I get so angry when I read
the nightmare stories many of you have experienced. All you did
wrong was to get sick. Then the medical industrial complex made your
life miserable. The medical industrial complex includes the drug
companies who are not interested unless they make a big profit, the
health insurance companies who will use any excuse to deny patients
medications or testing, and the disability industry who survive only
because they take your money and deny benefits if you get sick. All
of this is done under the guise of “modern evidence-based medicine”.
But evidence-based medicine only works in illnesses like
hypertension where yo! u have enormous funding.
I think I
have become an old codger. Cynical, disappointed….. Enough of that.
In my office I have a sign for ME/CFS patients “Whining will be
allowed for ten minutes only”.
In the past week I have
seen two patients who had an exercise lactate test which showed an
elevation of blood lactate after mild exercise. They were told by
their physician that they had “mitochondrial disease”. They were
advised to take some vitamins, maybe some CoQ10, and have a nice
day. Like nearly everything else, the term mitochondrial disease
left these patients feeling bewildered and somewhat lost. While I
agree that ME/CFS is a mitochondrial disease, this term needs
clarification because ME/CFS is a mitochondrial disease like no
Until recently, when a
child was diagnosed as having a mitochondrial disease, it was a
disaster, even a death sentence, for it meant that there were major
abnormalities in the mitochondrial or nuclear DNA that regulated
energy production. Without energy (ATP) it is impossible to survive.
These diseases are called MELAS, Kearns-Sayre, Leber hereditary
optic neuropathy and so on.
Nearly three hundred
mitochondrial illnesses have been identified from genetic mutations.
It is a specialized area of pediatrics, where it is possible to
measure severe abnormalities in the mitochondria on muscle biopsy
testing. This is what most clinicians think of when the words
mitochondrial disease are mentioned, but these illnesses do not, in
general, apply to ME/CFS. Many patients with ME/CFS have had muscle
biopsies and most of the mitochondrial tests on these biopsies are
relatively normal. We will return to why! this is in a bit.
What are mitochondria?
Think of mitochondria as the power factories of the cell. Nearly
every cell in the body has them, usually around 500 or so in every
cell. They take in oxygen and glucose and put out carbon dioxide and
energy (ATP). There are two hundred different steps in this process
and we will quiz you after this article. Actually all you need to
know is ATP, the prime energy storage
chemical (battery) of the body, and oxidative phosphorylation (ox-phos)
the complex electron transport chains that do the major work.
Because the mechanism of energy production is essential to nearly
every cell, a defect will have symptoms in every organ system. Sound
Oxidative metabolism, the
ability to utilize oxygen to produce energy, is quite efficient, and
it is fascinating to look at the theories of how they came to be
part of our cells. However, when the energy demand is excessive, the
cells revert to a more primitive, and less efficient, form of energy
production, anaerobic metabolism (metabolism without oxygen). For an
interesting study on the anaerobic threshold in ME/CFS, see the
literature review article that follows.
When to suspect
In a recent review article
(Haas 2007) there is a list of symptoms that suggest looking for
mitochondrial disease. Among these symptoms are neurologic symptoms
such as ataxia, myoclonus, and encephalopathy, exercise intolerance,
sensitivity to general anesthesia, and constipation. A score sheet
has been developed to help in when to suspect mitochondrial disease
and most ME/CFS patients would fall into the positive range. For
lots of information on mitochondria please go to
www.mitosoc.org, but remember that they are talking
about “conventional” mitochondrial disorders, not ME/CFS.
There is another form of
mitochondrial disease, or secondary mitochondrial disease. In
secondary mitochondrial disease the primary problem is not with the
mitochondria, but some other problem messes up mitochondrial
function. There are many illnesses where the primary defect ends up
causing problems with the generation of energy
in mitochondria. For
example, thyroid hormone is needed for successful oxidative
phosphorylation. With hypothyroidism (low thyroid) energy production
is impaired and fatigue, weakness, temperature regulatory problems,
and difficulty concentrating result. This is one of the reasons that
when you start to describe fatigue to your primary care physician,
he or she begins to write out a script to test for thyroid hormone.
So what is the
Why has ME/CFS not been
diagnosed, studied and classified as other mitochondrial diseases?
