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How long does your PEM last?

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
@GracieJ I was also a non salt person for many years and around 14yrs ago something clicked, the day after I treated myself to pizza I felt so much better. It happened every time and then I finally made the high sodium connection.

I salt everything now, including fruit, love chunky sea salt crystals on my pears and apples.

I love salt, but on fruit? Yuck!
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
Yes and apparently coffee and dark chocolate are good for us too :p so stock up!

Probably best to go easy though, and get sugar-free chocolate if poss. I have a delicious one - a dark one sweetened with xylitol - this is it. But I only have a max 3-4 squares a day. If I have more, I think it adversely affects my bowel function, which in turn worsens other symptoms.

I try to avoid having chocolate or coffee after mid-afternoon, as I think it might adversely affect sleep if I have it later. I think someone else noted this.
 

Mij

Messages
2,353
Probably best to go easy though, and get sugar-free chocolate if poss. I have a delicious one - a dark one sweetened with xylitol - this is it. But I only have a max 3-4 squares a day. If I have more, I think it adversely affects my bowel function, which in turn worsens other symptoms.

I try to avoid having chocolate or coffee after mid-afternoon, as I think it might adversely affect sleep if I have it later. I think someone else noted this.

I've never seen this brand before. I'll bet you can't taste the difference between xylitol and regular sugar either. Chocolate in moderation is considered healthy and it just does something for the soul. which is your favourite flavour? Do you think coffee at all?

The health food store I go to has so many different brands of chocolates with all sorts of natural sweetners, but they are $5-6 a bar + tax. I started making my own. I use raw cacao powder, vanilla powder, coconut nectar syrup and coconut oil, melt it all down, sprinkle it with chunky sea salt and put it in the refrigerator to harden. I'll drink a small espresso 2-3x week, before noon and I'm ok. I *try* not to eat the chocolate after 5pm because it can give the jitters before sleeping.
 

Mij

Messages
2,353
Like others, it depends. My PEM often starts during activity/exertion. In the past, I could sometimes stop activity before PEM started. These days, most minimal daily living activities cause PEM. Certain activities trigger PEM instantly. Others are tolerable for a bit.

My PEM can last minutes to hours to days to months. The months-long PEM often turns into a permanent illness setbacks. Do others have this wide a variance in their PEM? This has always been the case for me, even when my condition was moderate. I also have a very long list of worsening symptoms during PEM (from pain, immune symptoms, heightened sensory sensitivity, fluctuating chills....). I do have OI and this influences my specific brand of PEM.

People may be answering different questions in this thread, though. For me, minimal daily activities cause PEM. For others, they may be talking about what happens after they walk for fifteen minutes. Others may be relaying what happens after they go out to dinner with friends. The variation of activities and severity influence which question people are answering. I haven't read through the whole thread. Don't know if this has already been discussed.

I have not had the variations you experience with PEM. Once it starts I can not reduce the severity or length of time. It just has to take it's course and the severity depends on how much I overdid. I don't overdo now and haven't experienced PEM for several months. I watch the clock and time everything I do.

I would also say that OI (if this is what I have) makes the PEM very distressful for sure. I didn't have PEM for the first 7yrs years but when I started to run (!!) is when it got worse and worse over the years. Probably the stupidist thing I ever did, and the fact I was warned not to so. I thought that because I recovered after a day or two I ok was again. :ill:
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
I've never seen this brand before. I'll bet you can't taste the difference between xylitol and regular sugar either. Chocolate in moderation is considered healthy and it just does something for the soul. which is your favourite flavour? Do you think coffee at all?

The health food store I go to has so many different brands of chocolates with all sorts of natural sweetners, but they are $5-6 a bar + tax. I started making my own. I use raw cacao powder, vanilla powder, coconut nectar syrup and coconut oil, melt it all down, sprinkle it with chunky sea salt and put it in the refrigerator to harden. I'll drink a small espresso 2-3x week, before noon and I'm ok. I *try* not to eat the chocolate after 5pm because it can give the jitters before sleeping.

My favourite chocolate flavour is plain, strong chocolate - no extra flavours! The Plamil brand is absolutely delicious. I do find that xylitol tastes exactly the same as sugar.

