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BMJ article on infectious mononucleosis incl. paragraph on CFS

Dolphin

Senior Member
Messages
17,567
(Not a recommendation)

"Infectious mononucleosis" is often called "mono" or "glandular fever".

http://bmj.com/cgi/content/extract/350/apr21_2/h1825?ct

BMJ 2015;350:h1825 doi: 10.1136/bmj.h1825 (Published 21 April 2015)

Clinical Review

Infectious mononucleosis Paul Lennon specialist registrar 1 , Michael Crotty general practitioner 2 , John E Fenton professor 1

[..]

Does infectious mononucleosis lead to chronic fatigue syndrome?

Chronic fatigue syndrome is defined as severe fatigue and disabling musculoskeletal and cognitive symptoms without another explanation that lasts for at least six months and results in severe impairment in daily functioning.w47

There has been much debate about the cause of this disorder.

Some authors suggest that it is precipitated by an acute infection, such as infectious mononucleosis, as many patients relate the onset of their illness to an initial infection from which they never recovered.w48

Prospective studies have reported an incidence of chronic fatigue syndrome of 7.3-12% in adults six months after infectious mononucleosis.w49 w50

However, the relation between chronic fatigue syndrome and infectious mononucleosis is still questionable.

A study of over 1300 patients diagnosed as having infectious mononucleosis by serology, found that although 10% of patients reported fatigue none fulfilled the criteria for chronic fatigue syndrome (table 2⇓).15

The cause of chronic fatigue syndrome is likely to be multifactorial.

A trial that compared activity with imposed bed rest in the management of infectious mononucleosis found that those patients who were allowed out of bed as soon as they felt able reported a quicker recovery.w52

A brief intervention at the time of diagnosis of infectious mononucleosis to allay fears of a prolonged disease may help to prevent the development of chronic fatigue syndrome.w53

A recent editorial commented that chronic fatigue syndrome is unlikely to be a consequence of Epstein-Barr virus but a heterogeneous family of disorders arising from a constellation of pathophysiological causes.16

w53 Candy B1, Chalder T, Cleare AJ, Wessely S, Hotopf M. A randomised controlled trial of a psycho-educational intervention to aid recovery in infectious mononucleosis. J Psychosom Res. 2004 Jul;57(1):89-94.

Lennon et al. Table 2.png
 
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Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
BMJ study said:
A study of over 1300 patients diagnosed as having infectious mononucleosis by serology, found that although 10% of patients reported fatigue none fulfilled the criteria for chronic fatigue syndrome (table 2⇓).15
Huh? Both the table 2 and the individual studies (at least the ones I've read) state the patients were diagnosed with CFS, though some relied on questionnaire report rather than clinical examination. Do you have reference 15?

eg
White 1998 said:
Incidence, risk and prognosis of acute and chronic fatigue syndromes and psychiatric disorders after glandular fever.
...The prevalence of CFS was 9-22% six months after glandular fever,...
The most conservative measure of the incidence of CFS was 9% after glandular fever, compared with no cases after an URTI. A conservative estimate is that glandular fever accounts for 3113 (95% CI 1698-4528) new cases of CFS per annum in England and Wales
 

Marco

Grrrrrrr!
Messages
2,386
Location
Near Cognac, France
A study of over 1300 patients diagnosed as having infectious mononucleosis by serology, found that although 10% of patientsreported fatigue none fulfilled the criteria for chronic fatigue syndrome (table 2⇓).15

A trial that compared activity with imposed bed rest in the management of infectious mononucleosis found that those patients who were allowed out of bed as soon as they felt able reported a quicker recovery.w52 A brief intervention at the time of diagnosis of infectious mononucleosis to allay fears of a prolonged disease may help to prevent the development of chronic fatigue syndrome.w53

These two statements strike me as a little contradictory. If the relationship beween infectious mononucleosis and chronic fatigue syndrome "is still questionable" then why the need for a brief 'psycho-educational' intervention to prevent it?
 
Messages
13,774
A study of over 1300 patients diagnosed as having infectious mononucleosis by serology, found that although 10% of patientsreported fatigue none fulfilled the criteria for chronic fatigue syndrome (table 2⇓).

That study's here: http://qjmed.oxfordjournals.org/content/99/1/49 (They added an extra r to Petersen's name in their table).

It looks like patients weren't examined for CFS, so they just didn't happen to get a diagnosis in their routine medical care (and knowing that lots of people who fulfil the criteria don't get a diagnosis, I'm not sure how important this is [edit: especially as follow up was only one year]).

