Order it from 877-997-9338, my office at 800-333-5287 or my Web site at www.endfatigue.com.
	2.	Acidophilus or Milk Bacteria can be very helpful.  Take 3 to 6 billion units a day (a unit is the same as a bacteria).  Do not take acidophilus within 3 to 6 hours of an antibiotic.  Take it either on an empty stomach or with milk.  
	3.	Caprylic Acid is another natural remedy that can be helpful.  The usual dose is 1800 to 3600mg a day with 1/3 of the dose being taken at each meal.  Unfortunately, it often causes an acid stomach with a “funky” tasting reflux. 
	4.	Oregano Oil - enteric coated oregano oil - 1 to 2 capsules, 2 to 3 times a day with food, may be more effective and better tolerated than Caprylic Acid (both can cause stomach acid reflux).  
	5.	Fresh Garlic, if you can handle it well, can also be very effective.  Daily, crush 1 to 3 garlic cloves in olive oil, add salt, spread it on bread and eat it.  It can be quite tasty and lethal to whatever infections you have in your gut.
	6.	Olive Leaf 500mg, 2 to 4 capsules three times a day between meals, can also be very helpful in treating yeast overgrowth.
	7.	Pau De Arco in either tea or capsule form is also helpful in yeast suppression.  Although I use Pau De Arco infrequently for yeast over-growth, many people find that it can be helpful.
	8.	Grapefruit Seed Extract (e.g., Citrucidel) is a popular treatment for yeast overgrowth and is well-tolerated.  

More Information On Yeast Treatments

		If symptoms of yeast are caused by an allergic or sensitivity reaction to the yeast body parts, the symptoms may flare when mass quantities of the yeast are suddenly killed off.  This is called a yeast “die-off” reaction.  If you get this reaction, start your treatment with acidophilus and a sugar-free diet for a few weeks followed by oregano oil and/or olive leaf (1500mg to 2000mg, 3 times a day between meals) before beginning Nystatin.   Take Nystatin (by mouth) in the form of 500,000-IU tablets or powder.  I generally recommend beginning with 1 tablet a day for 1 to 3 days, and increasing by 1 tablet every 1 to 3 days (or slower if yeast “die-off” is a problem) until 2 tablets 2 to 4 times a day is reached.  If you get nausea, take a lower dose.  Take Nystatin, 4 to 8 tablets daily, for 5 to 8 months.  I add the Diflucan or Sporanox one month after beginning the Nystatin.  Take 200mg every morning for six weeks. If symptoms flare, take just 100mg per morning for the first 3 to 14 days.  If symptoms recur after stopping the Diflucan or Sporanox, I recommend continuing the medication for an additional 6 weeks at 200mg a day.
		Sporanox should be taken with food.  If it is taken alone, its absorption is greatly reduced.  When taking Diflucan or Sporanox, DO NOT use the antihistamines Seldane or Hismanal, Quinidine (a heart medicine), cholesterol-lowering medications in the Mevacor family, or the bowel medicine Propulcid.  These can be fatal combinations!  Also, antacid medications (such as Tagamet, Axid, Zantac, and Pepcid) prevent the proper absorption of Sporanox.  At the high price of Sporanox per dose, you will want to absorb every last bit of the medication.  If you need to be on an antacid medication, use Diflucan instead of Sporanox.  Unfortunately, a less expensive antifungal, called Lamisil (at 250mg a day), does not seem to work very well for candida yeast overgrowth (although it works well for nail infections).  I am currently trying patients on 500mg of Lamisil a day to see if this dose works better.  
		I feel that once the yeast has been effectively decreased and kept that way for six to twelve months, it is safe to try to add small amounts of sugar back into the diet.  If symptoms recur, however, stop the sugar again. Continuing to eat yogurt with live and active acidophilus cultures (unless you are lactose-intolerant) or continuing to take acidophilus capsules may also help.
		Many books on yeast overgrowth (including Dr. Crook’s) advise readers to avoid all yeast in the diet.  This advice is based on the theory that an allergic reaction to yeast is the cause of the problem.  The predominant yeast that seems to be involved in yeast overgrowth is Candida Albicans, although I would not be surprised if researchers discovered that many other kinds of fungal infections are also involved. The yeast that is found in most foods (except beer and cheese) is not closely related to candida.
		In my experience, trying to avoid all yeast in foods results simply in a nutritionally inadequate diet and little benefit.  Although a few people do appear to have true allergies to the yeast in their food, they number less than 10 percent of my patients with suspected yeast overgrowth.  These patients may benefit from the more strict diet in Dr. Crook’s book. Interestingly, once their adrenal insufficiency and yeast overgrowth are treated, most people find that their allergies and sensitivities to yeast and other food products seem to improve or disappear.
		Nutritional deficiencies such as low zinc or low selenium may also decrease resistance to yeast over-growth.  A good multivitamin supplement, as recommended in my last newsletter, should take care of these deficiencies.  This is further evidence that all the factors involved in CFS are closely interrelated.
		The best thing that one can do to combat yeast overgrowth is to try to avoid it in the first place.  When you get an infection, begin treating it naturally immediately.  Hopefully, you can prevent it from turning into a bacterial infection which might require an antibiotic.  Ask your doctor what measures you can take before resorting to antibiotics.  Many good over-the-counter remedies are available.  A knowledgeable pharmacist may also be a wealth of information.  Your local book or health food store has books on natural measures.  Your health food store proprietor can also steer you to appropriate natural remedies.  For examples of the many helpful measures that one can take, see my newsletter article, Treating Infections Without Antibiotics, page ___).
		If you find however, that you must take an antibiotic, all is not lost.  One can still lessen the severity of yeast overgrowth by avoiding sweets and by either taking acidophilus capsules (again, not within 3 to 6 hours of an antibiotic) or by eating one cup of yogurt with live and active acidophilus cultures daily.  Don’t use the yogurt (or milk) if you have sinusitis or pneumonia because the milk protein thickens mucus and makes it hard for the body to fight these infections.  

How Can One Tell If The Yeast Is Coming Back?    
  
		It is normal for yeast symptoms to resolve after treatment.  After 6 weeks on the Sporanox or Diflucan, patients are usually feeling a lot better, but may have symptoms recur soon after stopping the antifungal.  In this case I would continue the Sporanox or Diflucan for another 6 weeks, or as long as is needed, to keep the symptoms at bay.  More frequently, people will feel better after treatment and stay feeling fairly well for a period of 6 to 24 months.  At that time, it is common to see a recurrence of symptoms, especially if one is eating too much sugar or is taking antibiotics.  The best marker that I have found for yeast overgrowth would be a return of bowel symptoms with gas, bloating and/or diarrhea or constipation.  If these symptoms persist for more than 2 weeks, especially if there is also even a mild worsening of the FMS symptoms, it is very reasonable to retreat yourself with 6 weeks of Nystatin and perhaps Sporanox or Diflucan.  In addition, I would also retreat if there’s a recurrence of vaginal yeast or sinus infections.  If re-treatment resolves the symptoms, one may opt to repeat this regimen as often as is needed  (usually every 6 to 24 months).  By using some of the natural remedies listed above, however, you may be able to avoid repeated use of these antifungals and the possible risk of becoming resistant to them.  Some patients also find that they need to stay on the antifungals for extended periods of time (years) or the symptoms will recur.  When this is necessary, I add the natural remedies.  I will, however, also use the medications when needed.  The main risk of long-term use of the antifungals Sporanox and Diflucan would be liver inflammation.  If these medications are being used for extended periods, consider checking liver tests (SGOT and SGPT) every 3 to 6 months and anytime that a severe flu-like feeling or worsening of symptoms occur.  As noted above, it is very important to take Lipoic Acid 200mg a day when on Sporanox or Diflucan.  Although I am not aware of any studies using Lipoic Acid with antifungals, in my experience I have seen no worrisome elevation on liver tests if patients are using this natural substance while taking these antifungals.  As an alternative, instead of taking the antifungals every day, many people find they can get long-term suppression of the yeast by taking Sporanox or Diflucan 200mg twice a day, one day each week (e.g., each Sunday). 
 	
Help For Chronic Bladder Infections

		Although we will be discussing some unusual infections, CFIDS/FMS patients also get more of the day-to-day variety of infections.  These include Urinary Tract (bladder) Infections (UTI).  The main symptoms of a UTI are discomfort (e.g., burning) when urinating (dysuria), urgency (which is the feeling that you have to go very badly and right away when there is not much urine there), and frequency with low volume.  These symptoms are also common in CFIDS/FMS patients in the absence of bladder infections and, when severe, is called Interstitial Cystitis.  I would not label someone as having Interstitial Cystitis unless this is the major symptom of their CFIDS/FMS, because almost everyone with this illness has some urinary urgency and frequency.  Because bladder symptoms can be seen in both UTI and CFIDS/FMS, it is important to have a urine culture done before treatment with antibiotics to make sure that there is an infection and not just muscle spasms in the bladder that are causing these symptoms.  If there is an infection, over 90% of the time it will be E-coli.  This bacteria is normally found in everyone’s gut and, with the exception of a few rare dangerous forms, is a healthy part of our normal bowel bacteria.  The problem occurs when the E-coli gets out of the bowel where it belongs and into the bladder.  Usually the bladder will wash out most infections when the urine comes out.  The E-coli however, have little velcro-like projections that stick to the bladder wall so that they can not be washed out by urination.
		Taking antibiotics will kill a bladder infection but will also kill the healthy bacteria in the bowel.  This sets one up for yeast overgrowth and other problems.  Because of this, unless there is fever or back pain over the kidneys or a toxic feeling, it is reasonable to try natural remedies for one to three days before going with the antibiotics.  One can start these treatments while waiting for the urine culture to come back.

What Natural Remedies Can Be Used For Bladder Infections?