I'm not sure whether you were asking about coffee-flavoured chocolate or coffee. Coffee-flavoured choc is my second choice after plain choc, I think. I don't drink much coffee now as it can make me jittery, but I think that people vary a lot. I used to be able to drink strong coffee at any time and it didn't affect my sleep.
 

MeSci

ME/CFS since 1995; activity level 6?
Messages
8,231
Location
Cornwall, UK
I have not had the variations you experience with PEM. Once it starts I can not reduce the severity or length of time. It just has to take it's course and the severity depends on how much I overdid. I don't overdo now and haven't experienced PEM for several months. I watch the clock and time everything I do.

I would also say that OI (if this is what I have) makes the PEM very distressful for sure. I didn't have PEM for the first 7yrs years but when I started to run (!!) is when it got worse and worse over the years. Probably the stupidist thing I ever did, and the fact I was warned not to so. I thought that because I recovered after a day or two I ok was again. :ill:

I wonder whether @oceiv is confusing PEM, which should perhaps be called 'delayed PEM', with the fatigue/exhaustion that can set in during exertion? With me that is simple fatigue, often accompanied by feeling very hot and slightly short of breath, whereas the real PEM has lots of other flu-type symptoms. I experience it as a combination between flu and a hangover, and once it starts it has to run its course.

I think I noticed from an old thread that Julia Newton was looking into preventing lactate build-up during exertion, which I think would probably prevent PEM, but I can't find it now and assume that she hasn't figured it out yet!
 

Mij

Messages
2,353
@MeSci I find a small amount of coffee (6 sips) gives me just enough boost, it does not affect my health negatively. I love coffee flavoured chocolate too.
 

Mij

Messages
2,353
I wonder whether @oceiv is confusing PEM, which should perhaps be called 'delayed PEM', with the fatigue/exhaustion that can set in during exertion? With me that is simple fatigue, often accompanied by feeling very hot and slightly short of breath, whereas the real PEM has lots of other flu-type symptoms. I experience it as a combination between flu and a hangover, and once it starts it has to run its course.

I think I noticed from an old thread that Julia Newton was looking into preventing lactate build-up during exertion, which I think would probably prevent PEM, but I can't find it now and assume that she hasn't figured it out yet!

It seems we have to be very specific when it comes to describing our PEM. Yes, "delayed PEM" is a much better term to describe the distinctive PEM.
 

oceiv

Senior Member
Messages
259
I wonder whether @oceiv is confusing PEM, which should perhaps be called 'delayed PEM', with the fatigue/exhaustion that can set in during exertion? With me that is simple fatigue, often accompanied by feeling very hot and slightly short of breath, whereas the real PEM has lots of other flu-type symptoms. I experience it as a combination between flu and a hangover, and once it starts it has to run its course.

I think I noticed from an old thread that Julia Newton was looking into preventing lactate build-up during exertion, which I think would probably prevent PEM, but I can't find it now and assume that she hasn't figured it out yet!

I've thought about your idea and looked at exertion intolerance symptoms for comparison, Exertion intolerance symptoms or ME/CFS fatigue during exercise symptoms do not describe my symptoms. My PEM is not solely exhaustion nor heat or being out of breath. My PEM includes pain, immune symptoms (like sore throat), chills/sweats, feeling cold, headaches, heavy limbs, increased sensory sensitivity and many more symptoms. These symptoms start for me during activity. There is no break in duration as these same symptoms continue to occur post-activity for various durations. These same symptoms occur during emotional exertion/stress/etc. and sometimes during mental exertion.

When first got diagnosed, I relayed these symptoms and their timing to my ME/CFS specialist. I had no idea what was happening. He didn't seem surprised (He was nodding and had a look of recognition) and immediately gave me advice. He said I should try to stop activity before these symptoms come on and told me how to do so. Also, he said should these symptoms come on despite my efforts, I should stop activity immediately. Whenever I read articles about PEM, they describe at least some and sometimes many of (depending on the account) my PEM symptoms. I thought that I had read accounts over the years, of some other patients who also experience what are for most patients PEM symptoms, except their PEM starts during activity. It hasn't been the majority, but I think other patients with this PEM timing are out there.

As a comparison, when the same ME/CFS doctor saw one of my symptoms at a different appointment and he had never seen it in all his years of practice, he honestly said he'd never seen this before. He was puzzled and stunned. When it comes to my health, I'm often the 1% of the 1%.
 

