Letter to the Editor

November 23, 2010
To the Editor
IACFS Bulletin

In early 2009 I had a case study published in the Journal of Clinical Pathology (1).  This involved a young teenage boy who was diagnosed as suffering from Chronic Fatigue Syndrome (CFS) following an attack of swine flu (HIN1).  His initial illness was severe, and he developed many symptoms in the following weeks.  Three months later he was still very ill, and a diagnosis of CFS was deemed appropriate, according to the pediatric version of the Canadian criteria (2, 3).  Since that time he has gradually improved although is still unwell and unable to participate fully in everyday activities or attend school regularly.

Here in New Zealand we have just emerged from another winter and already I have seen a further 5 patients with CFS following HIN1 swine flu.

I feel that primary care physicians need to be alerted to this possibility, and to identify at risk patients, so that suitable intervention can be instated. Early recognition of diagnostic vulnerability should give a better chance of earlier recovery.  Any person suffering a very prolonged recovery following acute infection needs careful follow up.  Suitable intervention would include: adequate rest, freedom from stress, cautious gentle exercise and a sensible diet.  Most of these patients will have problems with sleep, necessitating regular bedtime routine, and medication may be needed.  As pain is also a frequent symptom, a low dose tricyclic such as nortriptyline 5mg a few hours before bedtime may be appropriate.  These simple measures can enhance an earlier recovery.
Another associated issue for patients already suffering from CFS, or those who have recovered, is whether to have annual influenza immunisation.  The immunisation here does incorporate HIN1 also.  In general I recommend avoidance of any immunisation unless deemed absolutely necessary, as there seems to be accompanying risk of relapse for some patients.  I have seen several patients each year who have relapsed after various immunisations, and I also have documented a number of CFS patients whose illness actually began following an immunisation.  This does indeed produce a dilemma for both patient and physician. 

It would be interesting to hear from other physicians regarding their experiences, and hopefully this letter could generate some useful research to help guide us in future recommendations.

Rosamund Vallings,  MB BS
Address for correspondence:
140, North Road,  RD2 Papakura, 2582, New Zealand

(1)  Rosamund Vallings. A case of chronic fatigue syndrome triggered byinfluenza H1N1 (swine influenza). J Clin Pathol 2010 63: 184-185
(2)  Carruthers BM, Van de Sande MI, et al. Myalgic encephalomyelitis/chronic fatigue
syndrome: clinical working case definition, diagnostic and treatment guidelines.
J Chronic Fatigue Syndr 2003;11:7e115.
(3)  Jason LA. Pediatric case definition for ME/CFS. J Chronic Fatigue Syndr