Chronic Pain Control

Details

Last Updated: 20 November 2015 20 November 2015

by David S. Bell, M.D.

The Massachusetts CFIDS/ME & FM Association Spring 2000 UPDATE

One of the difficult but treatable symptoms of Chronic Fatigue Syndrome (CFS), chronic pain is rarely treated adequately. Headaches, lymph node tenderness, muscle pain (fibromyalgia (FM)) and joint pain cause consid­erable long-term discomfort—sometimes mild, sometimes severe. There may be fluctuations in the severity of pain.

If pain remains one of your most important symptoms of CFS/FM, be sure to address it specifically. There are several gen­eral principles of pain management that should be understood by the patient:

1. Always use the least amount of pain medica­tion. These drugs have side effects and may cause intolerance, and do nothing to cure the underlying cause. Don't use them if they are not necessary.
2. Do not treat general malaise with pain med­ication. Sometimes, you may feel rotten, but the pain is not that bad. Using pain medica­tion is unlikely to be of help.
3. Communicate the pain clearly to your physi­cian. There are many symptoms to address in CFS, and if I do not know that pain is the worst symptom, I may not attempt to address it. That is, if pain is one symptom listed among twenty, I will not pay special attention to it.
4. Be patient and observe patterns. (Keep a symptom journal.) If the pain is mild and tolerable for two months, then bad for one week, do not go to the "big guns" right away. If the pain eases off after a week, you will not know if it is the medication, or just the fluc­tuations of the illness. Once you understand the pattern, it may be reasonable to have a strong pain medication on hand for the bad episodes, and then stop it when possible.
5. Assess the response to one class of medications thoroughly before moving to the next class. Many individuals do not use ibuprofen correct­ly and thus reject it, thinking it doesn't help.
6. Do not jump to stronger pain medications early in the morning, if the pain and stiffness usually ease off after an hour. It will take the medications that long to work, and then you are left with the heaviness of pain med­ications for the next few hours without need­ing it. You can approach it by taking a longer acting medication at bedtime, or by stretching or showering in the morning.

Medications for pain by class

Non-steroidal anti-inflammatory drugs (NSAIDS)

This class is the standard pain relievers, many of them over the counter. If the response is not enough, make sure you are using them effec­tively and at the right doses. For example, ibuprofen may be effective taken three times daily to prevent severe pain, but may appear not to work if used only at crisis times.

All can cause upset stomach, and even ulcers.

Acetaminophen (Tylenol ® and others)

This medication has no effect on inflammation, but can be useful for headache and muscle-joint pain. It is a reasonable first attempt.

It can cause liver problems if used in very high doses and should never be taken excessively. If the regular dosage does not help, either add a NSAID or move to another medication, do not push the dose.

New NSAIDS

For reasons I do not understand, sometimes other NSAIDS work better than ibuprofen and can be taken regularly and less frequently during the day. It is reasonable to attempt others in this class, usually by prescription, before going to stronger medication.

These would include: Diclofenac (VoltarenTM) 50mgs three times a day, or the long acting VoltarenTM XL 100 mgs once daily; Sulindac (ClinorilTM) 100 to 200 mgs twice daily, do not exceed 400 mgs daily; Naprosyn and many others.

ArthrotecTM is a brand that combines diclofenac with the drug misoprostal to protect the stomach (50mgs/200mgs up to four times daily). Do not take if pregnant, or even if pregnancy is likely.

Tricyclics

These drugs are the old fash­ioned antidepressants (taken in low doses) and provide pain relief, but must be taken regularly to be effective. They should be used to prevent pain, and never be taken just when the pain is bad.

This is one type of medication that must be taken regularly, good days and bad. CFS patients are usually sensitive to them and lower starting doses should be used.

Tramadol (UltramTM 50 to 100 mgs three times daily)

I like this medication partly because the name sounds like Kurt Vonnegut designed it.

It should be used with caution in conjunction with ProzacTM and tricyclics. It is a cousin of the NSAIDS and has some effect on the serotonin and norepinephrine systems as well as being a very weak opiate.

While it is unlikely to cause dependence, some persons say it is unlikely to be of value. But it is worth a try.

Baclofen®

This is a nifty drug, cheap, and when it works—great. Unfortunately, it does not work very often.

It is best when the muscle pain is of a cramping or spasm quality, which is why it is used in multiple sclerosis.