Mij

Messages
2,353
@oceiv I've had symptoms similar to PEM (or can even call them the same) during exertion too, this was related to my immune system being activated by a virus or during allergy season. Could this be your situation?

In your last paragraph, what was the symptoms your doctor had not seen before?
 

oceiv

Senior Member
Messages
259
@Mij Interesting about your immune symptoms. When you had those symptoms, did the same symptoms continue with no break after exertion stopped? My symptoms happen year-round. I do have both allergies and recurring infections, but the PEM symptoms happen regardless of if these two are present or not.

I think one of the differences in my case wrt to PEM, may be due to the fact that my illness is and was from the start, very heavy on the pain, immune and neurological symptoms. My understanding of why what are typically post-exertion symptoms happen for me during exertion has to do with the time duration variance of PEM onset. PEM onset occurs on a time spectrum, with some patients having symptoms immediately after exertion, some 24-48 hours after exertion and some days after exertion. If we are on a spectrum, I'm at one end of the spectrum and patients whose PEM starts days later are at the other end. Sometimes, I do experience classic PEM. More often though, my symptoms start during physical/emotional/mental exertion. The PEM always starts with similar symptoms regardless of whether onset is during or post-activity.

What I wonder is if other patients continue exertion well-beyond the point they should, do their PEM symptoms still wait until afterwards? Or if not, what do they feel if they push themselves in this manner? One set of symptoms during the period in which they've pushed themselves and a different symptom set once PEM starts? It may just be that the same process is happening to all of us, but that I feel symptoms earlier in the process. Hypothetically, let's say that PEM was found to be only due to only one metabolic process (it's more complicated, but just for example's sake). I might feel symptoms when this process is on step 5, while others feel symptoms only on step 10. Still others feel symptoms only on step 20.

The mystery symptom was unrelated to PEM. (Okay, you asked...) It was that certain sections of several toes turned blue under certain conditions. :eek: My ME/CFS doctor, rheumatologist, cardiologist/OI doctor and several vascular specialists all had never seen anything like it. I also have Raynaud's, but this particular symptom didn't fit there either. I also did find a very old description of ME, which had an inclusion of cyanosis, but cyanosis usually presents differently.
 
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Mij

Messages
2,353
Mij Interesting about your immune symptoms. When you had those symptoms, did the same symptoms continue with no break after exertion stopped? My symptoms happen year-round. I do have both allergies and recurring infections, but the PEM symptoms happen regardless of if these two are present or not.
Yes the viral symptoms (and allergy symptoms) would continue but the shortness of breath and weakness/ shakiness would be less noticeable because I would stay lying down. I can deal with it, it's not distressing me.

It is not the same as delayed PEM though, when I get delayed PEM after over exerting I don't want to talk, think or deal with anything or anyone. It's so distressing I want to be put out until it's gone.
When you say PEM P=Post, if this is happening during exertion it's not "post". This is why I was asking whether you are experiencing an immune response to exertion and not necessarily PEM. Not sure if I"m explaining myself well.


What I wonder is if other patients continue exertion well-beyond the point they should, do their PEM symptoms still wait until afterwards? Or if not, what do they feel if they push themselves in this manner? One set of symptoms during the period in which they've pushed themselves and a different symptom set once PEM starts?

I have gone beyond my limits and that is what causes PEM. Yes PEM will always be delayed. Maybe I can explain better. I can do activities and not realize I'm overdoing because I don't feel any different- unless I do an extreme amount (over my boundary) My first symptoms would be equilibrium problems, leg tiredness and slurring words. This is when I know I need to stop what I'm doing. Just stay lying down until I'm ok again.
This will hopefull prevent delayed PEM (fingers crossed) It's tricky so I time everything now in advance and try not to put myself in that situation.

The mystery symptom was unrelated to PEM. (Okay, you asked...) It was that certain sections of several toes turned blue under certain conditions. :eek: My ME/CFS doctor, rheumatologist, cardiologist/OI doctor and several vascular specialists all had never seen anything like it. I also have Raynaud's, but this particular symptom didn't fit there either. I also did find a very old description of ME, which had an inclusion of cyanosis, but cyanosis usually presents differently.