		There are two excellent natural remedies that can keep the E-coli from sticking to the bladder walls so they can be washed out.  In addition, taking vitamin C in high dose (e.g., 500 to 5000mg a day) can acidify the urine, making it inhospitable to the bacteria.  Drinking a lot of water also helps to wash out the infection.
The two natural remedies that keep the bacteria from sticking are:
	1.	Cranberries—Because approximately 20% of the female population suffers from UTIs, several studies have been done looking at this remedy.  An early study of 44 female and 16 male patients with acute bladder infections drank 16 oz. of cranberry juice a day for 15 days.  Of these patients, 53% had positive responses and another 20% showed modest improvement.  Six weeks after stopping the juice, 27 patients did have persistent recurrent infections and 8 of these had no symptoms.  Seventeen patients had no symptoms and negative urine cultures.  
		In another study of elderly women (who are more likely to have bladder infections), 153 women either received 10 oz. of cranberry drink or placebo every day for 6 months.  The group that got the cranberry drink had 68% fewer bladder infections during that period.  In this study, the juice was sweetened with saccharin instead of sugar.  Other studies have also shown benefit using cranberry juice in bladder infections.
		Significant benefits are achieved by using 6 to 16 oz. of cranberry juice a day.  Because cranberry juice has a lot of sugar and can promote yeast overgrowth and aggravate other symptoms in CFIDS/FMS, I think it is much better to use pure cranberry juice powder in capsule or tablet form (standardized to contain 11% to 12% quinic acid).  The therapeutic dose is 1 to 2 capsules a day.  Conversely, you can use unsweetened cranberry juice and add Stevia as a natural sweetener.  In general, if one gives the usual cranberry juice cocktails a strength of 1 unit - then, cranberry juice drinks have a strength of ½; cranberry sauce a strength of ½; fresh or frozen cranberries are 4 times as potent; pure cranberry juice is 4 times as potent; and cranberry juice capsules from unsweetened cranberry juice powders are 32 times as potent.  
		Cranberries work to help bladder infections because they have a chemical (proanthocyanidins) that prevents the bacteria from sticking to the bladder wall.  They may also decrease the risk of kidney stones (although magnesium with B6 is much better for this), as well as possibly reduce urine odor.
2.	D-Mannose - This is more effective than cranberry juice.  Mannose is a natural sugar (not the kind that causes symptoms or yeast overgrowth) that is excreted promptly into the urine.  Unfortunately for the E-coli bacteria, the fingers that stick to the bladder wall stick to the D-Mannose even better.  When one takes a large amount of D-Mannose, it spills into the urine, coating all the E-coli’s little “sticky fingers” so that the E-coli are literally washed away with the next urination.  The nice thing about the natural approach, as opposed to antibiotics, is that the cranberries or D-Mannose will not kill the healthy bacteria, thereby not bothering the normal balance of bacteria in the bowel.  In addition, the D-Mannose is absorbed in the upper gut before it gets to the friendly E-coli that are normally present in the colon.  Because of this, it helps clear the bladder without causing any other problems.  In addition, the D-Mannose even tastes good. 
	The D-Mannose is quite safe, even for long-term use, although most people will only need it for a few days.  Those who have frequent recurrent bladder infections may, however, choose to take it every day.  The usual dose of D- Mannose is 1/2 teaspoon every 2 to 3 hours, while awake, to treat an acute bladder infection; and 1/4 to 1/2 teaspoon 3 to 4 times a day to prevent severe chronic bladder infections.  It is best taken dissolved in water.  For those who get bladder infections associated with sexual intercourse, one can take 1/2 teaspoon of D-Mannose 1 hour before and then just after intercourse to prevent an infection.  Remember, though, the D-Mannose (and cranberries) only work in the 90% of bladder infections caused by E-coli bacteria.  D-Mannose is available from several sources:
	1.	The Tahoma Clinic Dispensary (253-850-5661), which is associated with the well-known nutritional physician, Jonathan V. Wright, M.D.
	2.	The Biotech Company (800-345-1199).
	3.	My office (800-333-5287)  or my Web site at www.endfatigue.com. 
		The usual cost of D-Mannose is approximately $60 for 100 grams and $35 for 50 grams.  A 1/2 teaspoon is approximately 2 grams.  One should feel much better within 24 to 48 hours on D-Mannose.  If not, see a doctor for a urine culture (you may want to get the culture at the first sign of infection) and consider antibiotic treatment after two days if the culture is positive.  Some evidence exists that Macrodantin causes less yeast over-growth than do other antibiotics.  Even with other antibiotics, most bladder infections are knocked out by one to three days of antibiotic use (instead of the old seven-day regimen).

Prostatitis

		Although women tend to be the ones plagued with bladder infections, men don’t get off unscathed either.  It is very common in men with CFIDS/FMS to have Prostatitis.  Prostatitis is an inflammation or infection of the prostate which is usually seen in younger men between the ages of 20 and 50.  It falls into three main categories:
	1.	“Bacterial” Prostatitis is a acute or chronic infection in the gland that causes prostate swelling and discomfort.
	2.	Nonbacterial Prostatitis is when you feel swelling of the prostate without being able to detect an infection.  My suspicion is that it is not uncommon for prostatitis to be associated with yeast overgrowth or other infections that cannot be cultured (tested for). 
	3.	Prostadynia is a general irritation of the prostate which causes urinary burning, urgency and frequency but without there being any infection or swelling of the prostate.  This can come from a number of causes including, I suspect, chronic spasm or tightening of the muscles of the pelvic floor.  
	The symptoms of chronic Prostatitis can come and go and be mild or severe.  The symptoms include:
	1.	Pain or tenderness in the area of the prostate.  It is also common to have burning on the tip of the penis.
	2.	Discomfort in the groin and, occasionally, lower back pain.
	3.	Urinary urgency and frequency with pain on urination. 
	4.	Sometimes a slight penis discharge.  If the discharge is cloudy and larger than one drop, or even a large drop, it is most likely a bacterial Prostatitis and I would then prescribe antibiotics.  If a discharge is present, I would also check to make sure that there is not also a sexually transmitted disease (such as Chlamydia or Gonorrhea) before beginning treatment. 
	5.	Pain with ejaculation.  
		If severe symptoms with fevers, chills and extreme fatigue are present (symptoms of acute Prostatitis), antibiotics should be used.  The main treatment for bacterial Prostatitis consists of using the antibiotics Tetracycline (e.g., Doxycycline), Cipro, or Sulfa (Bactrim or Septra DS).  Unfortunately, since it is hard for the antibiotics to be absorbed into the prostate, the symptoms often recur even after six weeks of treatment.  If antibiotics are required, use Doxycycline or Cipro because these may be effective against other hidden infections that can cause CFIDS/FMS.  
		Although there are a number of causes of Prostatitis, excess caffeine, alcohol and spicy foods can also contribute to the symptoms.  Sitting for long periods while traveling (e.g., being a truck driver) can also cause irritation of the prostate.  Although normal bacteria are common causes, a few bacteria transmitted through sexual contact can also cause Prostatitis.  Some feel that the main psychological component of Prostatitis is shame.               

Bowel Parasite Infections

	A while back, the news focused our attention on Milwaukee because of repeated fatal outbreaks of an infection by a bowel parasite called Cryptosporidium.  A cartoon even made the rounds showing Mexican tourists being warned not to drink the water in Milwaukee!  Although this infection usually resolves on its own within a week or two, it may persist in those with immune suppression.  In fact, people with acquired immune deficiency syndrome (AIDS) are particularly susceptible and scores of Milwaukeens died from the Cryptosporidium outbreaks.
	Unfortunately, in many places throughout the United States, the water supply is contaminated, and parasites are no longer just a Third World problem.  Doctors frequently see cases of infection by giardia, amoeba and numerous other bowel parasites.  Parasitic infections can mimic CFS and, in immune suppressed situations like CFS, all parasites should be treated.
	Most laboratories miss the parasites when they do stool testing.  I initially tested for bowel parasites by sending my patients’ stool samples to a respected local lab.  The tests kept coming back negative, so I eventually stopped testing.  Finally, I started doing my own laboratory stool testing.  Doing the test properly was very time consuming, taking up to five hours per specimen.  However, processing it properly, my tests frequently turned out positive.  In my experience - and in that of other physicians as well - when you treat a patient for parasites, the patient’s fatigue and achiness often improves dramatically.
	If you would like your stool tested, make sure that the lab specializes in stool testing and that the sample is a purged specimen.  A purged stool specimen is watery and loose, brought about by the use of one-and-a-half ounces of Fleet’s Phospho-Soda (a laxative).  The purpose of the stool purge is to get the best possible stool sample to check for bowel parasites and yeast.  The laxative washes the organisms off the walls of the intestines so that they can be detected.  The routine random tests performed in almost all standard labs are generally not adequate or reliable.  In speaking with several lab technicians, I was told they had less than one hour of training in looking for parasites—which they found to be useless.  In fact, during one of our “doctors’” poker games, I spoke with a gastroenterologist friend who noted that during a certain bowel exam he had performed, he saw a large number of parasites swimming in the patient’s large bowel.  He removed a big glob consisting of nothing but mucus and parasites and sent it off to the major local laboratory, just for confirmation of the infection and identification of the parasite.  Even this sample came back negative for parasites!  This is why I stress that stool testing must be done at a lab that specializes in parasitology.  Because two excellent labs are now available to me to mail specimens to, I no longer have to do the testing in my office.  These labs are The Parasitology Center, Inc. (480-777-1078) and The Great Smokies Diagnostic Laboratory (800-522-4762).
	At this point, no consistently effective prescription medication is available for Cryptosporidium infections.  Artemisia annua, however, is an effective herbal treatment. For most of my patients, I recommend using 1,000 milligrams three times a day for twenty days.  Leo Galland, M.D., a parasite specialist, recommends a form of Artemisia called tricyclin for many parasitic infections. He recommends taking 2 tablets, 3 times a day after meals for six to eight weeks.  The cost of this antiparasitic herbal preparation is about $30 for fifty tablets.  See the treatment protocol below for regimens for some other parasitic infections.  The doctor who runs The Parasitology Center also has a review article discussing which natural remedies are effective against each type of parasite.  Common parasite treatment regimens also used in our office are on the treatment checklist below.