It is related to the benzodiazepines such as clonazepam or alprazolam and should be used cautiously with these. Some sedation is likely, and the dose should not exceed 10 mgs three times daily.

Seizure medications

These must be used with caution, as the side effects may be significant, but when they work they are great.

• Neurontin (GabapentinTM 900 to 1800 mgs daily). This medication was devel­oped for seizure disorders and may cause dizziness or increase fatigue. The mechanism of pain relief is uncertain. Significant side effects are possible and it should be reviewed carefully before use.

• Carbamazepine (Tegretol® 100mgs twice daily to a maximum of 1200 mgs a day. Tegretol® XR 100 mgs twice a day.) This seizure medication can cause excitation, bone marrow problems and allergic reactions, and should not be used with erythromycin, Prozac and other drugs. It is a cousin of the tricyclics and sometimes gives good pain relief.

Narcotics

While these drugs always have the potential for addiction, it is said that addiction rarely occurs when used to treat severe pain.

Intermittent use is best if possible. Doctors are usually reluctant to use narcotics because of the risk of addiction; you don't need any more problems than you already have.

Propoxyphene (DarvonTM) is my least favorite drug because it may have a high addiction potentia,l yet wimpy pain relief.

A note in conclusion

When people hear the side effects of medications, they frequently become afraid and unwilling to try medications. If you were to see the side effect profile of aceta­minophen (Tylenol®) you would probably never take it because it includes death.

When 280 million people use a drug, side effects are bound to occur. Keep in mind that if you saw the side effects and dangers of taking a shower (i.e. slip­ping in the bathtub, etc) people would not bathe. That, however, also has its side effects (loss of friends, physicians, etc).

Use common sense.

Any medication that does something will have side effects. Some of the safest medica­tions are only safe because they do nothing at all.

Consider medications as you would consid­er driving a car. They are both inherently dan­gerous, but are helpful if used properly.

Dr. David S. Bell is an internationally known ME/CFS clinician based in Lyndonville, NY, the site of a 1980s cluster outbreak. He has been researching the illness and treating patients in his rural practice ever since. While he has spe­cial expertise as a pediatrician in treating young people with ME/CFS, his practice encompasses adults as well as children. This column originally appeared in his publication, The Lyndonville News, and appears here by permission. [2015 Note—Dr. Bell is retired and his newsletter is no long available.]

Dr. Komaroff's Progress Report on Chronic Fatigue Syndrome Research - Sept. 2008

Details

Last Updated: 07 November 2015 07 November 2015

by Anthony L. Komaroff, M.D., September 2008

It has been several years since we sent you a Progress Report. I'm pleased to report that there has been a lot of progress in research and in public recognition of the problem of chronic fatigue syndrome (CFS).

International Research Conferences/National Meetings

October 2004: Madison, Wisconsin. An international research conference organized by the International Association for Chronic Fatigue Syndrome (AACFS) attracted over 500 attendees, and over 100 research presentations were made.

April 2006: Barcelona, Spain. Sponsored by the Human Herpesvirus-6 Foundation, this international research conference involved over 100 research presentations, from scientists all over the world. The conference focused on one virus, human herpesvirus-6 (HHV-6), that our research group first linked to CFS. Since then, the virus has been linked to several other diseases, as well.

November 2006: National Press Club, Washington DC. Organized by the CFIDS Association, this event was standing room only for the media. Recent research about CFS from the U.S. Centers for Disease Control & Prevention (CDC) and other research teams was summarized. Dr. Julie Gerberding (Director of the CDC), Dr. William Reeves (head of the CDC's CFS research program), Dr. Nancy Klimas (a noted immunologist) and I updated the national media about CFS research.

May 2008: United States Senate, Washington DC. Organized by the CFIDS Association, this well-attended event was held to acquaint members of Congress with the latest research on CFS.

June 2008, Baltimore, Maryland. The HHV-6 Foundation organized another international research conference on HHV-6, and a second conference on Viruses in CFS, which I co-hosted. Hundreds of scientists from all over the world attended (including two winners of the Lasker Prize for Medicine, regarded as second in prestige only to the Nobel Prize), and over 100 research presentations were made.

Studies of the Impact of CFS

Dismissed by some when it was first defined 20 years ago, studies from the CDC (and our research group and others) have determined that CFS may affect 1-4 million adults in the U.S. The CDC estimates that CFS causes over $9 billion/year in lost productivity—and billions more in medical costs.