I don't mean to scare you but when I worked for a Podiatrist we saw this in one patient and the doctor suspected a brain tumour. The patient went for an MRI or CT scan and sure enough it was a benign brain tumour weird eh?


 

taniaaust1

Senior Member
Messages
13,054
Location
Sth Australia
I wonder whether @oceiv is confusing PEM, which should perhaps be called 'delayed PEM', with the fatigue/exhaustion that can set in during exertion? With me that is simple fatigue, often accompanied by feeling very hot and slightly short of breath, whereas the real PEM has lots of other flu-type symptoms. I experience it as a combination between flu and a hangover, and once it starts it has to run its course.

I think I noticed from an old thread that Julia Newton was looking into preventing lactate build-up during exertion, which I think would probably prevent PEM, but I can't find it now and assume that she hasn't figured it out yet!

This is why I hate PEM being in diagnostic criteria as everyone has completely different ideas of what it is, situation probably even worst when it comes to doctors and trying to diagnose people.

For me my immune system symptoms can come in right away on exertion without the delay eg starting to get a sore throat is one of my early warning symptoms. I can also get an asthma attack. The exactly the same night as I've overdone, I can be feverish.
 

taniaaust1

Senior Member
Messages
13,054
Location
Sth Australia
The mystery symptom was unrelated to PEM. (Okay, you asked...) It was that certain sections of several toes turned blue under certain conditions. :eek: My ME/CFS doctor, rheumatologist, cardiologist/OI doctor and several vascular specialists all had never seen anything like it. I also have Raynaud's, but this particular symptom didn't fit there either. I also did find a very old description of ME, which had an inclusion of cyanosis, but cyanosis usually presents differently.

oceiv. I get that symptom at times with all this, I also used to get Raynauds with this too. Raynauds when I was getting it used to give me like white bloodless looking patches and blue patches in other parts (often the colour would switch at a joint).

I still have my toes go blue at times.. mostly on just one foot (my left foot).
 

taniaaust1

Senior Member
Messages
13,054
Location
Sth Australia
@Mij Interesting about your immune symptoms. When you had those symptoms, did the same symptoms continue with no break after exertion stopped? My symptoms happen year-round. I do have both allergies and recurring infections, but the PEM symptoms happen regardless of if these two are present or not.

I think one of the differences in my case wrt to PEM, may be due to the fact that my illness is and was from the start, very heavy on the pain, immune and neurological symptoms. My understanding of why what are typically post-exertion symptoms happen for me during exertion has to do with the time duration variance of PEM onset. PEM onset occurs on a time spectrum, with some patients having symptoms immediately after exertion, some 24-48 hours after exertion and some days after exertion. If we are on a spectrum, I'm at one end of the spectrum and patients whose PEM starts days later are at the other end. Sometimes, I do experience classic PEM. More often though, my symptoms start during physical/emotional/mental exertion. The PEM always starts with similar symptoms regardless of whether onset is during or post-activity.

What I wonder is if other patients continue exertion well-beyond the point they should, do their PEM symptoms still wait until afterwards?

It may wait.. a person may be able to push hard all day one day but then end up in bed for weeks starting the next day. I do think there is a set process going on which causes this. I used to have strongly delayed symptoms but now I get them more immediately including sore throat.

I do also think that maybe if a person can learn how much they can do without causing a delayed PEM reaction, it can really help stop go into that by restricting the activities more when needed. Before I got the early warning symptoms I do now, I used to go by the clock. I knew I could do certain things for certain time periods before I was at risk fo causing delayed PEM. eg Originally I didn't get a sore throat early warning sign to stop now and just didn't get the warning I do now.
 

oceiv

Senior Member
Messages
259
Yes the viral symptoms (and allergy symptoms) would continue but the shortness of breath and weakness/ shakiness would be less noticeable because I would stay lying down. I can deal with it, it's not distressing me.

It is not the same as delayed PEM though, when I get delayed PEM after over exerting I don't want to talk, think or deal with anything or anyone. It's so distressing I want to be put out until it's gone.
When you say PEM P=Post, if this is happening during exertion it's not "post". This is why I was asking whether you are experiencing an immune response to exertion and not necessarily PEM. Not sure if I"m explaining myself well.

