New Cardiomyopathy: Pilot Study of Intravenous Ganciclovir in a Subset of the Chronic Fatigue Syndrome

A. Martin Lerner, Marcus Zervos, Howard J. Dworkin, Chug-ho Chang, James T. Fitzgerald, James Goldstein, Claudine Lawrie-Hoppen, Barry Franklin, Steven M. Korotkin, Marc Brodsky, Daniel Walsh, and William O'Neil.

We describe a subset of patients with chronic fatigue syndrome (CFS) as defined by the CDC, a duration of overwhelming fatigue for <2 years, and oscillating repetitively abnormal aberrant T-waves at 24-hour electrocardiogram (ECG) recordings (Holter monitors). Baseline 12-lead ECF, 2-D echocardiogram, rest/stress myocardial perfusion (thallium 201 or TC-99 sestamibi) and rest/stress multiple-gated acquisition studies, as well as coronary angiography excluded coronary artery disease. Patients in this CFS subset had significant Ig (with or without positive IgM) human cytomegalovirus enzyme-linked immunoassay antibody titers. They had little or no evidence of concurrent Epstein-Barr virus (EBV) multiplication, corroborated by negative viral capsid antigen IgM antibody titer and an EBV total early antigen antibody of 40. Patients were given intravenous ganciclovir (5 mg/kg 1 12 h for 30 days). Before this treatment, none of 18 patients could work or manage a household. At evaluations, 24 weeks after ganciclovir, 13 patients (72%) returned to their premorbid health states (P<.05). There were no adverse effects from ganciclovir in these nonimmunosuppressed patients.

Introduction:

Chronic Fatigue Syndrome (CFS) is a disorder the natural history, clinical characteristics, pathologic physiology, and treatment of which remain uncertain [1]. Various hypotheses propose neuroendocrine or immunologic abnormalities or viral infections, including epstein-barr virus (EBV), human herpesvirus 6, and several enteroviruses and retroviruses [2]. There have been several studies of treatments [3-5]. Since the fatigue of the mononucleosis syndrome [6-8] resembles that of the CFS [9], we assayed antibodies to human cytomegalovirus (HCMV) and Epstein-Barr virus. High antibody titers to toxoplasmosis, an occasional cause of the mononucleosis syndrome [10], are unusual in CFS patients.

    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.

METHODS

PATIENTS:

From March 1993 through June 1994, three men and 15 women (mean age, 39.7 plus or minus 7.7 years) with CFS using CDC criteria were recruited from a single infectious diseases referral center in Birmingham, Michigan. Approximately 50 patients with CFS were screened for inclusion in this study. Demographics, including clinical and laboratory information , were obtained for all patients. HCMV ELISA IgM ( Detroit Biomedical Laboratories, Detroit,  Michigan) and HCMV ELISA IgG titers (Metpath Lavoratories, Teteboro, New Jersey), as well as EBV capsid antigen (VCA), ELISA IgM, and EBV total early antigen (EA) immunofluorescent antibody titers (Roche Laboratories, Columbus, Ohio) were essayed [16,17]. Buffy coats, urines, and myocardial biopsies were tested for infectious HCMV.
     As a control of the occurrence of HCMV and EBV antibodies in normal non-CFS persons (Results, Froup C) residing in this same area, 20 randomly chosen well individuals were tested for HCMV, IgM, and IgG antibodies and for EBV VCA IgM, and EA antibodies. Results of Holter monitoring, stress multiple-gaited acquistion (MUGA) studies and denomyocardial biopsies in these patients have been described [13-14, 18].
     Holter monitors, MUGA studies, and endomyocardial biopsies were read blindly (without kowledge of the patient). All such readings were repeated by at least one , and oftern several, other physicain-readers. Each CFS patient had a normal 12-lead standard ECG and a normal 2-D echocardiogram, except for occasional mitral valve prolapse. Mirtal 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.

ENERGY INDEX:

At each outpatient visit, a subjective evaluation of the patient's functional status was recorded. The Energy Index (EI) is defined as 10 when the patient is well. The EI records the average subjective vitality of the patient in the immediate 14 days before the specific outpatient visit. When minor illness (e.g., rhinovirus infection, sinusitis) complicated a visit, evaluation of the E1 for a patient was delayed until the intercurrent problem receded. A CFS patient with an E1 of 0 is bedridden. A CFS patient with an EI of 5 can work, provided his or her work is sedentary. Patients with EIs of <5 cannot perform a 40-hour a week job. Before the initiation of intravenous ganciclovir and, again, 6 months later, objective evaluations of the ability to work and the EI for each study patient were analyzed. At these times, the patient was either fully engaged in his or her premorbid activity at work or home (e.g., active homemaker), or he or she had not returned to the premorbid occupation.

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.

