Identify the signs of post viral fatigue syndrome and learn about the natural solutions to start your recovery
Post-viral fatigue (PVFS) was considered a nebulous condition for almost a century (until 1994), attributed to the manifestation of deep psychological trouble and historically described mostly in women. Sufferers however know that their condition is not ‘in their head’ and this condition can have a devastating impact on all aspects of their lives: professional, social, extracurricular, relational, often associated with long-lasting psychological consequences. Finally, the economic impact of PVFS in the UK was estimated at around £3.3 billion in 2014/15 (1). In this article I will review how post viral fatigue syndrome develops, what conventional treatments are usually prescribed, as well as the scientifically proven natural options that are available for the recovery from this disorder.
What is Post-Viral Fatigue Syndrome?
The term ‘post-viral fatigue syndrome’ (PVFS) is another name for ‘myalgic encephalomyelitis/chronic fatigue syndrome’ (ME/CFS, formerly referred to as ‘neurasthenia’), or sometimes ‘systemic exertion intolerance disease’ (SEID). It is an umbrella term that describes a variety of symptoms. To be diagnosed with PVFS the patient must be presenting with the following complaints:
- persistent tiredness that is not relieved by rest,
- post-exertional malaise,
- difficulty executing mundane daily tasks, noticeable reduction in the ability to engage in pre-illness levels of occupation (professional, social, pastimes),
And be presenting with at least one of the following symptoms:
- cognitive impairment,
- orthostatic intolerance (i.e. dizziness upon standing up after being sat or after lying for a while).
Other symptoms observed in PVFS patients include:
- Disturbed sleep patterns
- Myalgia and/or arthralgia (muscles and joints pains)
- Headaches
- Sore throat or sore swollen cervical (neck) or axillary (armpit) lymph nodes
- Flu-like symptoms
- Feeling dizzy or sick
- Irregular heartbeats, palpitations
- Altered cortisol regulation (hypothalamic-pituitary-adrenal axis dysregulation)
- Altered bowel habits
- Abdominal pain, bloating
- Major depressive disorder with psychosis
- Bipolar disorder
- Schizophrenia
- Dementia
- Delusional disorder
- Anorexia nervosa
- Bulimia nervosa
- Alcohol and/or substance abuse
- Obesity
The symptoms (summarised in figure 1) must be present for at least 6 months, and other possible diagnoses must be ruled out (by investigative procedures and tests).
Figure 1: symptoms of post viral fatigue syndrome.
How does Post-Viral Fatigue Syndrome develop?
A combination of factors is at play where post viral fatigue is concerned, but there is a consensus that it comes down to mitochondrial dysfunction (2,3).
Mitochondria are microscopic structures found in all cells of the body, that are responsible for producing energy. Although different cells have different amounts of mitochondria depending on their energy requirements, for example quadriceps muscle cells and liver cells have a lot more mitochondria than subcutaneous adipocytes (fat cells), all cells need mitochondria to function. Mitochondria dysfunction is implicated in a lot of signs of aging and in diseases (from greying hair to cancer and Alzheimer’s) (4).
To function optimally, mitochondria need specific nutrients and adequate levels of oxygen. The nutrients necessary for mitochondria to produce cellular energy are:
- D-ribose, normally made from glucose in the body, but it is a slow process and chronic fatigue sufferers may require supplementation.
- Magnesium is a required mineral to store energy in the form of ATP (adenosine tri-phosphate, the energy currency of the cells) and to release energy from ATP.
- Vitamin B3, or niacinamide, is an essential part of a molecule called NAD (nicotinamide adenine dinucleotide), which is essential for the breakdown of sugars and fats, the production of ATP in the mitochondria, and is central in many antioxidant and detoxification processes.
- Acetyl L-carnitine, found in red meat, but not in sufficient amount in very fatigued states. Essential for energy production.
- Coenzyme Q10, or CoQ10 or ubiquinol, helps limit damage from free radicals, maintain a healthy immune system, essential for cellular respiration and energy production.