Studies of the Immune System

In the 1980's and 1990's, our group and others studied circulating immune system cells and chemicals, and found evidence that in many patients with CFS the immune system is in a state of chronic activation—as if it is waging a war against some intruder, like an infectious agent. In the past 5 years, it has become possible to study which genes are turned on in immune system cells. Studies from the CDC and other laboratories around the world find that the genes that activate immune system cells are indeed turned on more often in people with CFS than in healthy people. In addition, immune system chemicals called pro-inflammatory cytokines are found at higher levels in the blood, and these cytokines are known to be capable of producing some of the symptoms of CFS.

Studies of Infectious Agents

As you may recall from past reports, 16 years ago we reported that the virus called HHV-6 was "active" (making copies of itself, and infecting new cells) more often in patients with CFS. We also had noted that some of our patients who met the CDC criteria for CFS had both symptoms and laboratory test findings that suggested seizure disorders and multiple sclerosis (MS). But in the past two years, considerable evidence has been published linking HHV-6 to temporal lobe seizures and to MS. (Another virus linked to CFS, Epstein-Barr virus, also increasingly is being linked to multiple sclerosis). It is not proven that there is a connection between CFS and MS, or CFS and temporal lobe seizures, and it is not proven that HHV-6 is a cause of CFS, seizures or MS. However, the evidence that the virus may be triggering these illnesses in some patients is considerably stronger than it was five years ago.

Neurological and Brain Hormone Studies

Brain hormone studies—Since the last progress report, many more published studies have found abnormalities in certain brain hormones in patients with CFS. The hormones studied most often are corticotropin-releasing hormone (CRH), growth hormone, prolactin and serotonin. In particular, evidence is emerging that various molecules that involve the body's "stress axis" and the communication between the stress axis and the brain's serotonin system are different in patients with CFS. Variations in genes for some of these molecules have been identified, and unusual patterns of gene expression (whether a gene is turned on or off) have been identified.

Collectively, all of these studies demonstrate that something is subtly interfering with the function of the hypothalamus, which is part of the limbic system of the brain. What that "something" is remains unclear: you can't just reach into the middle of the living human brain and study it, and so one tries to get clues by indirect techniques.

Autonomic nervous system (ANS) studies—The ANS begins in the brain, and sends nerves to all parts of the body. These specialized nerves control vital functions such as blood pressure, body temperature, and digestion. As described in past Progress Reports, many research groups including our own have found abnormalities in the autonomic nervous system. What is not yet clear is whether any particular treatments work to correct these abnormalities.

Other studies of the brain—The majority of studies using various techniques for taking pictures of the brain—CT scans, MRI scans, PET scans—continue to report abnormalities in patients with CFS. In addition, a recent study identified a group of proteins in the spinal fluid (which bathes the brain) of patients with CFS that were not present in the spinal fluid of healthy people. The proteins indicated a low-grade inflammation in the brain. We are currently analyzing electroencephalograms (brain waves) from patients with CFS, patients with depression and healthy people to see if there are clear differences: preliminary analysis indicates that there are.

Energy Studies in CFS

Every cell in our bodies requires energy to function. The tiny "power packs" inside a cell are called mitochondria, and they liberate energy from oxygen (a process called oxidation). There is growing evidence that the process of producing energy in cells is impaired. There are differences in the levels of several molecules important in energy metabolism, considerable biochemical and genetic evidence of "oxidative stress", and some evidence that the mitochondria are physically damaged. It seems simplistic, but it may be true: the lack of energy felt by a person may indicate that the person's cells are having trouble generating energy.

Diagnostic Tests for CFS

In the last Progress Report I mentioned that several studies had found a defect in an anti-viral enzyme system called the 2-5A system. This defect is found much more often in patients with CFS than in healthy subjects, and could reflect an underlying viral infection. In these preliminary studies, the test seemed to differentiate patients with CFS from patients with other fatiguing illnesses and from healthy people. Since then, other types of tests also have been rep reported that seem to be very accurate in diagnosing CFS. However, all of these tests currently work only in research laboratories. More work is needed to simplify them and further test them before they can be considered diagnostic tests.