A brief intervention at the time of diagnosis of infectious mononucleosis to allay fears of a prolonged disease may help to prevent the development of chronic fatigue syndrome.w53

Non-blinded trial that used subjective self-report measures as outcome and showed no difference between treatment group and control (who recieved a leaflet and no therapist time) at 12 months: http://forums.phoenixrising.me/inde...o-educational-intervention-to-aid-reco.13326/
 
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Simon

Senior Member
Messages
3,789
Location
Monmouth, UK
It looks like patient's weren't examined for CFS, so they just didn't happen to get a diagnosis in their routine medical care (and knowing that lots of people who fulfil the criteria don't get a diagnosis, I'm not sure how important this is).
Yes, that's a big database study, done entirely on codings entered into a database some time earlier.
although 10% of patients reported fatigue none fulfilled the criteria for chronic fatigue syndrome
So the studies where patients were prospectively followed and tested for CFS did have CFS post-glandular fever. The database study, where patients were not specifically checked for CFS, didn't find it.

So basically this is bunk, based on a misreading of a database study and ignoring specific CFS studies:
The new study said:
However, the relation between chronic fatigue syndrome and infectious mononucleosis is still questionable.
 

Jonathan Edwards

"Gibberish"
Messages
5,256
One wonders why an ENT registrar would be writing a clinical review on infectious mononucleosis (or the relation to CFS). Reviews like this tend to be writing projects given to registrars with essentially no experience of the relevant disease by a boss who is keen for both of them to get a paper on their CV. It is hardly surprising that you often end up with something that looks as if it is written by someone who has no idea of the subject (they don't). It is disappointing that this is published in the BMJ.
 

user9876

Senior Member
Messages
4,556
These two statements strike me as a little contradictory. If the relationship beween infectious mononucleosis and chronic fatigue syndrome "is still questionable" then why the need for a brief 'psycho-educational' intervention to prevent it?


A trial that compared activity with imposed bed rest in the management of infectious mononucleosis found that those patients who were allowed out of bed as soon as they felt able reported a quicker recovery.w52 A brief intervention at the time of diagnosis of infectious mononucleosis to allay fears of a prolonged disease may help to prevent the development of chronic fatigue syndrome.w53

I would have read this as those who were recovering quicker got out of bed earlier. The language 'allowed out of bed' is strange and leading.
 
Messages
13,774
Unimportant note:

A trial that compared activity with imposed bed rest in the management of infectious mononucleosis found that those patients who were allowed out of bed as soon as they felt able reported a quicker recovery.w52

They reference this review:

w52. Candy B, Chalder T, Cleare AJ, et al. Recovery from infectious mononucleosis: a case for more than symptomatic therapy? A systematic review. Br J Gen Pract 2002;52(483):844-51.

[Free: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1316091/ ]

Which cites this paper:

Dalrymple W. Infectious mononucleosis—2. Relation of bed rest
and activity to prognosis. Postgrad Med J 1964; 35: 345-349.

Which I can't find.

To some extent, I tend to assume that people are best off doing what they want when sick rather than being told to behave in some way or other. I was surprised I'd not heard of that trial as the reference was from 2002, but am less surprised if the trial was from 1964.

I was hoping we'd be able to look at the peer review for this, but maybe the BMJ only does open peer review for certain sorts of papers? I couldn't see anything for this.
 
Messages
13,774
A couple of rapid responses for this posted, one from Shirwan Mirza says:

One of the most common myths associated with infectious mononucleosis is chronic fatigue syndrome (recently re-named mysteriously as systemic exertion intolerance disorder, SEID).

In this review, Dr. Paul Lennon and colleagues mention that there is 7.3-12% chance of chronic fatigue associated with infectious mononucleosis 6 months after diagnosis 6 months after diagnosis. Most of these patients do not meet the international criteria for myalgic encephalitis/ chronic fatigue syndrome/ SEID.

http://www.bmj.com/content/350/bmj.h1825/rapid-responses
 

Snow Leopard

Hibernating
Messages
5,902
Location
South Australia
A couple of rapid responses for this posted, one from Shirwan Mirza says:
http://www.bmj.com/content/350/bmj.h1825/rapid-responses

Has anyone here heard of Shirwan Mirza?

His point is frustrating, in that it is all in what he doesn't say, rather than what he does say. We know that EBV is not the specific cause of ME or CFS and evidence of chronic EBV is fleeting. However, we also know that in prospective studies, that CFS is indeed a consequence of EBV at a high rate - this is where that 7.3-12% figure comes in and this is high quality evidence. Other infections may trigger the illness, but that does not mean the EBV link is unimportant.

Edit- additional links related to Shirwan Mirza:
https://www.facebook.com/MECFSmetabolicapproach
Apparently he is a doctor that does lots of metabolic testing and tries to find exclusionary diagnoses to CFS if at all possible.
 
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Forbin

Senior Member
Messages
966
One of the most common myths associated with infectious mononucleosis is chronic fatigue syndrome (recently re-named mysteriously as systemic exertion intolerance disorder, SEID).


Yes, it certainly is mysterious. All we have to go on are sightings of this ghostly 305 page report by the Institute of Medicine.

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