Adolescent and Young Adult ME-CFS After Confirmed or Probable COVID-19
Summary
Introduction
- Study Focus: Understanding the onset of myalgic encephalomyelitis/chronic fatigue syndrome (ME-CFS) in adolescents and young adults post COVID-19.
- Concern: Persistent fatigue and impaired daily physical and cognitive function post COVID-19 raises concerns of a surge in ME-CFS cases.
Methods and Results
- Participants: Three adolescent and young adult patients with confirmed or probable COVID-19.
- Findings:
- All reported orthostatic intolerance symptoms early in their illness, aligning with Postural Orthostatic Tachycardia Syndrome (POTS) diagnosis.
- After 6 months, all met the ME/CFS criteria.
- Common features: strong allergy histories, and limitations in limb and spine motion.
- Conclusion: COVID-19 can trigger ME/CFS, necessitating further research on treatment and pathogenesis.
Detailed Observations
- Orthostatic Intolerance:
- Present in 90% of adult and over 95% of adolescent ME/CFS patients.
- Unclear if it is a primary contributor or a secondary phenomenon.
- Participants:
- Experienced ME/CFS symptoms prominently from the outset.
- Underwent detailed physical examinations and history evaluations.
Case Reports
Patient 1
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Age & Background: 19-year-old male from Florida with a history of Gilbert syndrome and allergies. Before falling ill, he was a college student and an athlete involved in track and cross-country, running 60-70 miles per week.
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COVID-19 Onset: Developed symptoms 3 days after exposure to a relative who later tested positive for COVID-19. He tested positive on June 18, 2020.
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Symptoms:
- Initial: Cough, sore throat, headache, fatigue, and loss of smell.
- Post-acute: Persistent fatigue, unrefreshing sleep, Post-Exertional Malaise (PEM), lightheadedness, headaches, chest pain, and increased heart rate during light activities.
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Physical Examination:
- Orthostatic intolerance symptoms appeared early, with a 70 bpm difference between his lowest supine and peak standing heart rate, indicating Postural Orthostatic Tachycardia Syndrome (POTS).
- Limited range of motion in various tests and a positive Hoffman sign.
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Treatment:
Medications:- Lexapro (5 mg daily): Prescribed for post-illness anxiety.
- Loratadine (10 mg daily): Used to manage allergic symptoms and histamine elevations.
- Famotidine (40 mg twice daily): Used to manage allergic symptoms and histamine elevations.
- Methylphenidate (Ritalin) (10 mg each morning): Served as a vasoconstrictor.
Lifestyle adjustments:
- Increased Sodium Intake: To manage symptoms of POTS.
- Compression Garments: Worn to help control POTS symptoms.
- Physical Activity: Limited to two to three 15-minute walks daily to avoid triggering excessive tachycardia or post-exertional malaise (PEM).
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Current State:
- 7 months post-COVID-19, he experiences persistent fatigue, limited exercise tolerance, unrefreshing sleep, PEM, lightheadedness, and headaches.
- Able to undertake two to three 15-minute walks daily without inducing excessive tachycardia or PEM.
Patient 2 and 3
- COVID-19 Onset: Both had close contact with individuals confirmed to have COVID-19 and developed symptoms like anosmia and dysgeusia lasting up to 5 months. COVID-19 was not confirmed through testing but was highly probable given their symptoms and exposure history.
- Symptoms:
- Both developed symptoms of orthostatic intolerance early in their illness, within the first two weeks.
- Physical Examination:
- Both met the criteria for ME/CFS 6 months after the onset of symptoms.
- Exhibited profound POTS with a significant increase in heart rate during the first 10 minutes of standing, accompanied by a reproduction of orthostatic symptoms.
- Allergic Phenomena:
- Both had histories of allergic inflammation, with one having a history of oral allergy syndrome and the other experiencing urticaria after exposure to citrus.
- Neurological Abnormalities:
- Both exhibited signs of neuroanatomic abnormalities, with one meeting the criteria for hypermobile Ehlers-Danlos syndrome and the other showing signs of mast cell activation.
Notes
The case reports of these three patients indicate that ME/CFS can be triggered by COVID-19 in adolescents and young adults, even in cases of probable but unconfirmed COVID-19. The early onset of orthostatic intolerance symptoms suggests that these could be a direct result of the virus rather than a secondary phenomenon arising from inactivity or deconditioning. The findings call for further research to understand the pathogenesis and to develop optimal treatment strategies, focusing on the identified comorbid features.
Funding and Ethics
- Funding: Supported by the Sunshine Natural Wellbeing Foundation Professorship in Chronic Fatigue and Related Conditions.
- Ethics: Approved by the Johns Hopkins Institutional Review Board, with informed consent waived for this retrospective study using routine care data.
Conclusion
The study identifies a potential onset of ME/CFS in adolescents and young adults following COVID-19, highlighting the need for further research to understand the pathogenesis and to develop optimal treatment strategies, focusing on identified comorbid features. The small sample size and the focus on a specific demographic necessitate broader studies to validate these findings.