Antiparasitic Treatments

1.	Flagyl (Metronidazole) – 750 mg, 3 times a day for 10 days, followed by Yodoxin for many parasites.  For Clostridium Difficile take 250 mg, 4 times a day, or 500 mg, 3 times a day.  It may cause nausea and vomiting (uncomfortable but usually not worrisome).  Do not drink alcohol while on this medication as it will make you vomit.  The SR (sustained release) form is easier on the stomach (as is the brand-name form).  If you get numbness or tingling in your fingers (or it worsens if you usually have it) stop the Flagyl.

2.	Yodoxin (Iodoquinol) – 650 mg, 3 times a day, for 20 days after Flagyl is completed.

3.	Tinidazole – 2000 mg, once daily, for 3 consecutive days with food (for Entamoeba Histolytica) – OR -  3 doses, each 2 weeks apart (for Giardia or Dientamoeba Fragilis); Available at Clark’s Pharmacy (800-480-3432).

4.	Humatin (Paromomycin) – 500 mg, 3 times a day, for 10 days (for Cryptosporidium).  For Blastocystis add Yodoxin.

5.	Zithromax – 250 mg, once a day on an empty stomach for 10 days, along with Bactrim, 1 tablet twice a day for 10 days (alternate treatment for Cryptosporidium).  Add Artemesia.

6.	Bactrim DS - 1 tablet, twice a day, plus Yodoxin 650 mg, 3 times a day with food for 10 days.  Do not take Folic acid supplements (e.g., B Complex or multivitamins) during these 10 days (for Blastocystis).

7.	Amphotericin B – 100 mg, two times a day, plus Tinidazole 500 mg, twice a day, plus Furoxone (Furazolidone) 1 tablet, twice a day.  Take these three together with food for 5 to 7 days (Amphotericin B and Tinidazole are available from Clark’s Pharmacy 800-480-3432) (treatment for refractory Blastocystis).

8.	Lactoferrin – 350 mg, 1 to 3 capsules at bedtime. 

9.	Multi-pure Water Filter - Most other filters (except for reverse osmosis) are ineffective.  (Available from Bren Jacobson, 410-224-4877).

10.	Artemesia Annua (a herbal antiparasitic) – 500 mg, 2 tablets, 3 times a day for 20 days.

11.	Tricyclin (a herbal antiparasitic) - 2 tablets, 3 times a day, after meals for 6 to 8 weeks (concentrated Artemesia).
	
12.	Colostrum (mother’s milk) - 3 capsules, 3 times a day, for 8 to 12 weeks.  Then stop or use the lowest dose needed for symptoms.  If nausea or indigestion occurs, lower the dose to a comfortable level for 1 to 2 weeks until it passes.  Take on an empty stomach.
	
13.	Quinacrine – 100 mg a day for 5 days.  May be useful for empiric therapy of suspected but not identified parasites (controversial).

14.	Albendazole – 400 mg a day for 5 days.  May be useful for empiric therapy of suspected but not identified parasites.

Filter Your Water

	Water filters can be very helpful in the fight against parasitic infection. However, not all units are designed to filter out parasites. For a water filter to remove parasites, it must have a submicron solid carbon block filter.  A good example is the Multi-pure Filter.  Check the Consumer’s Digest and Consumer’s Report for other good units.  Multi-pure Filters are available from Bren Jacobson at 888-801-8176 or 410-224-4877.  He is a very reputable and knowledgeable person and does not believe in “high pressure sales” (again, I get no money from people or companies whose products I recommend). 
	When shopping around for a water filter, request the National Sanitation Foundation (NSF) International Listing for the specific unit you are considering. NSF is an independent not-for-profit organization that tests and certifies drinking water treatment products.  The unit you buy should meet both NSF Health Effects Standard 53 and NSF Aesthetics Standard 42, with Class I reduction of chlorine and particulate matter.  Any unit that does not meet both of these standards, particularly the health standard, is not adequate.  To verify that a unit does meet these standards, call the NSF at 313-769–8010.
	In addition to verifying that a water filter meets the NSF standards, ask to see its Product Performance Data Sheet.  Many states require that this sheet be given to all prospective customers of drinking water treatment devices.
	Ask about the range of contaminants that the unit can reduce under NSF Health Effects Standard 53.  Most units certified under Standard 53 list only turbidity and cyst reduction.  The number of units that also reduce pesticides, trihalomethanes, lead, and volatile organic chemicals is very small. Make sure that the water filter you are considering can remove the specific contaminants that concern you.
	Ask if the unit is licensed in such states as California, Colorado and Wisconsin.  These states have some of the toughest certification procedures in the United States.
	Finally, ask about the unit’s service cycle, which is stated in gallons of water treated.  Find out how often you will need to change the filter and what the replacement filters cost.
	As the American water supply becomes more contaminated, parasitic bowel infections will likely become more common.  These infections, as well as the overgrowth of yeast or toxic bacteria caused by antibiotic use, contribute to feeling poorly.

The Role Of Other Infections In CFIDS/FMS

	Many infections have been found in CFIDS.  That people may have not just one, but several of these simultaneously is significant.  It suggests that although these infections may be a trigger, in most patients the immune system is suppressed and therefore they become a setup for unusual infections that persist.  These infections may then “drag you down,” further suppressing your immune system. 
	Fortunately, most people improve (and often get very healthy) by simply treating the sleep, hormonal, nutritional and yeast problems.  Once these areas are treated, your body can usually eliminate any persistent infections by itself.  A subset, though, have infections that need treatment with antivirals and/or antibiotics.

How Can I Tell If I Need These Treatments? 

	First, I would try the other approaches discussed in my From Fatigued To Fantastic! book and newsletters.  I would try these treatments if symptoms persist:
	1.	Those with predominantly flu-like symptoms with debilitating fatigue and little or no pain or fever are more likely to have an underlying persistent viral infection (e.g., HHV-6, Epstein Barr, CMV, etc.).
	2.	Those with fevers (i.e., anything over 98.6°F in this illness - even 99°) and/or lung congestion, sinusitis, skin pustules or other chronic bacterial infections seem more likely to have infections (i.e., bacterial, Mycoplasma, or Chlamydia) that respond to special antibiotics.  Let’s look at these two groups and how to approach them.

HHV-6 And Other Viral Infections

	HHV-6 (Human Herpes Virus 6) is a virus that is related to the Epstein Barr Virus (EB), Cytomegalovirus (CMV), and also to the Herpes Viruses that causes cold sores and Genital Herpes.  HHV-6 is transmitted like the common cold and many people have had it, as well as the EB Virus and the Cold Sore Virus by the time they are twenty years old.  The body usually gets rid of all of these viruses on its own.  Because of this, if you do routine (IGG) antibody testing, almost everybody will be positive for EB and many for HHV-6 and CMV viruses.  However, the IGG test will not tell you if you have active infections unless the IGM antibody is also positive (suggesting a new infection).  The IGM antibody is the one that increases in the first six weeks of an infection.  This is followed by an elevated IGG antibody, which stays elevated your whole life and acts as your body’s surveillance system.  All an elevated IGG means is that your body has seen this infection and, if it sees it again, it’s ready to knock it out quickly.  This is how immunizations work.  The immunization creates the IGG antibody, so that instead of taking one to two weeks to gear-up to fight the infection, your body can eliminate that infection very quickly.  Unfortunately, in CFIDS you can have a chronic low-grade infection—even if your IGG antibody is positive (elevated) - making the IGG antibody test for HHV-6, EB Virus and CMV unreliable in CFIDS/FMS.  In addition, the IGM antibody will usually not be present in elevated levels in the low-grade infections with these viruses that may be seen in CFIDS and FMS.  
	What makes this important is that Valtrex at high-dose can eliminate Epstein Barr virus, but will not work if active HHV-6 or CMV infection is present.  As I will discuss later, the only tests I would rely on to diagnose active HHV-6 are “rapid cell cultures” or PCR testing.  Because some insurance companies are more likely to pay for IGG than PCR testing, an argument can be made for checking IGG antibodies first.  If the EBV IGG is positive and HHV-6 and CMV IGG are negative, one may choose to proceed with Valtrex 1000mg, 4 times a day, for 6 months, without PCR testing.  If the HHV-6 or CMV IGG antibodies are positive, then check the CMV and/or HHV-6 PCR tests to be sure they are negative.
	