Treatments

There still are no treatments for CFS that have been proven in large, randomized clinical trials to be effective. One study conducted by the manufacturer found that a drug called Ampligen® improved the level of function. The drug must be given intravenously (it is not a pill) and is still experimental: it is not available for use.

A small non-randomized study conducted at Stamford University, and published late in 2006, suggested that treatment with an anti-viral drug called valganciclovir (Valcyte®) helped patients with CFS and evidence of reactivated infection with human herpesvirus-6 and/or Epstein-Barr virus. A small randomized trial is now underway, and has not yet been published. Valcyte is a pill, and is already on the market. I am waiting to see results of the randomized trial before considering prescribing it.

Conclusion

There continues to be progress in understanding CFS, and a growing number of scientists around the world who are studying it. This should be heartening for all of us who study CFS, and for those who suffer from it.

Publications By Our Research Group, Since the Last Progress Report

Schacterle RS, Milford EL, Komaroff AL, "The frequency of HLA class II antigens in chronic fatigue syndrome," JCFS 11 (2003) :33-42.

Schacterle RS, Komaroff AL, "A comparison of pregnancies that occur before vs. after the onset of chronic fatigue syndrome," Arch Intern Med 164 (2004) :401-4.

Robertson MJ, Schacterle RS, Mackin GA, Wilson SN, Bloomingdale KL, Ritz J, Komaroff AL," Lymphocyte subset differences in patients with chronic fatigue syndrome, multiple sclerosis, and major depression," Clin Exp Immunol Aug 141 (2005) :326-32

Matthews RM, Komaroff AL, "Changes in functional status in chronic fatigue syndrome over a decade: Do age and gender matter?" J Chr Fatigue Synd 14 (2007) : 33-42.

Komaroff AL, "Fatigue and chronic fatigue syndrome. "In: Karlson KJ and Eisenstat SA, eds. Primary Care of Women, Second Edition. St. Louis, MO: Mosby 2002, 615-23.     ­

Komaroff AL. "Chronic fatigue". In: Branch WT, Jr. Office Practice of Medicine (4th ed). Philadelphia: W.E. Saunders, Inc. 2003 , 957-966.­

Komaroff AL, "Chronic fatigue syndrome." In: Rakel RE, ed. Conn's Current Therapy 2003. Houston, TX: WB Saunders, 2003:119-23.

Komaroff AL, Jacobson S, Ablashi DV, Yamanishi K, "Highlights from the 5th International Conference on HHV-6 and -7," Herpes 13 (2006) : 3 .

Komaroff AL, "Is human herpesvirus-6 a trigger for chronic fatigue syndrome?" J Clin Virol 37 (2006) :S39-S46.

Lerner, Zervos, et al., "New Cardiomyopathy: Pilot Study of Intravenous Ganciclovir in a Subset of the Chronic Fatigue Syndrome," Infectious Disease in Clinical Practice, 1997; 6: 110-117

Details

Last Updated: 01 December 2015 01 December 2015

This article reviews a pilot study to test the efficacy of the anti-viral drug ganciclovir in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) patients. As part of the study, cardiac abnormalities were assessed in the patient group.

A study of 18 CFS patients (diagnosed according to both the 1988 and 1994 Centers for Disease Control & Prevention (CDC) criteria)) were recruited from a single infectious disease referral center. Anti-body titres for CMV (cytomegalovirus) and EBV (Epstein-Barr Virus) were performed on patients. A subset of 13 patients (group A) had high CMV IgG anti-body titres and no demonstrable titres to EBV (VCA), and 10 of the 13 patients had little or no evidence of EBV multiplication (EBV-EA).

A second subset of the remaining 5 patients (group B) had no antibody to CMV (3 patients) and a greater response to EBV anti-body titre tests (3 patients).

Group A "CMV patients" had been ill only an average of 1.6 years as opposed to a mean duration in Group B "EBV patients" of 2.6 years.

The study included a control group for the occurrence of CMV and EBV antibodies in normal, non-CFS persons. The controls "...commonly had IgG anti-bodies to HCMV...,"

The controls also had "lesser experience and lower mean titres of anti-bodies to EBV EA and in 55% of the group there was no evidence of current multiplication of EBV by EA titre."

Although differences were found in CMV and EBV anti-body titres among groups A, B, and C, these differences were not statistically significant.