There are several reasons:
a) Mitochondrial disease
is thought of by clinicians as a fatal disease of infancy, not one
that occurs later in life.
b) Mitochondrial disease
is usually thought of as a fixed, structural disease, and ME/CFS is
a relapsing, remitting illness with some persons even becoming
c) Mitochondrial diseases
are hard to diagnose, requiring muscle biopsies and detailed ox-phos
d) Ox-phos testing is
often normal in ME/CFS, and this has been the critical piece that
has diverted attention from mitochondria.
e) Physicians are used to
thinking of organ-specific diseases (liver, kidney, etc) and
mitochondria are in all cells.
f) Few physicians have
taken ME/CFS seriously until recently, and research in this area has
Of the above reasons, only
reason “d” is important to us here. In 1990 I did a muscle biopsy
study on ten ME/CFS patients with Dr. June Aprille. All ten persons
had relatively normal ox-phos studies. Although we did not publish
this finding, it is consistent with the few published studies that
have been done. How can you have mitochondrial disease when the
mechanism tests normal? I think that the answer to this paradox is
just around the corner.
If you have a patient with
emphysema who is sitting in an armchair, he or she is not out of
breath. You can measure the damage in tests, but to make symptoms,
you have to “stress” the system – make the patient run up and down
stairs. If a person with G-6-PD deficiency is sitting quietly, the
blood looks normal. But feed this person fava beans and
abnormalities quickly become obvious.
Persons with ME/CFS keep
themselves at a balance point. They rest for two hours, then do a
half hour of activity, then rest, then do more and so on. The worse
the illness, the less overall activity is possible. If a ME/CFS
patient does absolutely nothing for a few days, they usually feel
pretty good. But go to the shopping mall for eight hours and the
crash occurs. Here is the problem: in the patients studied for
mitochondrial disease, they have been resting up (staying above the
balance point) and a muscle biopsy done at that moment will probably
not show much. But have a ME/CFS patient exercise, and then study
mitochondrial function. My hunch is that the ox-phos reactions will
be seriously impaired, but this has not been systematically and
methodically done. For me, this hypothesis is generated by the
VanNess, Snell, and Stevens study described in the next section.
There are lots of studies
that implicate mitochondrial problems; Dr. Kuratsune and carnitine.
Dr. Versnon and genomics; Dr. DeMeileir, Dr. Pall, Dr. Cheney and
many others. But this problem cannot be studied in tiny fragments.
It is time for a good study to look at the different steps of the
body’s ability to generate energy. Lets hope we get to see it within
1. Haas R, Parikh S, Falk
M, Saneto R, Wolf N, Darin N, et al. Mitochondrial Disease: A
practical approach for primary care physicians. Pediatrics
Review of the
“Two-day Exercise Test”
In the most recent
Journal of Chronic Fatigue Syndrome (Vol 14, Number 2, 2007)
there are two articles which may be the first to offer an objective
proof of disability in ME/CFS. More importantly, if shown to be
correct, they may give us an avenue to test and measure the
biochemical abnormality which causes the symptom pattern. In this
short review I would like to review these two papers and present a
case of pediatric CFS which demonstrates the same abnormalities.
In the first of these
papers, Margaret Ciccolella, a lawyer, teams up with Staci Stevens,
Chris Snell, and Mark Van Ness of the University of the Pacific to
review the legal issues surrounding exercise testing and disability
(1). As everyone familiar with CFS well knows, insurance companies
require proof of disability, which a standard exercise test may or
may not demonstrate. However, even if disability is present,
insurance companies have been quick to say that the patient was not
trying hard enough, or that the patient is de-conditioned. The
second paper of this series by VanNess, Snell and Stevens explain
the two-day exercise test and presents results for six patients with
As clinicians have
observed, the symptom of “post-exertional malaise” is one of the
most distinguishing features of CFS. This symptom is listed as one
of the eight in the criteria of the Centers for Disease Control (3),
and is central to the diagnosis in the recent Canadian Case
Definition (4) and the proposed pediatric case definition (5). It is
beginning to look like the symptom of post-exertional malaise is at
the root of disability, and may be central to the pathophysiology of
this complex illness spectrum.
