John K. S. Chia

Chronic fatigue syndrome is associated with chronic enterovirus infection of the stomach

Background and Aims: The aetiology for chronic fatigue syndrome (CFS) remains elusive although enteroviruses have been implicated as one of the causes by a number of studies. Since most CFS patients have persistent or intermittent gastrointestinal (GI) symptoms, the presence of viral capsid protein 1 (VP1), enterovirus (EV) RNA and culturable virus in the stomach biopsy specimens of patients with CFS was evaluated. Methods: 165 consecutive patients with CFS underwent upper GI endoscopies and antrum biopsies. Immunoperoxidase staining was performed using EV-specific monoclonal antibody (mAb) or a control mAb specific for cytomegalovirus (CMV). RT-PCR ELISA was performed on RNA extracted from paraffin sections or samples preserved in RNA later. Biopsies from normal stomach and other gastric diseases served as controls. 75 samples were cultured for EV. Results: 135/165 (82%) biopsies stained positive for VP1 within parietal cells, whereas 7/34 (20%) of the controls stained positive (p⩽0.001). CMV mAb failed to stain any of the biopsy specimens. Biopsies taken from six patients at the onset of the CFS/abdominal symptoms, and 2–8 years later showed positive staining in the paired specimens. EV RNA was detected in 9/24 (37%) paraffin-embedded biopsy samples; 1/21 controls had detectable EV RNA (p<0.01); 1/3 patients had detectable EV RNA from two samples taken 4 years apart; 5 patient samples showed transient growth of non-cytopathic enteroviruses. Conclusion: Enterovirus VP1, RNA and non-cytopathic viruses were detected in the stomach biopsy specimens of CFS patients with chronic abdominal complaints. A significant subset of CFS patients may have a chronic, disseminated, non-cytolytic form of enteroviral infection, which could be diagnosed by stomach biopsy.

Candida albicans Endocarditis Associated with a Contaminated Aortic Valve Allograft: Implications for Regulation of Allograft Processing

A patient developed Candida albicans endocarditis and fungemia after undergoing aortic valve replacement with an allograft. The allograft had been found during tissue bank processing to be contaminated with C. albicans, but it was culture-negative for C. albicans after routine disinfection with an antifungal-containing antimicrobial solution. Comparison of the preimplantation and postimplantation C. albicans isolates revealed remarkable genetic similarity, but antifungal susceptibility testing showed that the postimplantation isolate was more resistant to fluconazole and amphotericin B than the preimplantation isolate, suggesting emergence of resistance after disinfection. Implantation of a contaminated heart valve allograft can occur despite disinfection during processing and can result in endocarditis in the recipient. Antimicrobial disinfection protocols that include antifungal drugs may be ineffective. Current U.S. Food and Drug Administration regulations do not require companies to specify details concerning allograft processing. Additional measures may be required to prevent tissue bank release of allografts contaminated with C. albicans or other pathogens.

Acute enterovirus infection followed by myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and viral persistence.

Aims Enteroviruses are well-known causes of acute respiratory and/or gastrointestinal infections and non-specific flu-like illness. Although enterovirus protein, RNA and non-cytopathic viruses have been demonstrated in the stomach biopsies of patients with myalgia encephalomyelitis/chronic fatigue syndrome (ME/CFS), causality for chronic diseases is difficult to establish without having well-documented cases of acute enterovirus infections. The aim of this study was to link acute enteroviral infection to viral persistence in patients with ME/CFS. Method Patients admitted to the hospital with acute febrile illnesses were screened for enteroviral infections. Acutely infected patients were followed longitudinally, and those who developed symptoms of ME/CFS underwent oesophagogastroduodenoscopy and biopsies of the antrum to document viral persistence by immunoperoxidase staining for viral protein and viral RNA assay. Results Three representative patients with different manifestations of acute enterovirus infections progressed to have chronic symptoms of ME/CFS. Persistent viral infection was demonstrated in the antrum years later. Conclusion After acute infections, enteroviruses can persist in patients resulting in manifestation of ME/CFS. Chronic enterovirus infection in an immunocompetent host may be an example of a stalemate between attenuated, intracellular viruses and an ineffective immune response.

Diverse Etiologies for Chronic Fatigue Syndrome

Sir—Koelle et al. [1] recently studied 22 pairs of identical twins discordant for chronic fatigue syndrome and concluded that there was no major contribution for viral infections in the perpetuation of chronic fatigue syndrome (CFS). The authors should be commended for their methodology and the use of well-matched control subjects. However, the study raised several issues. First, similar to previous studies, the approach of Koelle et al. [1] was to look for statistical differences among the well-matched pairs with respect to the presence of viral antibodies and, more specifically, the presence of DNA of the viruses studied. Although these viruses were no more prevalent among the patients with CFS than among their healthy twins, one cannot conclude that these viruses are not the cause of CFS in a small subset of patients. CFS has been described in a small number of patients who had had well-documented acute Epstein-Barr virus (EBV), cytomeg-alovirus (CMV), and parvovirus B19 infections [2–4], and many of the patients responded to specific antiviral therapy. Of the first 200 patients with CFS who we evaluated for viral etiologies (table 1), only ∼10% had etiologies that were attributed to the viruses studied by Koelle et al. [1]. Chlamydia pneumoniae infection, an uncommon , although treatable, cause of CFS, was also dismissed in a previous, smaller study [5]. Second, latent EBV DNA and EBV viruses were often found in the blood and saliva, respectively, of asymptomatic, sero-positive individuals [6, 7], and, therefore, by themselves, are not ideal markers of active viral infection or the resultant symptoms of CFS. Would detection of virus specific mRNA be more indicative of smoldering infection in the PBMCs, and would a positive response to antiviral therapy increase the specificity of the finding? Third, the tissue localization and persistence of viruses may be responsible for the symptoms of CFS, and viruses may not be detected by viral assay of PBMCs or plasma. We have seen 2 patients with CFS who, after acute viral infection, had urine samples positive for EBV DNA and urine cultures persistently positive for CMV growth during a period of 6 months, but whose blood samples tested negative for EBV DNA and CMV DNA, respectively. Both patients improved after receiving intravenous cidofovir therapy. About one-half of our first 200 patients with CFS had significantly elevated levels of neutralizing antibodies to coxsackie-virus B and echoviruses, compared with control subjects from the community. On repeat …