I understand and think you're explaining well. You have two different sets of symptoms, one during exertion and one post-exertion. You're right that it's not completely accurate when I say PEM because it's not only "post." But the 2 reasons I refer to it with this term is 1) other patients, family and knowledgeable doctors know the symptom cluster to which I'm referring vs. them thinking what I'm experiencing is what you, @MeSci or others experience during exertion. 2) It is one complete, uninterrupted process for me. I do also feel the fatigue, blood pressure drops, heat and other symptoms other ME/CFS experience but when the PEM-type symptoms occur, they are distinct from the other set of symptoms. So, it wouldn't be quite accurate if I called them DEM (during exertion symptoms) symptoms either, because while they start during activity, the same symptoms continue post-activity. It wouldn't be descriptive of what I experience to say these are two distinct sets of symptoms, because they are one long set of the same miserable symptoms.




I have gone beyond my limits and that is what causes PEM. Yes PEM will always be delayed. Maybe I can explain better. I can do activities and not realize I'm overdoing because I don't feel any different- unless I do an extreme amount (over my boundary) My first symptoms would be equilibrium problems, leg tiredness and slurring words. This is when I know I need to stop what I'm doing. Just stay lying down until I'm ok again.
This will hopefull prevent delayed PEM (fingers crossed) It's tricky so I time everything now in advance and try not to put myself in that situation.

I too have equilibrium problems, leg tiredness as well as my legs giving out if I overdo it. These are signs that I should stop activity and I also try to avoid getting to that point. Although, it is harder since my illness got more severe. But I also start getting PEM/PENE-symptoms during activity and those also signal me to stop, as well. We just have a different presentation of the same symptoms. Most CFS/ME patients experience these symptoms post-exertion, but some patients vary from this onset pattern. I hope I've explained myself well.



I don't mean to scare you but when I worked for a Podiatrist we saw this in one patient and the doctor suspected a brain tumour. The patient went for an MRI or CT scan and sure enough it was a benign brain tumour weird eh?

Thanks for telling me. Very weird. But my problem isn't continuous or worsening. It only happens under certain conditions. It has also gotten somewhat better over time.
 
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oceiv

Senior Member
Messages
259
This is why I hate PEM being in diagnostic criteria as everyone has completely different ideas of what it is, situation probably even worst when it comes to doctors and trying to diagnose people.

For me my immune system symptoms can come in right away on exertion without the delay eg starting to get a sore throat is one of my early warning symptoms. I can also get an asthma attack. The exactly the same night as I've overdone, I can be feverish.

I understand why you do hate it. I don't hate the inclusion, but do wish it was more clearly stated that people have different symptom clusters during PEM, that PEM can vary widely in duration and that the onset may vary. Also, it would be good to emphasize more that it takes different levels of activity for different patients to bring PEM onset. It also varies within one patient; one day standing for 5 minutes can bring on PEM, another day standing for one minute could do it. Your early-warning sore throat and/or low-grade fever/under-fever sound exactly like what I get. It's like an alarm. I also get a host of other early-warning symptoms. If I continue exertion beyond that point, I get severe, pro-longed PEM. If I listen to the early-warning during activity, my PEM will be less severe and less-prolonged. Obviously, it would be better to stop before I get to that point, but I need to do at least some daily living activities. When I was moderately-ill, avoidance was possible more often, but my PEM onset was more unpredictable. My OI can often bring on mild asthma attacks.




It may wait.. a person may be able to push hard all day one day but then end up in bed for weeks starting the next day. I do think there is a set process going on which causes this. I used to have strongly delayed symptoms but now I get them more immediately including sore throat.

I do also think that maybe if a person can learn how much they can do without causing a delayed PEM reaction, it can really help stop go into that by restricting the activities more when needed. Before I got the early warning symptoms I do now, I used to go by the clock. I knew I could do certain things for certain time periods before I was at risk fo causing delayed PEM. eg Originally I didn't get a sore throat early warning sign to stop now and just didn't get the warning I do now.

It sounds like we had a similar progression of our PEM experiences, learning how to manage activity and that similarly, our current early-warnings are more frequent than they used to be. Early on in my illness, I could push hard through activity, but then would end up sidelined for weeks or months. I was also paradoxically, much more functional. But I always had those early-warning, PEM-type symptoms during many activitities. I just didn't recognize them as warnings. All of the symptoms were new to me and overwhelmingly blended together. Now my illness is severe and the early-warnings come with most activity. If I may ask, is your illness also severe and heavy on either pain, immune and/or neurological symptoms? My theory is that greater severity and a different initial symptom set might distinguish who gets these early-warnings or not.