Vitamin B12 is necessary for maintaining healthy levels of red blood cells and haemoglobin, which provide adequate levels of oxygen to the tissues of the body. Vitamin B12 is also essential in DNA and protein synthesis, in detoxification pathways, and energy delivery mechanisms.
Figure 2: nutrients necessary to mitochondrial function
Factors that can have a negative impact on mitochondrial function include:
· Sugar
· Gut dysbiosis (yeast overgrowth)
· Some prescription medications, including some antivirals, antibiotics, anti-cancer drugs, statins, anti-inflammatories (NSAIDs), ADHD treatments.
· Alcohol
· Artificial sweeteners
· Acute and chronic viral infections
· Environmental chemicals
If mitochondrial dysfunction is not corrected, overtime it leads to increased systemic inflammation, oxidative damage, lactic acid build up, poor recovery, suboptimal cellular function, muscle fiber degradation, cognitive impairment, and other symptoms of chronic fatigue syndrome.
What are the risk factors of post viral fatigue?
The exact mechanism of how a viral infection can trigger such debilitating and long lasting effects on the body is not yet elucidated. It is hypothesised that the mitochondrial dysfunction associated with post-viral fatigue is the result of a combination of factors. Predisposing factors include:
- Genetics: many studies have highlighted the possible implication of a few genes in the aetiology of chronic fatigue syndrome:
o Genes involved in the regulation of the immune system
o Genes involved in neurotransmitters production, transport, and degradation
o Genes involved in the regulation of the hypothalamic-pituitary-adrenal (HPA) axis
o Genes involved in the maintenance of the circadian rhythm
o Genes involved in immune system regulation
For more information, please refer to the following publications: 5-13
- Microbiome: irritable bowel syndrome (IBS) occurs in about 50% of chronic/post viral fatigue sufferers (14). It has become increasingly clear in recent years that dysbiosis (disequilibrium between beneficial and detrimental bacteria in the gut) plays a central role in IBS (15), as well as in diseases of the central nervous system (16) and autoimmune disorders (17). Although a consensus is far from being reached there is increasing evidence that the composition of the gut microbiome is one of the contributing factors in the development of post-viral/chronic fatigue syndrome (18,19), and the oral microbiome could also be a determining factor in whether a person goes on to develop chronic fatigue or not (20). Some probiotics seem to be beneficial in protecting against viral infections, especially Lactococcus lactis JCM 5805 (21). A pilot study recently demonstrated that targeted repopulation of the gut microbiota in ME/CFS patients led to better sleep quality, improved cognitive flexibility, better short-term memory (22) In recent years, the virome (viral equivalent of the microbiome) has become the subject of more research and some viruses, especially of the human herpes virus (HHV) family, could predispose someone to developing post viral fatigue syndrome (19).
- Poor thyroid function: hypothyroidism or thyroid hormone resistance (when the cells and organs don’t respond to normal levels of hormones) can contribute to the development and/or the maintenance of post viral fatigue syndrome. The thyroid gland is responsible for the energy delivery in the body, it naturally slows down in the winter, when the focus of the body is to conserve energy, but it should naturally pick back up in spring. Hypothyroidism shows the following symptoms:
o Fatigue, lack of energy
o Weight gain or inability to lose weight
o Constipation
o Loss of circadian rhythm: difficulty falling asleep, difficulty waking up
o Fluid retention (swollen ankles, puffy face, puffy eyes, carpal tunnel syndrome)
o Infertility
o Hair loss (in particular the outer third of the eyebrows)
o Swollen tongue
o Dry skin and hair
- Prolonged stress: when faced with stress, our body produces adrenaline (to cope with it in the short term), and cortisol (to cope with stress in the long term), which is mitigated by DHEA. However, when stress becomes chronic, the adrenals keep producing high quantities of cortisol and DHEA, slowly draining themselves out. When the adrenals are exhausted, they cannot produce adequate levels of either of these hormones and symptoms of chronic fatigue occur.