Tell Me More About HHV-6 And CFIDS

	Unfortunately there is no currently accepted standard treatment for the HHV-6 Virus.  Even though it is related to other Herpes viruses, HHV-6 is resistant to Acyclovir, Valtrex, Famvir and the other antivirals that are commonly used in Herpes infections.  The only antiviral known to be effective against HHV-6 is Ganciclovir.  This has significant side effects and has to be given intravenously and possibly forever to maintain the antiviral effect.  Unfortunately, this is not a viable option in day-to-day life and has been only moderately successful when used.  The main doctor who has been using Ganciclovir to treat HHV-6 in the United States is Joe Brewer, M.D., (816-531-1550) in Kansas City, Missouri.  He found that 140 out of 207 CFIDS patients had positive HHV-6 cell cultures.  Forty percent of CFIDS patients were positive on their first test and 70% were positive after three tests.  This contrasts to 60 healthy patients he checked in which none of the HHV-6 tests were positive.  Cultures are more likely to be positive during acute flares of the disease, when the viral level in the blood rises (see Page 9 for more on HHV-6 PCR testing).
	As is often the case in CFIDS, there is conflicting data on infections in Chronic Fatigue Syndrome.  A recently published study (Reeves WC, et al., Clin Infect Dis, 2000 July; 31 [1] pp48-52) examined 26 patients with Chronic Fatigue Syndrome and 52 healthy patients in Atlanta, Georgia, at the CDC.  In this study, several tests for HHV-6 and HHV-7 were done, including Polymerase Chain Reaction (PCR).  HHV-6 DNA was found in 11% of CFIDS patients and 28% of healthy patients, suggesting that the HHV-6 was actually less common in Chronic Fatigue Syndrome than in healthy patients.  At this time, as the conflicting data shows, although HHV-6 may be one of many suspect infections in CFIDS, it is not yet clearly the cause of this illness.  
	When HHV-6 is present, it seems to infect the natural Killer Cells, important cells in your body’s defense (immune) system that are critical in fighting infections.  A number of studies have shown these Killer Cells to be malfunctioning in CFIDS.  HHV-6 infection does not necessarily decrease the number of the natural Killer Cells but does decrease their function.  Natural Killer Cell function is described in what is called Lytic Units—which means the ability of cells to lyse or break down foreign invaders.  An average person will have a Lytic Unit level of 20 to 250 with over 80% of healthy patient being over 40 units.  Dr. Brewer finds that in CFIDS the mean Natural Killer Lytic Cell level is 12 units.  Dr. Brewer uses Specialty Labs in California for his Natural Killer Lytic Cell testing and finds that the Lytic level stays the same on repeat testing and seems to be a reliable test for Natural Killer Cell function testing in CFIDS.  Lytic unit levels will, however, decrease during flares of symptoms.  In Dr. Brewer’s experience, this test is very specific for CFIDS and Multiple Sclerosis.  He has treated ten MS patients and five CFIDS patients with the I.V. Ganciclovir.  He found that it helped to stabilize the MS patients.  In the CFIDS patients, two to three were much improved, one still had a positive viral culture and one had a poor response.  Unfortunately, maintaining patients on I.V. Ganciclovir forever (as noted above) is not a viable option.  Fortunately, an oral pill form of Ganciclovir (Valganciclovir) is currently being developed!  It should be noted that the HHV-6 virus is similar to CMV (Cytomegalovirus), and that whatever is effective against one, tends to be effective for the other.  This is a helpful bit of information as we follow new research looking for clues on how to eliminate HHV-6 infection.

What Roles Does The Epstein Barr And Cytomegalovirus Play In CFIDS?

	Again, the roles of the EB and CMV viruses are not clear.  It is not uncommon for antibody levels of these viruses to be elevated in Chronic Fatigue Syndrome.  As noted above, it is not clear whether this simply reflects a previous or ongoing infection with these viruses.  Research by a husband and wife team (the Glasers) at Ohio State University, suggests that Epstein Barr Virus is still quite active and playing a role in many patients with these infections.  In addition, work by Martin Lerner, M.D., also suggests that EB Virus and CMV are active as well.  In speaking with Dr. Lerner’s research assistant, I found out that he has found EB Virus and CMV to both be fairly common in patients with Chronic Fatigue Syndrome (with and without pain).  He found that about 20% had positive IGM and/or elevated EA (early antigen) tests to the EB Virus with negative Cytomegalovirus.  Of these, two-thirds improved with high-dose Valtrex (an oral antiviral).  Despite my teasing and prodding, his associate refused to give out the dose of Valtrex they prescribed because Dr. Lerner does not want to be responsible for people using these higher doses until he completes the double-blind trial that is currently in progress.  On the other hand, another study of his did use 1000mg, 4 times a day, giving the antiviral for 6 months.  It takes about 3 to 4 months before patients start to improve and after 6 months people can stop the Valtrex without the symptoms coming back.  However, if there is no improvement in 6 months, consider it to be a negative result.  They also found that, as noted above, the IGM is almost always negative using the reagents used in most labs.  They found that only Epstein Barr IGM antibody testing, using a reagent by the Diasorin Company (800-328-1482), has been useful in showing a significant number of positive tests.  When we called the company, the only lab in the Washington, D.C., area using it was at the NIH.  The company may, however, be able to give you the name of a lab near you that can do the test.  What was fairly common, though, (and present in most patients) was either positive tests for Epstein Barr, CMV, or a combination of both as noted above.  When CMV or HHV-6 are present, the Valtrex is less likely to work because it is not effective against these viruses.  
	In another study done by Dr. Lerner (Infectious Diseases In Clinical Practice, 1997; 6:110-117) he found that patients who had elevated CMV IGG antibodies, but no significant evidence of associated Epstein Barr virus (i.e., negative IGM and early antigen (EA) antibody total less than 40), did improve with I.V. Ganciclovir at 5mg per kg of body weight given every 12 hours I.V. for 30 days.  In this study 72% (13 of the 18 patients) improved markedly at the end of a month without any significant side effects.  As noted, an oral form of Ganciclovir is currently in development as well.  It should be noted that 36% of the Chronic Fatigue Syndrome patients that Dr. Lerner checked (18 out of 50) did turn out to have elevated CMV antibodies (albeit IGG) in the absence of IGM and EA antibodies to EB Virus (i.e., no evidence of active Epstein Barr Virus).  It should be noted, though, that 70% of healthy patients also had positive IGGs to CMV (as per our discussion above) in the study and appears that the overall level of the IGG was not much higher overall in the Chronic Fatigue group than in the healthy controls.  On the other hand, the higher the level of CMV antibody in the Chronic Fatigue group, the more likely they were to improve with the I.V. Ganciclovir.
	What this means is that patients with Chronic Fatigue Syndrome don’t necessarily have different blood tests for antibody levels than healthy people for these viruses.  However, if one has a higher level rather than a lower level, one is more likely to improve with the Ganciclovir.  Previous research has not shown benefit from antiviral therapies in CFS (Straus SE, et al., New England Journal of Medicine 1988; 319:1692-1698).  Our experience using a fairly high dose of Valtrex or Famvir (1500mg and 2250mg a day respectively) also showed no significant improvement on these regimens after 6 weeks, at which time we considered it to be ineffective.  On the other hand, Dr. Lerner’s research is suggesting that perhaps we gave it for too short a time and at too low a dose.  When treating himself and a few other patients, he used Valtrex by mouth at a dosage of 1000mg, 4 times a day, for 6 months.  Using the higher dosing and the extended period of time, as well as separating out groups that have Epstein Barr Virus (sensitive to the oral Valtrex) without CMV or HHV-6 (resistant to oral Valtrex but sensitive to I.V. Ganciclovir), may make an important difference in making treatment effective.  No major Valtrex toxicity was seen.  As noted above, a double-blind study is currently in progress and we are beginning to try the higher dose of Valtrex in the 15% of our patient population that have not improved adequately and have positive EBV, and negative CMV and HHV-6 tests.  We hope to give you follow-up information on the treatment’s effectiveness as soon as we know!
	In addition, Dr. Lerner suspects that these infections affect the heart muscle contributing to much of your symptoms.  I am not convinced that this is the case because EKG changes are common in CFS.  This can occur because the autonomic (brain) dysfunction and hormonal changes seen in CFS can cause these same EKG changes without heart damage.  Regardless, he found that these changes went away with treatment (as has been our experience in treating Chronic Fatigue Syndrome—patient’s EKG changes improve even without antivirals).  Dr. Lerner is currently recruiting patients for a double-blind study using the high-dose Valtrex.  His phone number is 248-540-9688 in Beverly Hills, Michigan.
   
Does This Mean There Is Nothing We Can Do Now?      

	Although there is no currently accepted specific treatment for the CMV and HHV-6 viruses, there are still a number of things that may be very helpful in fighting this infection.  

1.  	Lithium tends to be antiviral and has been shown to decrease pain in FMS patients when added to treatment with Elavil.  Lithium is commonly used in manic depressive illness and is a natural mineral despite being sold by prescription.  In high doses, it can cause some neurologic symptoms and suppression of the thyroid gland, but these can usually be treated by taking a small amount of Essential Fatty Acids and thyroid hormone.  Lithium might also worsen Restless Leg Syndrome.  Although we have no direct evidence of Lithium being an effective antiviral against HHV-6, it may well be effective because it works against a number of other viral infections.  In our experience, 200mg to 600mg a day seems to be the effective dose in treating FMS patients.  As noted above, I would check the thyroid blood tests at 3 months, 6 months and then yearly (check a Free T4 and a Total T3 - not a TSH).  A Lithium level should also be checked at the same time to be sure that it not above the upper limit of normal.  The level can be below the normal range, which is fine as long as the treatment is effective.  You may find that you can lower the Lithium dose after you have been on it for several months.

2.  	Heparin (a blood thinner, see Page 12) also has antiviral properties.

3.	It is worth considering trials of high-dose Valtrex.  It should be noted that 1000mg, 3 times a day, is used for shingles in older patients and appears to be quite safe.  On the other hand, higher dosing at 8 grams a day in AIDS patients did result in uncommon (under 2%) life threatening problems.  This is common even with day-to-day drugs in AIDS patients (for example, regular sulfa antibiotics have often resulted in severe toxicity in AIDS patients).  Nonetheless, we will be limiting the dose to 1 gram, 4 times a day, in our practice.  It is important to note that taking Tagamet and/or Probenecid (Benemid) will raise the blood level of Valtrex.  Tagamet has powerful immune modifying properties and is very helpful in acute cases of Epstein Barr (mono) infections.  Because of this, we are adding Tagament 300mg, 4 times a day (but not Probenecid), to the Valtrex.  As I noted, we are beginning this treatment with some of our patients and will let you know what we find.