I wonder if the fact that severe patients aren't often studied contributes to the lack of knowledge of how severe patients experience PEM and that a severe patient's PEM might be different from a moderate patient's PEM. At least, this was the case with me.




oceiv. I get that symptom at times with all this, I also used to get Raynauds with this too. Raynauds when I was getting it used to give me like white bloodless looking patches and blue patches in other parts (often the colour would switch at a joint).

I still have my toes go blue at times.. mostly on just one foot (my left foot).

Wow! You are the first person who has recognized these symptoms. Did your doctors think it was part of the Raynaud's or just something that happened at the same time? I also had it only on one foot. My right side is worse wrt to all of my symptoms. Is your left-side also worse with other symptoms? I'm sorry you shared this symptom, but it's also really comforting to know that someone else understands. Thank you.
 
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taniaaust1

Senior Member
Messages
13,054
Location
Sth Australia
Your early-warning sore throat and/or low-grade fever/under-fever sound exactly like what I get. It's like an alarm. I also get a host of other early-warning symptoms.

Me too, I don't just get those as early warning symptoms, I get other warning symptoms too before what I'd call ME crash fatigue hits. eg nausea is an early warning symptom for me too and comes day before like severe ME exhaustion hits me and headache is another of my early warning symptoms coming in before fatigue. I nowdays get so many early warning symptoms its impossible for me to miss them (and they can come on strong), so another reason why if I didn't have to over do things in life at times, I can then to stay out of PEM.

If I continue exertion beyond that point, I get severe, pro-longed PEM. If I listen to the early-warning during activity, my PEM will be less severe and less-prolonged. Obviously, it would be better to stop before I get to that point, but I need to do at least some daily living activities. When I was moderately-ill, avoidance was possible more often, but my PEM onset was more unpredictable. My OI can often bring on mild asthma attacks.

Interesting thanks, I never thought about OI bringing in asthma attacks.

It sounds like we had a similar progression of our PEM experiences, learning how to manage activity and that similarly, our current early-warnings are more frequent than they used to be. Early on in my illness, I could push hard through activity, but then would end up sidelined for weeks or months. I was also paradoxically, much more functional. But I always had those early-warning, PEM-type symptoms during many activitities. I just didn't recognize them as warnings.

In my case I didn't previously have the early warning symptoms such as sore throat etc My ME has gone through several different presentations of it over the years. I agree that one is more functional when symptoms are rather delayed then coming in very early. In my now I have very severe OI problems (several different ME dysautonomias) which flare up so quickly causing me to have to sit or lay down that its hard for me to do enough any more to get the delayed PEM I used to get.

Now my illness is severe and the early-warnings come with most activity. If I may ask, is your illness also severe and heavy on either pain, immune and/or neurological symptoms?

I used to get severe pain everywhere and of many types but don't get much pain at all now. My illness is currently severe (I end up in hospital sometimes as much as every 2 weeks with it) but now strongly immune, neurological (I have like seizures) and severe autonomic dysfunction eg my BP can go down to 0 or up to near 200.

I wonder if the fact that severe patients aren't often studied contributes to the lack of knowledge of how severe patients experience PEM and that a severe patient's PEM might be different from a moderate patient's PEM. At least, this was the case with me.

Im not sure of that as mine has followed many different patterns even when in a severe stage.

Wow! You are the first person who has recognized these symptoms. Did your doctors think it was part of the Raynaud's or just something that happened at the same time? I also had it only on one foot. My right side is worse wrt to all of my symptoms. Is your left-side also worse with other symptoms? I'm sorry you shared this symptom, but it's also really comforting to know that someone else understands. Thank you.

Unfortunately I was too severe at times to see doctor for this symptom and on the rare occasions I can get to a doctor, I have so much other severe stuff going out of control that things like colouring of toes don't get mentioned. The only time I've mentioned my feet due to anything ME has triggered off was when I developed Chilblanes in my toes and hence couldn't wear my shoes as they swelled up bad (note I was only in my late 30s too, I got that in the time I used to get the Raynauds in my fingers and on my nose)
 
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