- Personality: several studies reported that a high neuroticism score correlate with a CFS diagnosis (23). Neuroticism is the tendency to experience negative emotions, such as anger, anxiety, self-consciousness, irritability, mood swings, and depression. People who score high on the neuroticism scale tend to respond poorly to stress, feel overwhelmed by minor frustrations, and experience everyday events as potentially life-threatening (24).
- Other possible risk factors:
o a history of psoriasis (a dermatological autoimmune condition) seems to increase risks of developing chronic fatigue syndrome later in life (25).
o Patients diagnosed with chronic fatigue syndrome tend to score higher on the Adverse Childhood Events Questionnaire (26)
o Exposure to environmental toxins and chemicals has been shown to induce damage to mitochondria, which in turn can trigger symptoms of chronic fatigue (27).
o Over the past three decades some vaccinations (in particular against hepatitis B and against human papillomavirus HPV) have been linked to the occurrence of chronic fatigue syndrome (28,29).
What are the conventional pharmacological treatments offered to post viral fatigue sufferers?
- Long courses of antiviral drugs have been found to be beneficial for up to 40% of PVFS sufferers (30,31)
- Anti-inflammatory drugs (such as NSAIDs) are sometimes prescribed to decrease levels of inflammation in the body and to relieve the widespread pains that can sometimes present in post viral fatigue syndrome. Combining antiviral and anti-inflammatory pharmaceuticals has been found quite effective inreducing symptoms of pain and fatigue in chronic fatigue syndrome patients (32).
- Low-dose hydrocortisone treatment seems to have beneficial effects on fatigue and overall wellness scores (33). However, those improvements tend to be in the short-term, with symptoms worsening progressively after treatment cessation, and long-term corticosteroids treatments are best avoided due to their possible side effects.
- Antidepressants from the monoamine oxidase inhibitors (MAOi) and the serotonin and noradrenaline reuptake inhibitors (SNRI) families have been shown to improve symptoms of depression, anxiety, insomnia, pain, and fatigue (34).
NATUROPATHIC WAYS TO ADDRESS POST VIRAL FATIGUE SYNDROME
A report published in 2007 by the NICE Clinical guidelines states that 74% of CFS sufferers said they found relief in using complementary and alternative medicines (35). Complementary health approaches can be taken alongside pharmaceutical treatments.
Listed below are the naturopathic strategies that have been shown to be the most effective for the recovery from post viral fatigue syndrome.
- Diet: the diet should be designed to bring nutrients essential to mitochondrial function, reduce the oxidative load, and support healthy detoxification pathways. To that aim, some foods and drinks should be avoided/eliminated:
- alcohol: alcohol increases the detoxification workload of the liver, which then struggles more to remove other toxins from the bloodstream. It is estimated that 90% of PVFS sufferers are intolerant to alcohol (it tends to make their symptoms worse within 24 hours). Chronic alcohol consumption also depletes the body of vitamins and minerals, contributes to metabolic syndrome, and impairs immune function.
- sugar: induces insulin spikes and can lead to blood sugar levels fluctuations and metabolic syndrome. It also can be detrimental when trying to tackle bacterial overgrowth or Candida in the gut. Limit fruit consumption
- artificial sweeteners and food additives: poorly processed by the liver, can increase toxic load
- stimulants such as caffeine and energy drinks can slow down adrenal function recovery.
- foods that cause intolerances such as dairy, gluten, eggs (some people) should be reduced to a minimum if possible. These foods can contribute to low-grade constant inflammation, putting strain on the organism.
- hydrogenated fats: can disrupt cellular function.
Nutritional guidelines:
- Aim for 5-7 cups of vegetables per day (organic and in season, preferably), with an emphasis on cruciferous vegetables (as they promote liver detoxification, and antioxidant production).
- Include oily fish (salmon, trout, sardines, mackerels, herrings, anchovies) 2-3 times per week (omega 3 are great natural anti-inflammatory)
- To keep blood sugar levels steady, try to eat small meals every 4 hours, with proteins, fibers, and healthy fats at each meal.