A person with ME/CFS may
be at home for several days doing little except basic activities of
daily living. When this patient decides to go shopping, he or she
will drive to the mall and shop for one or two hours. During this
time, observers would say that the person looks entirely well, not
appearing disabled. However, following this activity the patient
will experience an exacerbation of pain and other symptoms of
ME/CFS. This exacerbation may last one, two or three days, and, in
my opinion, the more severe the illness, the longer and more severe
the exacerbation. This phenomenon is known as post-exertional
malaise. The symptoms of the illness (malaise) are exacerbated by
mental, physical or emotional activities (post-exertional). In an
employment environment, the patient may be able to do a job well for
one or even several days. However disability lies in the inability
to sustain this normal ! level of activity. The two-day exercise
test is the first to begin to explain this phenomenon.
The exercise test is no
different from what has been used for years. The patient exercises
on a stationary bicycle (bicycle ergometry) and breathes through
plastic tubing to measure the concentration of oxygen and carbon
dioxide as well as the total amount of air. The six female patients
and six sedentary matched control subjects of the study were all
able to achieve maximal exertion. The ME/CFS patients had a slightly
lower V02max (maximal oxygen utilization) than controls (28.4
ml/kg/min vs. 26.2 ml/kg/min) and lower VO2 at anaerobic threshold
(15.01 ml/kg/min vs. 17.55 mg/kg/min) on the first day of exercise
testing. These values are not dramatic nor are they statistically
significant. It is on the second day that interesting results are
The same test was repeated
the following day for all twelve subjects. As is often the case,
sedentary controls improved slightly in their ability to utilize
oxygen, going from 28.4 to 28.9 ml/kg/min for VO2max and from 17.55
to 18.00 ml/kg/min for oxygen utilization at anaerobic threshold.
The CFS patients however worsened in both categories: VO2max fell
22% from 26.23 to 20.47 ml/kg/min, and oxygen utilization at
anaerobic threshold fell 27%, from 15.01 to 11.01 ml/kg/min. To put
this into perspective, these values are in the severe disability
range on the AMA guidelines, and the decline in function from day
one to day two cannot be explained by inactivity.
de-conditioned persons do not change their oxygen utilization
because of an exercise test. Even patients with heart disease,
cystic fibrosis or other diseases do not vary more than 7% from one
day to the next. However, the patients with ME/CFS in this study had
a significant drop; something occurred because of the test on the
first day interfered with their ability to utilize oxygen on the
next day. And this is exactly what patients with ME/CFS have been
describing with the symptom of post-exertional malaise. As the
authors state, “The fall in oxygen consumption among the CFS
patients on the second test appears to suggest metabolic dysfunction
rather than a sedentary lifestyle as the cause of diminished
exercise capacity in CFS.”
The results of the two-day
exercise testing are objective and not dependent upon subjective
symptoms. Moreover hypochondriasis, intentional falsification,
and/or poor effort can be detected by the physiologic parameters.
Therefore the two-day exercise test, if confirmed in a larger trial,
could become a clinical trial end point. More importantly,
evaluations could be designed which would demonstrate the specific
metabolic abnormality generated by the exercise of day one and
demonstrated on the second day exercise test. It would be my hope
that these findings be explored without delay.
M, Stevens S, Snell C, VanNess J: Legal and Scientific
Considerations of the Exercise Stress Test. JCFS 2008,
2. VanNess JM, Snell CR, Stevens S:
Diminished Cardiopulmonary Capacity During Post-Exertional Malaise.
JCFS 2008, 14(2):77-85.
3. Fukuda K, Straus S, Hickie I, Sharpe
M, Dobbins J, Komaroff A, Group ICS: The chronic fatigue syndrome: a
comprehensive approach to its definition and study. Ann Intern
Med 1994, 121:953-959.
4. Carruthers B, Jain A, DeMeirlier K, Peterson
D, Klimas N, Lerner A, Bested A, Flor-Henry P, Joshi P, Powles ACP
et al: Myalgic encephalomyelitis/chronic fatigue syndrome:
Clinical working case definition. diagnostic and treatment
protocols. J Chronic Fatigue Syndrome 2003, 11(1):1-12.
5. Jason L, Bell D, Rowe K, Van Hoof E, Jordan
K, Lapp C, A G, Miike T, Torres-Harding S, De Meirleir K. A
Pediatric Case definition for myalgic encephalomyelitis and chronic
fatigue syndrome. J CFS 2006, 13:1-44