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donderdag 22 december 2011

Unexpected cardiac symptoms with cytomegalovirus CMV infection

Rowe and colleagues [11] described seven nonsyncopal adolescents presenting with fatigue an lightheadedness and demonstrated abnormal responses to upright tilt. They followed this work with a prospective, nonselected, nonblinded study confirming a strong association between neurally mediated hypotention and CFS [12]. An abnormal response to upright tilt was observed in 22 of 23 patients with CFS vs. four of 14 controls (P<.001). Open, nonblinded therapy directed at this abnormal reflex with fludrocortisone, B-adreniergic blocking agents and disopyramide appeared beneficial in this nonblinded trial. The authors concluded that neurally mediated hypotension is a cause of the symptoms of CFS or that it is strongly associated with another important etiologic factor.

We reported in 1993 that repetitively oscillating abnormal T-waves inversions and/or T-wave flats during 24-hour electrocardiogram (ECG) monitoring are present in patients with CFS, ECG abnormalities that are nonspecific but seen less frequently in non-CFs patients (P-<.01) [13]. Abnormal left ventricular myocardial dynamics are present in a cohort of patients with CFS. Decreased and /or flat ejection fractions with stress, , abnormal wall motion at rest and stress, dilatation of the left ventricle, and segmental wall motion abnormalities in CFS patients[14].

We now report a subset of CFS patients with (1) high human cytomegalovirus (HCMV) IgG enzyme-linked immunoassay antibody titers (ELISA), (2) minimal or no serologic evidence of concurrent EBV multiplication, and (3) oscillating ECG abnormalities at Holter monitoring. We performed a pilot study to assess the possible efficacy of ganciclovir, an antiviral nucleoside useful in the treatment of several HCMV infections in immunosuppressed patients.

... Mitral valve prolapse without significant mitral valve insufficiency does not cause abnormal T-wave oscillations at Holter monitoring [19]. As previously, 24-hour continuous ECGs were obtained using a mdified standard lead I and precordial lead V [13]. A patient's 24-h Holter monitor was considered flat, i.e., the T-waves were below the horizontal described by inceptions of p and Q waves in on the the two monitored lead with two or more episodes for at least 25.0 normally conducted QRS complexes. A uniformly flat T-wave were evaluated independent of possible ST segment changes. Biphasic T -wave were considered normal. U waves ( a small, shollow, positive, rounded delflection inscribed immediately after the T-wave) did not interfere with this analysis, Labile T- wave abnormalities at Holter monitoring were present in each CFS patient.

Validation of EI for the severity of the CFS:

Grade 0: Patients are confined to bed by number and severity of symptoms listed below.

Grades 1-2: Any activity leads to overwhelming, incapacitating fatigue. Patients are lightheaded, unable to think clearly, concentrate, or read for any extended period (over 60 minutes). Left-sided chest aches, palpitations, sore throats, and feverishness are frequent. Patients can be out of bed only for intermittent, brief parts of each day.

Grades 3-5: With great effort, patients can be out of bed and perform nonphysical activities for several hours each day. Any exertion markedly worsens fatigue. Patients variably express lightheadedness and inability to think clearly or read normally. Left-sided chest aches, palpitations, sore throats, and feverishness are frequent. Patients cannot perform a 40-hour a week sedentary job or maintain the duties of homemaker (e.g., cooking, cleaning, doing laundry, shopping, driving).

Grades 6-9: Patients can assume normal activities, maintain a 40-hour work week, and with pacing, maintain a household. Overwhelming fatigue is lessened. Rare-to-no lightheadedness, foggy thinking, chest aches, palpitations, feverishness, and sore throats are present. Patients can perform light physical work (or exercise) in moderation without fatigue.

Grade 10: Patients are well, with normal energy level, stamina, and sense of well-being. Exercise in moderation leads to an increased sense of well-being. Lightheadedness, difficulties in concentrating and reading ability, chest aches, palpitations, sore throats, and feverishness are absent.

After placement of a peripherally inserted central or Groshong catheter, ganciclovir (5 mg/kg q 12 h) was given intravenously for 30 days. ... After completion of ganciclovir, patients were encouraged to renew normal activities in gradual increments as tolerated. They were asked to not exercise until six months after completion of ganciclovir.

At the start of ganciclovir, the severity of fatigue (E1) in all patients was similar (e.g., 3, mean grade, group A vs. 2, mean grade, group B). Six months later, the energy indices diverged. Mean EIs were grade 7 and grade 4 for groups A and B, respectively (table 4). Before therapy with ganciclovir, n patient (group A or group B) could work or function normally (e.g., homemaker).
After treatment with ganciclovir, the 13 patients from group A, but no patient from group B, returned to his or her premorbid activity. A repeat measures analysis of the EI values between cohorts indicated that patients in group A had greater improvement than those in group B (P <.05).

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