- Use spices and culinary herbs, they tend to help maintaining a healthy immune system.
In summary, a diet resembling the auto-immune paleo diet seems to be the most
appropriate to start recovering from post viral fatigue syndrome.
- Supplements: while most vitamins and minerals necessary for good health should be obtained from foods as much as possible, in cases of chronic fatigue the absorption capacity of the digestive system might be compromised and essential elements should be considered for supplementation. In some cases intravenous vitamin infusions can be a great way to kickstart the recovery process. Vitamin and minerals found to help with symptoms of post viral fatigue include:
- Vitamin B complex: essential for energy production in the mitochondria, vitamin Bs also play a crucial role in the maintenance of mental health (36). In particular, niacinamide (B3), folic acid (B9) and cobalamin (B12) have been found to be particularly useful in alleviating symptoms of chronic fatigue. It is recommended to choose a methylated form of B9 and B12 (methylfolate and methylcobalamin), to circumvent possible suboptimal methylation pathways (such as with genetic mutations in the MTHFR gene).
- Vitamin C: powerful antioxidant, it helps prevent oxidative stress damage to the cells, and is also central in the optimal function of the adrenal glands. Vitamin C levels can become depleted in situations of chronic stress. Buffered forms of ascorbic acid (vitamin C) tend to be better tolerated by the digestive system. Up to 1 g twice a day is a generally recommended dose.
- Magnesium: essential cofactor for energy production, it is also necessary for muscle relaxation, neurotransmitters balance and pain signalling. 300-400 mg per day is a dose that has good clinical outcomes.
- Omega 3 fatty acids: help to rebalance the inflammation and pain pathways, facilitates cellular and nerve communication. A minimum of 1 g total of EPA + DHA (eicosapentaenoic acid + docosahexaenoic acid) is recommended, along with 120 mg of GLA (gamma-linolenic acid).
- Zinc: supports optimal immune function and helps to keep inflammation levels low. 10-25 mg per day (preferably at night) seem to help alleviate symptoms of fatigue.
- Acetyl-L-carnitine: shown to help reduce feelings of ‘brain fog’, up to 2g/day, in divided doses.
- Glutathione: the ‘master antioxidant’ of the body, it helps to prevent oxidative stress damage. Patients supplementing with 400mg per day report significantly better clinical outcomes than those who don’t (37). A liposomal form has more bioavailability.
- Coenzyme Q10 and NADH: essential mitochondrial nutrients. Small trials show positive results with doses of 200 mg CoQ10 and 20 mg NADH per day, respectively.
- D-ribose: for a subset of patients, supplementing with D-ribose, which is an essential element of the energy production process in the mitochondria, is beneficial, but for others it is potentially a fermentable sugar and can worsen symptoms in patients with gut dysbiosis.
There are a few commercially available well-rounded supplements designed to help mitochondrial function, I selected a few: Mitochondrial Resuscitate from NutriAdvanced (see here), Mitochondrial NRG from Designs For Health (see here), MitoGuard from Biocare (see here).
Other nutritional supplements can be added depending on the individual presentation of the syndrome: some patients may need to add gut repairing nutrients, others might need more liver detoxification support or more help for emotional symptoms.
- Herbal medicines: because of the wide variety of medicinal herbs available, all aspects of post viral fatigue syndrome can be addressed with a well-thought-out formulation. The most important herbs to support PVFS recovery belong to the following families of action:
o Antivirals and immune-modulating herbs: antivirals are used to help remove viral particles from the body. It is hypothesised that parts of viruses can stay in the body for many years after the initial infection. Using antiviral and immune-modulating herbs stimulate the body to get rid of leftover viral particles. Potent antiviral plants include: >Hypericum perforatum (St John’s wort), especially efficacious against envelop viruses such as Epstein-Barr virus. Contraindicated with pharmaceuticals.