     The validity of the EI index was tested by the method of construct validity [20]. A random sample of 22 mon-CFS persons was scompared with 20 CFS patients. The Non-CFS sample included 17 women and five men whose mean age was 35 years (median age , 38 years; range, 19-62). The mean E1 of the CFS group was 3.6 (median E1, 4; range,1-5). The gender and ages of the CFS and non-CFS groups were similar (Fisher's exact test and t test). The E1s (CFS, 9.9 vs. non-CFS , 3.6) of the groups are different (P<.0001). The power of the t test is 1.0. The effect size of the data is 0.25. A small effect size is 0.2, a medium effect size is 0.5, and a large effect size is 0.8.

INFUSIONS OF GANCICLOVIR:

After placement of a peripherally inserted central or Groshong catheter, ganciclovir (5 mg/kg q 12 h) was given intravenously for 30 days. Initial infusions were administered in an outpatient short-stay unit of the hospital, as an inpatient. After the safety of the intravenous infusions was established, treatment continued at home. Patients were seen once a week by the same physician, and CBC, SMA values, and urine analysis were performed. After 30 days, patients were seen and evaluated at intervals of 4-6 weeks. They were advised to avoid exercise, fatigue (e.g., lifting, shopping, heavy household duties), and alcohol. A regular sleeping pattern was encouraged. As needed, temazepam (15 mg) and/or fluoxetine hydrochloride were given for insomnia or severe reactive depressions, which sometimes accompany CFS. None of these patients had had psychiatric illness before the onset of CFS. 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.

CARDIAC, VIROLOGIC, AND ELECTRON MICROSCOPIC STUDIES:

Twelve-lead ECG, 2-D echolcardiograpy, Holter monitoring, and stress MUGA studies were performed on each patient. Myocardial perfusion rest/stress (thalluim 201 or TC-99 sestamibi) studies were performed on 14 patients. Coronary angiograms were performed when indicated to exclude coronary artery disease. Right ventricular endomyocardial biopsies were performed in seven patients. Cardiac tissues were cultured in tissue culture for the presence of infectious HCMV. Another section of the biopsy was taken immediately in 2.5% cacodylate buffered glutaaldehyde, postfixed in 1% osmuim tetroxide, and embedded in Epon 812. Thin section for electron microscopy were stained with uranyl acetate, followed by lead citrate.

STATISTICAL METHODS:

Eighteen patients (three men and 15 women) whose mean age was 39.7 years (range, 29-51 years) were enrolled. Therapeutic efficiency could be determined for all patients. Follow-up information at 6 months post therapy was available for all patient. Statistical significance between patients meeting the criteria for the HCMV subset and other patients CFS was evaluated using tests of homogeneity of odds, x2 analysis, and the two-tailed Fisher's exact test for bivariate analysis of dichotomous data. Continuous variables were compared with the Wilcoxon rank sum test. Differences in EBV and EA antibody titers between groups A, B, and C were tested by x2 analysis.

RESULTS:

Demographics. Demographic findings and outcomes are shown in Table 1. Thirteen patients improved.The non-CFS control group (group C) is a random group of well persons. The gender and ages of CFS patients who improved (group A, 13 patients) and the other CFS patients who did not (group B, five patients) were similar. Groups A, B, and C were mostly women. Mean ages were 37 years (group A), 41 years (group B), and 32 years (group C). Patients in groups A and B had no known preexisting chronic illnesses. One patient each in group A and B smoked and a single patient in group A had elevated cholesterol level (265 mg/dL).

     The mean duration of fatigue before therapy was longer in group B (2.8 years) than in group A (1.6 years) patients. Before receiving intravenous ganciclovir, patients in both CFS groups A and B experienced marked worsening of fatigue with exercise. Myalgia; lightheadedness; and dull, nonspecific left-sided chest aches not related to activities were noted in both CFS groups. Physical examinations were normal in all patients except as noted. Two group A patients had mitral valve prolapse; another group A patient had an occasional mild episode of bronchial asthma. Euthyroid goiters were present in two group B patients. Reactive depressions were more common in group A. Eight group A and two group B patients complained of difficulty concentrating.

TABLE 1

Clinical findings in 18 cfs patients treated with intravenous ganciclovir

CARDIAC STUDIES:

Results of cardiac test are shown in table 2. Twelve-lead ECGs were normal except for single lead T-wave inversions in standard lead IIII (seven patients, group A; 2 patient, group B). Two-dimensional echocariograms (both groups) were generally unremarkable. Mitral valve prolapes was found in three patients. (two patients, group A; one patient, group B). Every patients in groups A and B showed abnormal T-wave oscillations by Holter monitoring [13]. Myocardial perfusion rest/stress studies (thallium-201 or TC-99 sestamibi) were normal in 13 of the 14 patients (groups A and B) on whom this study was performed. Two patient, one from each group had normal coronary angiograms. One 41-year-old millwright (see Case Report) form Group A had a normal coronary angiogram but with exercise demonstrated reversible "ischemia" of the anterior apical and inferior walls [18]. At right ventricular endomyocardial biopsy, varying degrees of cardiomypatic changed (figure 1) characterized by myofiber disarray, myofiber dissolution, myofiber dropout with fibrous replacement, and occasional myofiber hypertrogy were evident (five group A patient, two group B patient). Cultures of cardiac tissues for infections HCMV were negative.