Intestinal intussusception in adults due to acute enterovirus infection

Three adult cases of intussusceptions, associated with enteroviruses occurring within a 3-week period, are reported. Virological studies include viral RNA detection in stool samples and staining for enterovirus protein by immunoperoxidase staining of the resected intestinal tissues. A new mechanism for intussusception associated with enterovirus is proposed. Tap water was implicated in the outbreak. Better monitoring of drinking-water may prevent other cases of non-polio enterovirus infection.

Acute Gastritis Associated With Enterovirus Infection

To the Editor.—We read with interest the article by Sepulveda and Patil. Other than cytomegalovirus gastritis, viral infections of the stomach were not discussed in the article. Although enteroviruses were thought to be common causes of acute gastritis, few patients had endoscopies and biopsies to confirm the diagnosis. Enteroviruses do not form intracellular inclusion bodies and could be easily missed by routine examination without special immunohistochemical stain. A lack of neutrophilic response may not rule out an acute enterovirus infection of the stomach because acute enterovirus meningitis is usually associated with lymphocyte-predominant pleocytosis. Immunoperoxidase staining for enteroviral capsid protein 1 (VP 1) allowed us to identify enterovirus infection in 82% of the stomach biopsies taken from 165 patients with chronic fatigue syndrome and chronic upper gastrointestinal symptoms, as compared with 20% of the control subjects. Most of the biopsy specimens had minimal chronic inflammation by pathologic examination, and Helicobacter pylori was only demonstrated in 5% of the specimens. We investigated the role of acute enterovirus infection in stomach biopsies taken from 20 immunocompetent patients (age 50 6 22 years, 14 women, 6 men) who were hospitalized for severe vomiting and epigastric pain without known etiology after extensive laboratory and radiographic studies. Endoscopic examinations demonstrated minimal erythema or subepithelial hemorrhage in the antrum in 20 of 20 patients, and the pathologic examination showed mild, nonspecific, chronic inflammatory changes in 20 of 20 biopsies. Six of 20 (30%) had 1+ stainable enterovirus protein in the antrum; 13 of 20 (65%) had extensive staining (2+) of the specimens with only minimal chronic inflammation (Figure, A through D). Helicobacter pylori was seen in 2 of 20 samples (10%), but both patients also had positive enterovirus staining. All 20 specimens failed to stain with anti-cytomegalovirus monoclonal antibody of the same isotype. Two of 3 biopsy specimens grew enterovirus in cell culture, and 2 of 4 other specimens tested positive for viral RNA by reverse transcriptasepolymerase chain reaction, using previously described procedures. Two of 8 perirectal swabs tested positive for enterovirus RNA. Stool cultures and examinations for ova and parasites were negative for all 20 patients. In contrast, 2 of 10 volunteers and 0 of 7 patients who had antrum biopsies for anemia, or gastropathy related to nonsteroidal antiinflammatory drug and alcohol, showed 2+ enterovirus staining. Interestingly, of the 2 volunteers who stained positive, one had recent history of cyclical vomiting and the other had chronic symptoms of gastroesophageal reflux. The difference between the patients and control group was statistically significant (P , .01, x test with Yate correction). On follow-up, 17 of 19 patients had chronic, recurrent symptoms of epigastric pain, dyspepsia, nausea, anorexia, reflux, and bloating that lasted 3 months to more than 12 months. Five patients had cyclical vomiting; 1 patient was treated with parenteral hyperalimentation for at least 1 month after the hospitalization. In the United States, at least 30 million people develop symptomatic enterovirus infection per year. The most common route of transmission is oral fecal. Stomach is likely one of the first sites of viral replication because our previous study demonstrated chronic persistent infection in the stomach, and enterovirus infection of animal stomach has been well documented by a recent study. Although most cases of acute infection Letters to the Editor

Carcinoid tumour associated with enterovirus infection

Enteroviruses commonly infect the gastrointestinal tract, and replication of enteroviruses has been well documented in the Peyer patches of the small bowel. Chronic enterovirus infection has been found in the stomach and terminal ileum of patients with myalgic encephalomyelitis/chronic fatigue syndrome. The authors report the unexpected finding of enterovirus VP1 protein, by immunoperoxidase staining, in carcinoid tumours found in one patient with myalgic encephalomyelitis/chronic fatigue syndrome and another patient with chronic lower quadrant abdominal pain, and suggest a possible association between enteroviruses and tumorigenesis.

Varicella-zoster virus reactivation during acute enterovirus infection is associated with CD8 lymphocytopenia.

The trigger or triggers for reactivation of varicella-zoster virus have not been well defined in the medical literature. We investigated the role of enterovirus infections in triggering herpes zoster in five patients and correlated the reactivation with transient CD8 T lymphocyte depletion during the acute enterovirus infection.