>Andrographis paniculata
>Thymus vulgaris (thyme)
Immune-modulating herbs that have shown some clinical efficacy in the treatment of PVFS include Echinacea angustifolia (Coneflower) and Astragalus membranaceus (Milk vetch).
o Anti-inflammatory herbs: reducing general inflammation is an important part of the treatment plan for PVFS, as it also helps reducing pain that sometimes occur with this syndrome. Most studied herbs to carry out that action are:
>Curcuma longa (turmeric)
>Boswellia serrata (frankincense)
>Zingiber officinale (ginger)
>Apium graveolens (celery seed)
o Adaptogenic herbs: this special category of plants act on regulating the hypothalamus-pituitary-adrenal (HPA) axis, which governs stress response, energy regulation, hormonal balance, sleep patterns, immune system. They help the body adapt to environmental stressors. The most useful ones in addressing PVFS are:
>Eleutherococcus senticosus (Siberian ginseng): helps to increase vitality and general wellbeing. Best taken for a few months to experience benefits
>Rehmannia glutinosa (Chinese foxglove): helps restore adrenal function
>Glycyrrhiza glabra (Licorice root): known to be a great adrenal support, it is also a strong anti-inflammatory (contraindicated with high blood pressure)
>Rhodiola rosea (Arctic root): improves physical and emotional fatigue, cognitive and immune function, and is also an antidepressant.
>Ganoderma lucidum (Reishi mushroom): has immunomodulatory properties, protects the liver, is a mild sedative that helps reducing anxiety.
>Withania somniferum (Ashwagandha root): it is a nourishing herb that helps build nerve strength, reduce fatigue, strengthen the immune system, promote sleep, increase resilience to stress.
o Sleep and anxiety herbs: PVFS sufferers tend to experience non restorative sleep or insomnia, as well as anxiety, which in turn does not help with sleep. Some herbs that are known to help promote sleep are:
>Withania somnifera (see above)
>Passiflora incarnata (Passionflower), especially recommended for patients who experience circular thoughts at night which prevent sleep
>Valeriana officinalis (Valerian root), best for people who tend to feel irritable in the evening
>Ziziphus jujuba (Red Date): especially good for those whose sleep is interrupted by vivid dreams/nightmares.
Other herbs can be added to address other symptoms such as brain fog, digestive issues, heart palpitations, if they present themselves.
Please note that a lot of medicinal herbs are contraindicated in pregnancy, breastfeeding and with some medications. Please seek advice from a trained herbalist.
- Sleep hygiene: lack of sleep has a negative impact on immune function, exercise recovery, appetite regulation, mood, mental focus. It is therefore central to start the recovery from PVFS. Below are a few tips to promote better quality sleep:
o Going to bed and getting up at the same time every day is a good habit to pick up. It helps reset the circadian (sleep-wake) clock, and cortisol levels.
o Exposing yourself to natural daylight early in the morning and opting for blackout curtains in the bedroom or eye mask in the evening will help regulate melatonin and cortisol production.
o Limiting exposure to blue light during the day. Blue light is emitted by electronic screen devices.
o Avoiding television and phone / tablet / computer at least 2 hours before bedtime. Try to replace these with relaxing activities such as reading, taking a bath, spending time with family and friends, meditating.
o Using Epsom salts (magnesium sulphate) flakes in the bath in the evening promotes relaxation.
o Using essential oil diffusers with relaxing blends of essential oils (lavender, chamomile, rose, jasmine, sandalwood)
o Avoiding consumption of stimulants (coffee, tea, energy drinks) after 2pm.
o Avoiding alcohol
o Supplements such as 5-HTP, valerian root or ashwagandha root can be helpful.
- Graded exercise program: for many reasons, keeping physically active is beneficial for health and longevity. However, because of the overwhelming fatigue often aggravated by exercise and the possible muscular and joint pains that can occur with post viral fatigue, it can feel extremely difficult to find forms of exercise that are appropriate and sustainable for PVFS sufferers. Several studies showed that patients who engage in graded exercise therapy (GET) have better health outcome and fatigue recovery that those who stay passive (38).