Natural Remedies

	1.	Olive Leaf - This is an herbal which is known to have a wide spectrum of anti-infectious activity.  It has been shown to be effective against the HHV-6 virus in the test tube.  I have not, however, seen studies testing its effect in human beings infected with HHV-6.  Nonetheless, a number of physicians have found that using Olive Leaf in Chronic Fatigue Syndrome is very effective.  There is controversy over whether the form and source of the Olive Leaf is critical.  We recommend that you use a form that has at least 6% Oleuropein, which is one of the most active antiviral components in the Olive Leaf.  Other components may be important and some people also feel that you must use the Mediterranean Olive Leaf  vs. the American Olive Leaf.  Other people argue that you should have a form that is organically grown, without pesticides.  At this point it is not clear whether this is simply marketing or important in day-to-day life.  Nonetheless, I would be picky about the companies you buy the Olive Leaf from.  I would use one of these sources: 
	a.	My office (800-333-5287) or my Web site at www.endfatigue.com.
	b.	Pacific Research Labs (800-325-7734).  This is owned by R. J. Marshall, Ph.D., who has done a fair bit of work treating CFIDS patients with Olive Leaf.  I will be describing the protocol that he uses below.
	c.	General Nutrition Centers (GNC). 
	Dr. Marshall feels that during infections, the body becomes overly acidic.  He tests the morning urine specimens with pH paper (which is very easy to do at home) and gives a shell extract, which raises the body’s alkalinity.  He feels that having a normalized acid-base balance in your body helps it to fight infections.  He then adds his form of Olive Leaf, called Infectostat (which also contains mushroom extracts to stimulate the immune system), giving 3 to 4 capsules, 3 to 4 times a day, to help fight the infections.  Usually, the patient should start feeling better within four weeks on this protocol.  Although we have found it helpful in fighting colds and other common respiratory infections, we are just starting to explore Olive Leaf’s use in a few of our patients who have not responded to standard treatment and are still quite ill.  We will let you know our experience with this in an upcoming newsletter issue.  My guess, though, is that simply using regular (6% Oleuropein) Olive Leaf 500mg capsules, 3 to 4 capsules, 3 to 4 times a day between meals, will probably be equally effective and cheaper for most people than the expensive forms.  How long one needs to take Olive Leaf in Chronic Fatigue Syndrome is yet to be determined.  
	Initially, a pharmaceutical company was developing the Oleuropein in Olive Leaf as an antiviral.  Because it gets bound to the blood proteins, they thought that Oleuropein might not get to the tissues.  More importantly, Oleuropein is a natural product and therefore hard to patent.  Because of these problems, they stopped research on it.  Years later this research was rediscovered and explored further.  In addition to being an effective antiviral agent, Olive Leaf is reported to be effective on a number of bacterial and yeast infections as well.  What is most exciting regarding the Olive Leaf is:
	a. 	That some doctors have found it to be effective in CFIDS, and 
	b. 	That in tests against HHV-6 and CMV virus (remember that if something is effective against one, it tends to be effective against the other) the Olive Leaf extract did not just suppress the virus but killed it.  That is very promising.

2.	Pro-Boost - Thymic Protein A (used to be called BioPro) -  This is the immune stimulant that I discussed in my newsletter, Vol. 2, Issue 2.  Although not a hormone, Pro-Boost mimics the natural hormone produced by your Thymus - the gland which stimulates your immune system.  I find it to be extraordinarily effective in fighting common infections of any kind that seem to pop up.  For the more deep-seated infections of CFIDS, the higher dose (1 packet, 3 times a day) will likely be needed.  Once the infection seems to be in check and you are feeling better (i.e., after 6 weeks), you can taper down to the lowest dose that maintains the effect. 

3.  	IP6 - This natural immune stimulant is an extract of bran (phytates).  It is less expensive and is sometimes combined with vitamin C.  The dose of IP6 (available from many sources) is 5 to 8 grams a day.  Do not take IP6 within 3 hours of vitamin/mineral supplements.

4. 	MGN3 - This is a very concentrated mushroom extract, which has been shown to stimulate Natural Killer Cell immune function.  In one study, it actually tripled Natural Killer Cell function—an effect that, as the HHV-6 virus can suppress Natural Killer Cell function, could be very powerful.  Unfortunately, it is horribly expensive in the recommended dose (250 mg capsules) of 2 to 4 capsules, 4 times a day for 2 weeks, followed by 2 capsules, 2 times a day.  Other mushroom extracts are cheaper but may not be as effective. 

5.   Intravenous Vitamin C at high-dose (15gm to 50gm) has been suggested to have antiviral effects in a number of other infections and is often dramatically helpful in CFIDS when given in the I.V. nutritional therapy called “Myers Cocktails” (see my newsletter, Vol. 3, Issue 3).

6.	Lysine 1000 mg, 3 times a day - This amino acid protein is safe and inexpensive (27¢ a day).  It inhibits oral/genital herpes (by depleting the Arginine the virus needs to grow).  I do not know if it also inhibits EBV, HHV-6 or CMV viral infections.
	I would take the combination of these together (as is affordable)—perhaps leaving the MGN3 for later if needed, giving the treatment for at least a 6 to 8 week trial to see if it’s effective.  If you are feeling better at 6 weeks, you can then taper down the dose slowly as long as the benefit is maintained.  When able, you can wean yourself off the treatments.  If symptoms recur, go back up to the dose that maintains the benefit or consider increasing the dose further.  As we are just starting to use this protocol in our patients, I do appreciate your feedback on what has worked for you and what has not.  You can “vote” for what helped or didn’t help you on our Web site at www.endfatigue.com.  You can also see other people’s votes. 
	In addition, your clotting system may be activated by several infections making it difficult to eliminate them.  Using the anti-clotting treatments that we will discuss later can also make it easier for your body to eradicate infections.

Mycoplasma And Chlamydia   

	Other infections have also been found to be very important in CFIDS.  Dr. Garth Nicolson and his wife, who were on-faculty at the University of Texas Medical School at Houston and the Department of Microbiology and Immunology at Baylor College of Medicine in Houston, Texas, are the leading proponents of treatment of these infections.  Dr. Garth Nicolson was an endowed chair and department chairman at the University of Texas, the M.D. Anderson Cancer Center in Houston, Texas, and a Professor of Internal Medicine at the University of Texas Medical School, also in Houston.  Dr. Nicolson’s wife had Chronic Fatigue Syndrome years ago.  They were surprised that her test turned out to be positive for Mycoplasma fermentans (also known as Mycoplasma fermentans incognitus).  This Mycoplasma was found to be resistant to the Penicillin- and Keflex-family antibiotics that most doctors use, but was sensitive to long courses of Doxycycline and Cipro.  After an extended course of Doxycycline treatment, she was much better.  The Nicolsons then went on to develop their own tests for Mycoplasma using PCR testing.  Dr. Nicolson tells me that, in addition, when his step-daughter came home after serving in Desert Storm, she came down with Gulf War Illness (GWI).  They tested hundreds of Gulf War veterans with GWI and 40% to 45% were positive for Mycoplasma infections—almost all with Mycoplasma fermentans.  This has been confirmed by other labs and a large Veterns Aministration study involving over 2,000 patients.  In contrast to this, soldiers who were not deployed to the Gulf during the war, had less than a 6% incidence of being positive for these infections.   
	Interestingly, the Nicolsons  found that in patients with Chronic Fatigue Syndrome or Fibromyalgia, approximately 70% (144 out of 203 patients) had a positive PCR test for one, or usually several species, of Mycoplasma. When the Nicolsons tested 70 healthy patients, only 6 patients (less than 9%) were positive for any of the Mycoplasma species.  This is a highly significant difference.  Only 2 of these 70 healthy people were positive for Mycoplasma fermentans.  Similar results have been found by other doctors and have been published.  
	As we have said before, it is likely that there is a group of underlying problems and not a single one that triggers CFIDS/FMS.  This applies to infections as well.  This is why you can see tests be positive for both viral and Mycoplasmal infections in so many people with this disease.  For Mycoplasma alone, when they checked for four different types of Mycoplasma, over half of the 93 CFIDS patients that were positive had more than one type of infection.  Over 20% of them had three out of the four Mycoplasma infections test positive.  The more infections that were positive, the worse the patient’s symptoms were and the longer they had had CFIDS/FMS. 

What Are Mycoplasma?

	Mycoplasma are an ancient bacteria that lacks cell walls and are capable of invading a number of types of human cells.  They can cause a wide variety of human diseases. These organisms can cause the types of symptoms seen in Chronic Fatigue Syndrome patients and, according to Dr. Nicolson, tend to be immune suppressing.  Unfortunately, they cannot be readily cultured on a culture dish like regular bacteria.  In medicine, we have a bad habit on focusing on that which is easy to test for and making believe that that which is hard to test for does not exist.  Because of this, bacterial infections such as pneumonia, bladder infections and skin infections, where one bacteria on a cell dish will rapidly turn into millions by the next day and be visible to the human eye, get all our attention.  Unfortunately, Mycoplasma, which cannot be easily cultured, tends to be ignored.  It’s like the old story about the little kid who was looking for his lost keys under the street lamp one night.  His friends came by and asked him what was going on.  He told them and they all looked for the keys under that light for about an hour.  Finally, exasperated, they looked at the friend and said, “Where did you lose these keys?” The kid looked up and said, “Oh, about half a block down the street.”  They said, “Why are you looking for them here?”  He said, “Because there is a light here and I can see!”  This is kind of what it is like in medicine.  If there is a test for something (such as cholesterol and bacterial cultures) that is easy to do, we focus our attention on that test and make believe that it finds the main problem.  Unfortunately, in CFIDS and FMS, this is not the case. 
	The data suggests that many infections may trigger CFIDS/FMS or that CFIDS and FMS may cause immune suppression—which then sets you up to catch a whole bunch of different infections which your body has trouble clearing.  This is why it is important to treat all the underlying processes simultaneously as I discuss in my From Fatigued To Fantastic! book and newsletters.           

So, How Do You Look For These Infections?