An "Energy Index" (EI) was utilized in order to assist in determining the functional status of patients both before and after administration of ganciclovir. In this index Grade 0 indicates patient is bedridden; Grades 1-5 indicate moderate to severe illness; Grades 6-9 indicate ability to work with careful moderation. The mean EI of the CFS patient group was 3.6 and the control group 9.9.

Typical symptoms among CFS patients in Grades 0-5 include left-sided chest aches, palpitations, light-headedness, sore­ throats and feverishness.

Cardiac studies were performed on the patient group. ECG and echocardiograms were generally normal,  but "every patient in groups A and B showed abnormal T-wave oscillations by 24-hour Holter monitoring." (Patients in groups A and B had no known  pre-existing chronic illnesses.)

Moreover, "...abnormal myocardial dynamics by MUGA rest/stress studies were present in 6 of 13 patients (group A). These abnormalities consisted of problems with left ventricular dynamics...No patient in group B had abnormal ventricular dynamics."

Importantly: "These MUGA study changes are not seen in normal persons leading a sedentary life. Deconditioning and a sedentary life in normal patients are not causes of decreased or falling left ventricular EFs [ejection fractions]."

Infusions of Ganciclovir: All 18 patients were given ganciclovir intravenously for 30 days. They were advised to avoid exercise, fatigue and alcohol. Medication was provided to combat insomnia and severe reactive depression. "None of the patients had had psychiatric illnesses before the onset of CFS."  Patients "were asked not to exercise until 6 months after the completion of ganciclovir."

Results: At the start of treatment, the severity of the fatigue "was similar" in both CFS subgroups. "Six months later the energy index of patients in Group A was 7; but in Group B, only 4. There was very substantial improvement in the "CMV subset", but only slight improvement in the "EBV subset." (Remember also that Group A was sick for less time than Group B.) The study, however, was "..not blinded, randomized, or placebo-controlled."

In Group A, after treatment "...three patients with previously abnormal myocardial dynamics reverted to normal; in three others results of MUGA tests improved with lesser degrees of tardokinesis, hypokinesis, or left ventricular dilation."

Lerner, Goldstein, et al., "Cardiac Involvement in Patients with Chronic Fatigue Syndrome as Documented with Holter and Biopsy Data in Birmingham, Michigan, 1991-1993," Infectious Diseases in Clinical Practice, 1997; 6: 327-333

Details

Last Updated: 01 December 2015 01 December 2015

67 Chronic Fatigue Syndrome (CFS) patients with CFS (diagnosed both by the 1988 and 1994 Centers for Disease Control & Prevention (CDC) criteria) were screened for the study. Mitral valve prolapse (MVP) was not an exclusion criterion in the CFS and control groups. Patients and 78 non-CFS controls were younger than 50 and did not have any known heart or circulatory condition.

Controls were taken from patients seeking cardiac consultation for palpitations, chest pain or light­headedness. On the other hand, the 67 patient study sample was taken from an infectious disease practice, so patients were not pre-selected (apparently) for cardiac symptoms.

A higher number of controls had mitral valve proplapse than the CFS patients (35% vs. 12%). The percentage occurrence of MVP in the CFS patients is similar to MVP in the population at large, while the increased MVP percentage in the control group may account, partially, for their seeking assistance at the cardiological practice.

[Massachusetts CFIDS/ME & FM Association Comment: The prevalence of MVP between the two groups is important in interpreting the study's results. The finding that CFS patients have a higher rate of abnormalities by Holter monitoring indicates that such abnormalities are not due to MVP, since, if so, one would expect a higher rate of MVP similar to the control group. Moreover, the researchers assert, in the study reviewed immediately below, "New Cardiomyopathy: Pilot Study of Intravenous Ganciclovir in a Subset of the Chronic Fatigue Syndrome": "Mitral valve prolapse without mitral valve insufficiency does not cause abnormal or wave oscillations at Holter monitoring. "]

Both groups were subject to 24-hour Holter monitoring to measure cardiac function.

"The prevalence of both T-wave inversions (CFS 61% vs. 34%, P=.0l) and T-wave flattenings (CFS 96% v. 71%, P=.0l) were significantly different between the two groups."

In an earlier study ("Repetitively Negative Changing T waves at 24-hour Electrocardiographic Monitors in Patients with CFS," Chest 104 (1993): 1417-21), Lerner found that "In CFS patients, oscillating abnormal T-waves were regularly seen with the onset of sinus tachycardias, and the abnormal T­ waves typically then resolved with the reappearance of normal sinus rhythms."

