Would have been interesting if they included CIRS in that cytokine graph thing, its the most well understood chronic inflammation disease. Apparently the PEM is caused by lack of oxygen to the muscle cells which is caused by inflammation ( or microclot or other factors ), when that happens the cell sometimes produces only 2 ATP not 38 ATP, this makes glucose be used up faster ( lactic acid is produced at abnormal rate ) and eventually glycogen reserve is exhausted, and at this point the cells switch to alternative energy source and it starts eating up other things, not sure exactly what but its probably why BCAA helps, eventually it starts to eat proteins which is probably a factor of PEM but also PEM is the depletion of the glycogen store. " It is however good to know that it will take a minimum of 48 hours to fully replenish glycogen stores once they are depleted. This requires a high carbohydrate diet (60-70% of the energy coming from carbohydrates) and rest during the recovery time. ". It may also be why some people say their collagen is degraded over time, i'm not sure yet whether its a major issue for me ( after 6 years of illness ).