	I had the honor of speaking with Konnie Knox, M.D., a major re-searcher on HHV-6 testing in CFIDS/FMS, who uses a technique called Rapid Cell Culture.  She actually infects different test tube cells with HHV-6, grows them, and then looks for signs of HHV-6 in the cell.  In her experience, one out of three CFIDS/FMS patients are positive for active HHV-6 infection on the first blood test.  When multiple testing is done (e.g., three tests), 70% are positive.  This test is negative in the vast majority of people who are healthy.  The other main illness where the HHV-6 test is positive is Multiple Sclerosis.  At this time, HHV-6 Rapid Cell Culture and the PCR test at Dr. Nicolson’s lab (International Molecular Diagostics) are the only HHV-6 test I order.  For more information on Dr. Knox’s work, go to these Web sites: www.HHV-6.com and www.cnet.com.  For the IMD website, go to www.imd-lab.com.
	The Nicolsons use very sensitive PCR (Polymerase Chain Reaction) testing to actually look for DNA specific to Mycoplasma, HHV-6, and other infections.  Unfortunately, those DNA pieces are so microscopically small, that to look for just one is much worse than looking for a “needle in a haystack.”  With the PCR, if that Mycoplasma gene sequence is found, the technique multiplies it like a copying machine until millions of that sequence are present and can be picked up by testing.  Because of this, PCR testing is exquisitely sensitive and can find the proverbial “needle in a haystack.”  This makes it very powerful and the only testing that I would recommend in looking for these Mycoplasma and Chlamydia infections.  As noted above, IGG antibody testing is not reliable for Mycoplasma and Chlamydia testing in CFS. 

Where Do I Get These Tests Done And Should I Have Them Done?

	The tests for HHV-6 and Mycoplasma each cost about $180 to $250.  As noted above, the only places that I would get the HHV-6 test done (and the only tests I would do are PCR or viral culture testing) are at the Wisconsin Viral Institute (414-774-0311) or Dr. Nicolson’s lab.  I order all the lab testing for Mycoplasma and Chlamydia at the Nicolson’s lab, at International Molecular Diagnostics, 15162 Triton Lane, Huntington Beach, CA 92649  (714-799-7177 ext. 202 or 204).  The lab’s Web site is www.imdlab.com. 
	I can almost guarantee that if you do the Mycoplasma or Chlamydia tests at your local lab they will do the wrong tests and they will be useless for hidden CFS infections.  I have never seen one come back with any useful information.  What they usually do is check the antibodies (usually for the wrong Mycoplasma infection) which simply shows that you (like everybody else at some point in their life) have had a Mycoplasma infection.  It tells nothing about active infection and, again, is useless.  Be sure to do the PCR testing and do it at one of the two labs discussed above.  Dr. Nicolson has noted which tests he recommends in CFS/FMS, their cost and instructions for the lab.  We have reprinted this information on the next page (Dr. Nicolson’s lab also does viral PCR testing for CMV, as well as HHV-6).
	Even at the best labs, it is not uncommon to have a false-negative report (where you have the infection and it does not show up on the test).  Because of this, especially for HHV-6, multiple tests will often need to be done.  There are good arguments for not doing the tests and simply going ahead and treating empirically with the natural remedies discussed above for HHV-6, or for prescribing Doxycycline or Cipro for an extended period of time (see below).  If you feel better after four months on the treatment, then you know you are hitting an infection and you can always intermittently stop the treatments to see how long you will need them.  Also, there are many infections that are not tested for with these tests that would be effectively treated with the regimens that we are discussing.  Many of these are likely to be infections that we don’t even know exist.  Because of this, if resources are limited, I some-times simply treat the patient, based on clinical suspicion, without doing the tests.  
	Testing does have its benefits.  If the test is positive, I am likely to treat more aggressively and it helps guide me on how long to give the treatment.  For example, if after four months you are not better and the test is positive, I would be likely to go ahead and increase dosing or change to a different antibiotic.  If the test was negative, I would be more likely to just stop treatment and suspect that the infection is less likely.  This argues in favor of doing the tests.  One simple thing to do is to go ahead and check with your insurance company to see if they cover these tests.  This may make your decision much simpler.  Unfortunately, I suspect that the way that most labs draw and ship your blood sample may not be reliable because, in our experience, we have had less than 10% of patient’s tests come back positive for HHV-6 cell culture and only a modest percent come back positive for the Mycoplasma.  For the PCR Mycoplasma test, the blood has to be frozen (see boxed inset, Page 9).  If the blood is left at room temperature, most of the positive samples become negative after one to two days.
	Mycoplasma testing is not as specific as HHV-6 testing is for CFIDS/FMS/Multiple Sclerosis (i.e., it is positive in other illnesses).  For example, about half the patients with Rheumatoid Arthritis are also found to be infected with treatable infections, including Mycoplasma.  This goes along with my, and other doctors’ experience, that Doxycycline is often effective in treating Rheumatoid Arthritis.  Interestingly, although Mycoplasma is common in the environment, it usually is fairly noninvasive.  It may simply be that once your immune system is weakened, these infections can get into cells where they don’t belong.  When that happens, even some of the common ones that are considered noninfectious can wreak havoc.  When these infections repro-duce slowly, they tend to be low-grade, chronic infections, as opposed to the acute and more prominent symptoms seen with bacterial and viral infections that multiply and divide rapidly.

For CFS/ME or FMS or Autoimmune Disease Patients,
The Institute for Molecular Medicine suggests the following lab tests:
(Codes are I.M.D. or CPT Codes)

1.	Test Panel 1007 (CPT: 87798x3, 87581) Mycoplasma species panel of 4 pathogenic mycoplasmas (M. 	fermentans, M. penumoniae, M. hominis, M. penetrans) by PCR. 
Justification: Almost 60% of CFS/FMS and 50% of Rheumatoid Arthritis (RA) and other autoimmune patients have one or more intracellular, systemic mycoplasmal infections similar to those found in a variety of chronic illnesses [Nicolson, et al., Mycoplasmal infections in chronic illnesses: Fibromyalgia and Chronic Fatigue Syndromes, Gulf War Illness, HIV-AIDS and Rheumatoid Arthritis; Medical Sentinel 1999; 5:172-176].  Ultrasensitive and ultraspecific mycoplasma tests can only be done by a small number of labs, most university or government labs that have been trained by us under a U.S. government contract.  
Specimen Requirements: One (1) 5 cc Lavender-top Plastic Tube (EDTA).  The blood is collected, immediately mixed and placed on ice, then shipped on wet ice or immediately flash frozen and shipped with dry ice by courier (foreign shipments) to I.M.D. to arrive within 24-36 hours.  Cost=$250. (Note that other commercial labs charge $400-600.)

2. 	Test 1006 (CPT: 87486) Chlamydia pneumoniae test by PCR.  Justification: Many CFS, FMS, MS, RA and other patients have this systemic infection along with viral infection(s).  We were among the few labs that developed the molecular tests that are now done for this type of infection. The other labs that use these procedures are university labs.  
Specimen Requirements: One (1) 5 cc Lavender-top Plastic Tube (EDTA).  The blood is collected, immediately mixed and placed on ice, then shipped on wet ice or immediately flash frozen and shipped with dry ice by courier to I.M.D. to arrive within 24-36 hours. Cost=$180. (Note that other commercial labs charge $200-250.)

3. 	Test 07047 (CPT: 87476) Borrelia burgdorferi (Lyme Disease) test by PCR. 
Justification: Many CFS, FMS and RA patients have this systemic infection (diagnosed as Lyme Disease) along with other infection(s).  
Specimen Requirements: One (1) 5 cc Lavender-top Plastic Tube (EDTA).  The blood is collected, immediately mixed and placed on ice, then shipped on wet ice or immediately flash frozen and shipped with dry ice by courier to I.M.D. to arrive within 24-36 hours. Cost=$180. (Note that other commercial labs charge $200-250.)

4.	Test 07039 (CPT: 87532) Human Herpes Virus 6 (HHV-6) test by PCR. 
Justification: Many CFS and some FMS patients have this systemic viral infection, and it should be tested for in any autoimmune illness.  
Specimen Requirements:  Collect blood in one (1) 5 cc Lavender-top Plasma Tubes (EDTA), mixed and separate blood plasma by centrifugation.  The plasma is then shipped on wet ice or immediately flash frozen and shipped with dry ice by courier to I.M.D. to arrive within 24-36 hours. Cost=$180. (Note that other commercial labs charge $200-350.)

5. 	Test  07034 (CPT: 87496) Cytomegalovirus (CMV) test by PCR. 
Justification: Many CFS and FMS patients have this systemic viral infection, and it should be tested for in any autoimmune illness. 
Specimen Requirements: Collect blood in one (1) 5 cc Lavender-top Plasma Tubes (EDTA), mixed and separate blood plasma by centrifugation.  The plasma is then shipped on wet ice or immediately flash frozen and shipped with dry ice by courier to I.M.D. to arrive within 24-36 hours. Cost=$180. (Note that other commercial labs charge $200-300.)

For the best price and highest quality, the above PCR specialty tests for CFS/FMS patients can be ordered through International Molecular Diagnostics, Inc., 15162 Triton Lane, Huntington Beach, CA 92649, U.S.A.  Tel: 714-799-7177, ext. 202 (Client Services) or ext. 204 (Brant Blasingame).  Order forms and additional information are available upon request.  They also offer testing for blood clotting abnormalities (see below).  Tests must be ordered by a physician.  The I.M.D. Web site is www.imd-lab.com.  On this site you will find additional information about testing and disease.  The Institute for Molecular Medicine Web site is www.immed.org.  On this site you will find publications and documents on CFS/ME, FMS, autoimmune diseases and other chronic illnesses.  Immediate fax-back information is available 24 hours per day by calling our telephone number 714-903-2900.

Garth Nicolson, Adjunct Professor of Internal Medicine
President and Chief Scientific Officer, The Institute for Molecular Medicine
—A nonprofit institute dedicated to discovering new diagnostic and therapeutic solutions for chronic diseases—
15162 Triton Lane, Huntington Beach, CA 92649-1041, U.S.A. • Tel: 714-903-2900 • Fax: 714-379-2082

So, What Is Prescribed For Mycoplasma And Chlamydia? 