The two studies indicate that intermittent tachycardia, documented by Holter-monitoring T-wave abnormalities, is a frequent symptom of CFS. "This study confirms our earlier report that CFS patients uniformly have abnormal oscillating T-wave flattenings and T-wave inversions by Holter-monitoring. " They found 12-lead standard ECG's and 2-D echocardiograms did not generally show the cardiac abnormalities in CFS patients.

As part of the study, 9 CFS patients submitted to endomyocardial biopsies (the taking of heart tissue for examination). 8 of the specimens showed no active myocarditis (inflammation of heart muscle), mitochondrial abnormalities, and other pathological changes. Additionally, 7 of the biopsied patients also had electron microscopic studies (tissue samples examined under electron microscope). Six patients showed various electronmicroscopic myofiber abnormalities. [Cautionary note: These changes were noted in a very small number of CFS patients.]

Cardiac Symptoms and Abnormalities Documented in CFS Patients: (A summary of 4 studies by Lerner et al.)

Details

Last Updated: 10 January 2016 10 January 2016

Over the past several years, in a number of small studies, Dr. A. Martin Lerner and his collaborators at Wayne State University and the University of Michigan have objectively documented heart symptoms and abnormalities in a percentage of Myalgic Encephalomyelitis/chronic Fatigue Syndrome (ME/CFS) patients.

In one study, the administration of intravenous ganciclovir had a marked effect in a subset of ME/CFS patients in increasing their ability to function.

Studies ¹ and ² cited below objectively documented intermittent tachycardia in a very high percentage of CFS patients. The tachycardia is accompanied by T-wave abnormalities as measured by 24-hour Holter monitoring.

CFS patients for these two studies were selected from infectious disease practices, were younger than 50, and did not have any known heart or circulatory condition. Patients experienced left-sided chest pain, palpitations, rapid pulse and light-headedness.

Lerner found that, "In CFS patients, oscillating abnormal T-waves were regularly seen with the onset of sinus tachycardias, and the abnormal T-waves then resolved with the reappearance of normal sinus rhythms." ¹

"This study ² confirms our earlier report ¹, just quoted that CFS patients uniformly have abnormal oscillating T-wave flattenings and T-wave inversions by Holter monitoring."

In this study, 96% of 51 CFS patients (1988 and 1994 diagnostic criteria) had one or both of the T-wave abnormalities. The studies found that 12 lead standard ECGs and 2-D echocardiograms do not generally show these cardiac abnormalities in CFS.

In a new unpublished study ⁴, the researchers found "... 24% of 87 non-selected CFS patients from a recent consecutive case series exhibited left ventricular dysfunction, by stress radioscopic multiple gated acquistion (blood pool image) (MUGA) method. Abnormal cardiac wall motion at rest and stress, dilation of the left ventricle, and segmental wall motion abnormalities were present.

These abnormal ejection fractions demonstrate abnormal left ventricular function and are not seen with normal persons living a sedentary lifestyle."

In another study ³, 18 CFS patients were given the anti-viral ganciclovir intravenously for 30 days. A subset of patients, ill for an average of 1.6 years and with somewhat elevated CMV (cytomegalovirus) anti-body titres, experienced substantial improvement in overall ability to function. This study, "was not blinded, randomized, or placebo-controlled."

The following articles by Lerner et al. are the sources for the information in this article (the reference number for each article is used to cite the article in the text above):

1. Lerner et al., "Repetitively negative changing T waves at 24 hour electrocardiographic monitors in patients with CFS," Chest 104 (1993):1417-21.

2. Lerner, Goldstein, et al., "Cardiac Involvement in Patients with Chronic Fatigue Syndrome as Documented with Holter and Biopsy Data in Birmingham, Michigan, 1991-1993," Infectious Diseases in Clinical Practice 6 (1997): 327-333.

3. Lerner, Zervos, et al., "New Cardiomyopathy: Pilot Study of Intravenous Ganciclovir in a Subet of the Chronic Fatigue Syndrome," Infectious Diseases in Clinical Practice 6 (1997): 110-117.

4. Lerner, Sayyed, Dworkin, et al. "Abnormal Left Ventricular Dynamics in Patients with Chronic Fatigue Syndrome in Birmingham, Michigan, 1987-1994" (submitted for publication)