Before starting any exercise program, it is important that you reach a point where you feel fine (i.e. not exhausted) doing the minimum amount of activity every day for a while (this will happen as viral particles are eliminated, cellular energy is restored, hormones are balanced). Be always mindful that pacing yourself is key for long-term recovery, however frustrating it may feel at the time. Keep also in mind that, as you recover, there will be ‘good’ days and ‘bad’ days, listening to your body is essential.
Evaluate what is possible for you to do without feeling depleted of energy (it could be a 10 slow walk twice a week), then increase frequency or intensity progressively (walk a bit faster, or a bit longer, or more often). Swimming is a great option to improve cardiovascular health without putting any pressure on the joints. Remember to incorporate flexibility and mobility exercise (yoga, pilates). After a while, high repetition, low intensity movement should be adopted (bodyweight squats, knee press ups, crunches) for 30 second bouts, this will improve muscle tone. If possible, adding weights is a good milestone to reach, as it works to improve bone density.
Work with a personal trainer who understands your limitations, if this is available to you.
- Remove environmental toxins: some symptoms seen in post viral fatigue syndrome resemble symptoms seen in patients suffering from multiple chemical sensitivity disorder (also know as idiopathic environmental intolerances). If the detoxification pathways (gut and liver mostly) are not functioning optimally, toxins (from within the body and from the environment) will accumulate and cause havoc with various body systems (the brain and hormones are especially susceptible to environmental toxins). Easy routes to reduce toxic load are:
- Avoid caffeine, nicotine, alcohol, food additives, food colouring, artificial sweeteners (aspartame)
- Opt for pesticide-free produce
- Opt for organic skincare, toothpaste, shampoo, non chemical deodorants. Ingredients such as parabens (include dimethicone), SLS (sodium lauryl sulphate), benzophenone (BP), bisphenol A (BPA), phthalates.
- Limit exposure to heavy metals such as mercury (found in dentistry fillings and amalgams), lead (from leaded water pipes), nickel (coins and jewellery), aluminium (non stick cooking utensils, antacids, antiperspirants). Chelation therapy is an option if high metal toxicity levels are suspected (under strict medical supervision). Combining chlorella and zeolite can help with reducing low level metal toxicity (chlorella binds heavy metal from cells, while zeolite help eliminating them from the gut).
- Drinking filtered water (Brita® is a great entry budget option, while reverse osmosis and distillation remove almost all toxicants from water, but are much pricier)
- Drinking at least 2 L of filtered water per day, as it flushes out toxins, and prevents constipation (toxins can be reabsorbed in the bloodstream from faecal matter stuck in the colon)
- Far-infrared sauna sessions (10-20 minutes at a time) can speed up detoxification, but must be done only if well tolerated.
- Iodine supplementation must be considered (it displaces toxicants such as fluoride, bromide), in particular if the thyroid is a bit ‘lazy’. Supplements that raise antioxidant capacity include copper, selenium, zinc, manganese, glutathione.
- Massage therapy
Massage therapy can make a huge difference in the speed of recovery from chronic fatigue. There are a few reasons for that: massage therapy stimulates the immune system, it decreases anxiety, helps relaxation and sleep, speeds up muscle recovery from exercise. Myofascial release should be considered as well as fascial pains are often associated in chronic fatigue presentations.
- Acupuncture
Acupuncture can help improve symptoms of mental fatigue, insomnia, and general pain to some extent.
- Counselling and Cognitive Behavioral Therapy (CBT)
Some patients find it helpful to go to counselling or CBT sessions to learn ways to manage their symptoms and reduce anxiety and catastrophizing thinking patterns.
In conclusion, post viral fatigue has some core features, but also many other possible symptoms that vary from person to person. Recovery can be achieved in a sustainable fashion by taking many parameters into consideration and applying an individualised treatment plan targeting all aspects of the syndrome.
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