	Fortunately, Mycoplasma and Chlamydia infections are usually sensitive to the right antibiotics.  The antibiotics most likely to effect these organisms are:

1.	Doxycycline or Minocycline 100 mg, 2-3 times a day.  These two antibiotics are in the Tetracycline-family and should not be used in children under eight years-old because they can cause permanent staining of the teeth.  They are very effective, though, against a number of unusual organisms (e.g., Lymes Disease).  They will sometimes cause some stomach upset.  If this occurs, take the medicine with food and a full glass of water or lower the dose.  Do not use outdated/expired Tetracycline prescriptions—they can kill you!

2.	Cipro (Ciprofloxacin)  750 mg, twice a day.  Although expensive, this is usually a well-tolerated antibiotic.  It has a very wide range of effectiveness against a large number of organisms.  When treating males, the Cipro (as well as the Doxycycline) has the additional benefit of treating any hidden prostate infections.  Do not take oral magnesium within 6 hours of Cipro or you won’t absorb the Cipro.

3.	Zithromax 600 mg a day, taken with food, or Biaxin 500 mg, twice a day, taken on an empty stomach.  These are in the Erythro-mycin family.  Zithromax tends to be fairly well-tolerated.  The Biaxin is more likely to cause a bit of nausea in some patients, but it is usually well-tolerated.  Both are quite expensive.  They may work against infections missed by Doxycycline and Cipro.
	Although all of these antibiotics can be effective, it is not uncommon for infections that are sensitive to the Erythromycin antibiotics (#3 above) to be resistant to #1 and #2 above and vice-versa.  Therefore, it is best to try either Doxycycline or Cipro first.  If they are not effective, then try the Zithromax or Biaxin.  The antibiotic should be taken for at least 6 months.  If there is no improvement in 4 months, switch to or add the other antibiotic or simply stop the treatment. It is helpful to check for low-grade fevers.  I am more likely to use antibiotics for CFIDS patients who have temperatures over 98.6°F, even if it is only 98.8° (I consider 98.8° a fever because CFIDS/FMS patients usually have low body temperatures).  If you do have low-grade, chronic temperature elevations, be sure that you monitor your temperatures during treatment.  If your temperature drops with the antibiotic, it suggests that you do have one of these nonviral infections and the antibiotic is helping.  This would encourage me to continue the antibiotic trial - even if it takes up to 12 months to see an improvement in your symptoms.  
	If you are clearly better, I would probably take the antibiotic for at least 6 to 12 months.  It can then be stopped.  If symptoms recur, keep repeating 6 to 8 week cycles until the symptoms stay gone.  It may take several years of treatment for the infection to be totally eradicated.  To put it in perspective, this is how long children often take antibiotics for acne—which unfortunately, if not taken with anti-fungals, can lead to yeast overgrowth and possibly trigger CFIDS.  Be sure to take Nystatin, 2 tablets, 2 times a day, while on the antibiotics.  Also, please be sure to use alternative birth control if on “the pill.”  Birth control pills may be ineffective while taking antibiotics.  In addition, anti-depressants, codeine, antacids, and mineral supplements (e.g., magnesium) may block antibiotic absorption.  Take these at least three hours away from the antibiotic (and don’t take the antidepressant/codeine medications if they are not clearly helping).
	It is very common to get die-off (Herxheimer) reactions which include chills, fever, night sweats and general worsening of CFS/FMS symptoms when the antibiotic first kills off the infection.  These can be severe and last for weeks.  Dr. Nicolson encourages you “to be patient and not abandon therapy prematurely, because few patients who have been sick for years recover in less than one year of therapy... [don’t] be alarmed if some signs and symptoms occasionally return or worsen.  This is not unusual.  Eventually you will be off antibiotics or antivirals but you will need to continue various supplements to maintain your immune system and general nutritional status.”

Treatment for Bacterial, Mycoplasma, Chlamydia, E-coli, Bladder, Or Other Infections 

	(From the “Treatment Checklist” used in Dr. Teitelbaum’s office.  A full list is available on Dr. Teitelbaum’s Web site at www.endfatigue.com.)
	The Mycoplasma, Chlamydia, E-Coli, bladder and other bacterial infections usually take months to years to eradicate.  It is common to flare your symptoms (from the infection die-off) the first two weeks of treatment.  Take the antibiotics for six months and, if better, then repeat six-week cycles till your symptoms stay gone.  Antidepressants, Neurontin, and/or Codeine may block the antibiotic’s effectiveness.  Be sure to take Nystatin, 2 tablets twice a day, and Acidophilus while on the antibiotics.  If you have occasional low-grade fever (i.e., if over 98.6° F), check your oral temperature occasionally to see if the antibiotic reduces or eliminates the fever.  If so, stay on that antibiotic.  Also, see Dr. Nicolson’s Web site at www.immed.org for additional information.
	Useful antibiotic treatment for the above infections include:
1.	Cipro (ciprofloxacin) 750 mg, 2 times a day for 6 months.  Do not take magnesium products (e.g., Fibrocare, some antacids, Pro Energy, or (Dr. Teitelbaum’s) Foundation  Formula™) within 6 hours of Cipro because you won’t absorb the Cipro. 
OR
2.	Doxycycline (a tetracycline) 100 mg, 3 times a day for 6 months.  If symptoms recur when the Doxycycline is 	completed, keep repeating 6-week courses until the symptoms stay resolved.  Take Nystatin (at least 2, twice a day) while on the antibiotic.  Birth control pills may not work while on Doxycycline.  Do not take any expired Doxycycline tablets (it’s very dangerous).
OR
3.	Zithromax (azithromycin) 600 mg tablets, 1 tablet a day (take with food if it bothers your stomach).  Don’t take magnesium-containing products within six hours of the Zithromax.
OR
4.	Biaxin 500 mg, 2 times a day.

5.	D-Mannose ½ to 1 teaspoon (2.5 grams), stirred in water, every 2 to 3 hours while awake, for 2 to 5 days for acute bladder infections (may use long-term for chronic infections) caused by E-coli (this causes approximately 90% of bladder infections).  If not much better in 24 hours, get a urine culture and consider an antibiotic.  D-Mannose is available from BioTech (800-345-1199), my Web site’s “Vitamin Shop” at www.endfatigue.com or my office (800-333-5287).

What About Yeast Overgrowth?

	Yeast overgrowth is an important concern.  As I have mentioned before, nothing is all good or all bad.  Although cigarettes kill hundreds of thousands of people each year, they can be helpful in treating Parkinson’s Disease or ulcerative colitis.  Although antibiotics can trigger CFIDS, they can also be helpful in treating it.  This makes it important to know when and how to use them.  I strongly recommend that my patients take antifungals while on any antibiotics (e.g., Nystatin 500,000 unit tablets, 2 tablets, 2 to 3 times a day) to prevent yeast overgrowth.  It is also reasonable to add Oregano Oil and other natural antifungals.  Two Nystatin twice a day is what I usually prescribe.  Using probiotics (healthy milk bacteria-like acidophilus that helps your body) to compete with the yeast can also help.  I am concerned that if the acidophilus is taken with the antibiotic, they may simply cancel each other out.  Because of this, I usually begin probiotics  (Acidophilus or Lactobacillus in a dose of 3 to 6 billion units a day, taken on an empty stomach or with milk) after one has completed the course of antibiotics.  If you are only taking the antibiotic once or twice a day, and can find a time at least 6 to 8 hours away from another dose to take the probiotic, it is reasonable to take it at that time.  The entire daily probiotic dose can also be taken at one time.  If you find that you still get yeast overgrowth, it may be necessary to use some of the more potent prescription antifungals (Sporanox or Diflucan).  Because these can cause liver inflammation and are quite expensive, it may be adequate to take 200mg of either of these, twice a day, one day each week (e.g., take it every Sunday) instead of every day.  As discussed previously, be sure to take Lipoic acid 200 mg on any day you take Sporanox or Diflucan, to decrease the risk of liver inflammation. 

What Role Does My Blood Clotting System Play In This?

	Work done by David E. Berg, M.S., C.L.S. (N.C.A.), director of Hemex Laboratories in Phoenix, Arizona (800-999-2568), has shown that a number of infections can trigger our blood clotting system to become active, thus setting up a low-level, chronic clotting cascade.  These infections include HHV-6, Mycoplasma, CMV and Chlamydia which can trigger production of (IgA) antibodies against clot protective proteins on blood vessel inner surfaces (called antiphospholipid antibodies).  One of these is the Beta 2 Glyco-protein 1 (anti B2GP1—no, you are not going to be tested on this!).  This then triggers the clotting cascade.  Once the clotting system is triggered, a product called Soluble Fibrin Monomer (SFM) is made which is like the polymers in plastic.  The theory is that they create long thin sheets of a teflon-like substance, similar to the scab that covers a cut, but microscopic, which then coats the blood vessels.  This makes it hard for nutrients, oxygen, etc., to get in and out of the blood vessels to the cells where they are needed.  In summary, many infections can cause the blood clotting system to activate, resulting in a thin coating of Fibrin deposited on the blood vessels.  This prevents nutrients and oxygen from getting to the cells in your body.  

Why Would An Infection Trigger The Clotting System?

	Many infections (called anaerobic) do not survive well in the presence of oxygen.  One can theorize that these Mycoplasma (which may be anaerobic) and other organisms may trigger the clotting system to create a shell, which then acts like a suit of armor, protecting them from oxygen, your body’s defense system, and antibiotics.  This would explain why these infections could evolve a way to trigger the clotting mechanism.  The Fibrin armor preventing antibiotics from getting to the infection could also explain why some people with these infections may not respond to antibiotics.  Indeed, some physicians have found that the antibiotics work better once someone has been on a blood thinner (which may dissolve the armor).  
	This is an interesting theory, but how do we know this is going on?  Mr. Berg and others have done studies showing that the blood tests that look for these clotting changes (called the ISAC panel - available at Hemex labs) are abnormal in CFIDS/FMS patients while being normal in most other patients.  They use a criterion of two of these tests needing to be abnormal to be considered positive.  When this was done, 50 of 54 CFIDS/FMS patients had abnormal tests (i.e., only 7.4% of the patients had normal blood tests).  In healthy patients, 22 out of 23 had normal blood tests (i.e., 96%).  This means the test is both very sensitive and specific, picking up people with CFIDS and excluding healthy people.  Our experience has shown that almost everyone that we tested, who has CFIDS, has turned out to have a positive ISAC panel.  We have not personally sent in any tests on healthy patients to see if this also occurs.  Interestingly, this panel is also positive in many people with unexplained infertility (which can improve with Heparin) and may also be positive in people with Multiple Sclerosis, Parkinsons, Autism, Inflammatory Bowel Disease and some other illnesses.  This suggests that this test can be helpful in deciding whether to treat with blood thinners (Heparin) in CFIDS/FMS.

So, How Do I Treat The Clotting System?     

	First of all, it is important to remember that using injections of Heparin (the blood thinner) is still a controversial and experimental treatment for CFIDS/FMS.  We much prefer to use treatments that are as safe as possible.  Although Heparin is routinely used in the U.S.A. to treat blood clots, using it to treat CFIDS/FMS is very new.  Most of the doctors that I have spoken with have only treated a few CFIDS/FMS patients with Heparin and find that about half of these patients get better with treatment.  The treatment protocol, developed by John Couvaras, M.D. (602-996-2411), includes the following:
	1.	Remove wheat, alcohol and sugar from the diet, if possible.
	2.	Check the ISAC panel.  If there are at least two abnormal results, then begin treatment.
	3.	Give an antifungal for 14 days (he uses Lamisil 250mg a day—which I find to be poorly effective.  I would use 200 mg of Sporanox or Diflucan instead).
	4.	Give standard Heparin 4000 to 8000 units by injection subcutaneously (like an insulin shot) twice a day.  A (possibly safer) low molecular weight Heparin may also be used.
	5.	If the PA index (on the ISAC) is positive, add a baby Aspirin (81mg) each day.
	6.	After being on Heparin for one week, Dr. Couvares repeats the ISAC panel to adjust the dose of the Heparin and Aspirin.  He feels that the goal is to move all the blood tests into the normal range but not past the normal range into blood-thinning (therapeutic) levels.  If the values are still abnormal or the patient is still having symptoms, he then increases the Heparin dosage.  If the PA index (on the ISAC) is still high, he increases the Aspirin to twice a day.
	7.	If the patient feels better after one month of Heparin, he then switches to low-dose Coumadin (a blood thinner tablet—take 2 to 3 mg a day) and then stops the Heparin after 4 to 5 days of being on the Coumadin.  Once the patient has been on the Coumadin for two weeks he goes ahead and rechecks the ISAC panel to maintain the blood tests in the normal range.  
	8.	He also supplements patients with nutritional supplementation as needed. 
	In my practice, because the ISAC panel runs over $320, I check a baseline ISAC panel but do not repeat the ISAC panels to adjust therapy.  Instead, while on Heparin, we check a PTT (a blood thinning test) and platelets (a highly unusual, but potentially very dangerous side effect of Heparin is a severe drop in platelet count, which can cause life-threatening bleeding) every 3 days for the first 12 days and then every 2 to 4 weeks while on Heparin.  If the PTT is still within the normal range and the patient is not better, we increase the Heparin as high as 8000 units, twice a day (rarely we will go up to 8000 units, 3 times a day) and then also increase the Aspirin to 2 a day.  In comparison, hospital patients often require Heparin at 1000 units per hour (24,000 units a day) I.V., while most CFS/FMS patients only need 4000 to 5000 units, 2 times a day (8000 to 10,000 units a day).  If the patient is feeling better, however, we simply leave them at the initial dose.  Most patients will feel better at about the 10- to 14-day point if the Heparin is going to help.  At the end of 4 to 12 months, if the Heparin helps, we switch to Coumadin (as noted above) and check an INR (International Normalized Ratio), aiming to keep it below 1.3 while adjusting the Coumadin to the optimum does.  It is very important to know that most medications can change the blood level of Coumadin and that anytime anything is added to, or deleted from, your regimen (including natural remedies) you need to recheck the INR 4 to 7 days later to make sure that it is not going too high.  Heparin and Coumadin are powerful medicines and the main risk is bleeding.  Although we are using very low doses, which are usually very well-tolerated, one can rarely see a life-threatening bleed occur.  If you felt better on the Heparin and then the symptoms come back on the Coumadin, you may need to go back on the Heparin for several months to re-establish and maintain the benefit.  Occasionally, people will need to be on the Heparin for an extended period, in which case the blood tests (PTT and platelet count) should be checked every 2 to 4 weeks.  All of this being said, most people tolerate these treatments quite well and many, many more people die from taking Aspirin (e.g., for arthritis) than Heparin each year.  
	In summary, there are a number of infections that can cause or occur because you have CFIDS/FMS.  Once they occur, they can trigger the clotting cascade.   This may keep the nutrients from getting to your body and create a “suit of armor” for the viral and Mycoplasma infections.  Using a blood thinner can break down these armor coatings that protect the infections from our treatment and allow nutrients to get where they need to go.  Many tests can help.  The one that I use to decide whether to use the Heparin blood thinner is the ISAC panel (at Hemex Labs).  Testing for infections may be helpful, but can be expensive and less likely to effect my decision to treat.  If you can afford the tests and/or your insurance will pay for them, they are worth checking and will make it easier to adjust therapy over time.  If you can’t afford it, it is reasonable to treat empirically (i.e., without testing), except for high-dose Valtrex therapy.  If you have lung congestion and/or recurrent temperatures over 98.6°F, I would treat with the antibiotics.  If you feel chronically flu-like, I would consider the HHV-6 or (based on testing) the high-dose Valtrex regimen.  It is also reasonable to treat with antibiotics and antivirals simultaneously - especially if you are taking the anticoagulants.

Chronic Sinusitis The Yeasty Beasties Revisited!

	As was mentioned years ago, we speculated that the chronic sinus congestion seen in CFIDS/FMS could be caused by yeast overgrowth.  A recent interesting study from the Mayo Clinic Proceedings supports this thought.  In the study, researchers found that most people with chronic sinus infections had fungal growth in their sinuses.  They felt that the inflammation was being caused by an immune (the body’s reaction) response to the fungus.  This research is interesting because more and more studies are showing that treating chronic sinusitis with antibiotics doesn’t really do much and that shorter courses of treatment work just as well as the long courses.  We find that conservative treatment (see my newsletter article, Treatment Of Respiratory Infections Without Antibiotics, Vol. 2, Issue 2) is more effective than antibiotics for chronic sinusitis.  
	It’s good that medicine is finally starting to catch up with reality.  The report in The Mayo Clinic Proceedings noted that, “fungus allergy was thought to be involved in less than 10% of cases… our studies indicate, in fact, fungus is likely the cause of nearly all of these problems and that it is not an allergic reaction but an immune reaction.”  In this study, the researchers studied 210 patients with chronic sinusitis.  Using new methods to collect and test sinus/nasal mucus they found fungus in 96% of patients.  
	It’s interesting to observe how medical research works.  The researchers are now working with different drug companies to set up trials to test medications to control the fungus but feel that it will be at least two years before any treatments will be available.  In my experience, though, these problems often respond dramatically to either Sporanox or Diflucan - which, by no coincidence, are very powerful antifungal agents.  It is not clear why the researchers did not simply try Sporanox or Diflucan.  Un-fortunately, we find that the obvious is often overlooked.  This sometimes occurs as drug companies seek to make more money by finding new drugs instead of using the old things that are known to work.  It is important to distinguish between chronic sinusitis (which lasts for over three months) and acute sinusitis (which usually has been going on for a few days and less than a month).  For these shorter attacks of sinusitis, bacteria are a more common cause and antibiotics (combined with natural remedies) can be helpful.  Some researchers still continue to argue that fungus is not a cause of chronic sinusitis.  They note that fungi are seen even in healthy noses (which is correct) but neglect to discuss the immune changes that are also seen in these noses.  Because so many people have responded dramatically to antifungals in the treatment of their chronic sinusitis, my suspicion is that the Mayo Clinic researchers are probably correct.  Wouldn’t it be nice, if instead of arguing about treatments while people stay sick, they would just try the treatments to see if they worked!
	As you can see, your body’s defenses being down plays a large role in CFIDS/FMS.  The good news is, that by treating the many underlying infections common in CFIDS patients and by treating any hormonal and nutritional deficiencies, you can bring your immune system back to a healthy state!

Important Points

	•	An important component of CFS is disordered immune function, which opens the door to repeated infections, repeated treatment with antibiotics, and yeast overgrowth.
	•	Treat yeast overgrowth by avoiding antibiotics and sweets.  Many patients have found Nystatin and other antifungal medications, such as Diflucan and Sporanox, to be helpful. Acidophilus (milk bacteria) and natural antifungals such as Caprylic acid and garlic are also often useful.
	•	Bowel parasites are common in CFS patients, whose symptoms often respond dramatically to treatment. However, most labs do not adequately detect parasites through stool testing. To get an accurate test result, use one of the labs we recommended that specializes in stool testing.
	•	Treat Cryptosporidium with Artemesia annua or tricyclin (herbal antiparasitics).
	•	Treat constipation with Turkey Rhubarb (a herb).
	•	Prevent parasitic infection by using a Multi-pure water filter (available from 888-801-8176 or 410-224-4877)
	•	If you have temperatures over 98.6°F and/or chronic lung congestion, try long-term Cipro or Doxycycline (while on Nystatin).
	•	If you have chronic flu-like symptoms, despite yeast and Cortef treatment, consider the antiviral, immune stimulating protocol we discussed.