     Abnormal myocardial dynamics by MUGA rest/stress studies were present in six of 13 patients (group A). Two patient had reduced ejection fractions (EFs) at rest (40% and 45%); another patient had an EF that decreased during exercise form 51% to 36%. Two patients demonstrated tardokineses; three showed hypokinesis, and four displayed left ventricular dialation. No patient in group B had abnormal ventricular dynamics. A normal resting left ventricular EF at stress MUGA study is >50%. With exercise, the EF normally rises > 5%. A stationary or falling EF is abnormal. The variability of results of this test in our nuclear medicine department is 5%. All MUGA studies were read blindly by at least two subspecialist nuclear medicine physicians without any knowledge of this study. These MUGA study changes are not seen in normal persons leading a sedentary life. Deconditioning and sedentary life in patients are not causes of decreased or falling left ventriclur EFs [21].

After treatment with ganciclovir, three patients (group A ) with previously abnormal myocardial dynamics reverted to normal; in three others (group A), results of MUGA tests improved with lesser degrees of tardokinesis,or left ventriclular dialation. At follow-up 6 moths after intravenous ganciclovir, one patient (group B ) with an initial normal rest/stress MUGA showed up sepatal hypokinesis.

Table 2

Cardiac Findings in 18 CFS patients treated with intravenous ganciclovir

Two patients had mitral valve prolapse, and a second had mild left ventricular enlargement One patient with a normal coronary angiogram showed reversible ischemia at anterior, apical, and inferior walls with exercise. This patient is described in the Case Report. One patient had mitral valve prolapse and a second had mild tricuspid insufficiency.

HCMV and EBV antibody titers:

     Patients in Group A had high HCMV ELISA IgG antibody titers (mean 332 U; median 204 U; range 120-503 U). Two patients (group A) had positive HCMV IgM antibody titers. No patient (group A) had demonstrable IgM antibody titers to EBV; 10 of the 13 patients had little or no evidence of EBV multiplication as tested by an elevated antibody titers to EA (EBV EA titer 40).

     A somewhat different serum antibody profile was seen in patients from group B. Three of these five patients had no antibody to HCMV. On patient had a transient HCMV IgM titer. We suspect that this was a false-positive test because at repeated testing, the HCMV ELISA IgG titer was negative. Active EBV multiplication was more common in CFS patients in group B. EBV IgM titers were present in two patients, and the EBV EA titer was 320 in a third patient. Using x2 analysis, no statistical difference in HCMV IgM antibody titers was present between group A and group B. With the Wilcoxon rank sum test, HCMV IgG titers had higher values in group A compared with group B (P+ .15). For EBV VCA IgM (X2 analysis) and EBV EA (rank sum test) antibody titers, there were no statistical differences between the groups.

     Normal control non-CFS persons commonly had IgG antibodies to HCMV: 14 (70%) of 20 control person. Little difference in IgG or IgM responses between groups A, B, or C was apparent. (Table 3). On the other hand, lesser experience and lower mean titers of antibodies to EBV EA were present in non-CFS control persons from group C. In 55% of group C persons, there was little or no evidence of current multiplication of EBV by EA titer. These differences were not statistically significant (P=.25)

TABLE 3

Antibody titers to HCMV and EBV in 18 CFS patients treated with intravenous ganciclovir.

                                               Group A                      Group B                             Group C

         Antibody titer              Improved n=13            Unchanged n = 5              Non-CFS controls

CHANGES IN VITALITY AFTER IV 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 thatapy 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).

Table 4             

Severity of fatigue in 18 CFS patients after IV ganciclovir

Note: Energy indices in groups A and B are different (P<.05, repeat measures analysis).

TOXICITIES OF IV GANCICLOVIR:

A single patient (group A) had a transient increase in serum creatinine. She was obese, and when her ganciclovir dosage was recalculated on the basis of lean body mass, the serum creatinine reverted to normal. On repeated hematologic tests, biochemical tests, or urine studies, no other abnormalities were attributable to ganciclovir. Similarly, no adverse events or symptoms were attributable to ganciclovir. Ganciclovir was significantly less toxic in these nonimmunosuppressed CFS patients than in immunosuppressed cancer or AIDS patients [15]. We could find no previous experience in the literature on the expected toxicity of IV ganciclovir in normal persons, and there is no proven indication for ganciclovir in nonimmunosuppressed patients at this time.

CASE REPORT:

A 51 year-old millwright enjoyed excellent health. His only risk factor for coronary artery disease was cigarette smoking. Over several months, he experienced overwhelming, progressive fatigue that forced him to stop working on October 19, 1993. He could barely rise from his bed, and slight exertion further worsened his fatigue. He was lightheaded, had severe generalized muscle aches and an intermittent sore throat, and was unable to think clearly. Physical examination was normal except for a threefold enlarged nonnodular thyroid. Chest roentogenogram, CBC, total and high-density lipoprotein cholesterol, T3, T4, thyroid-stimulating hormone, SMA values, and urinalysis were normal. A resting 12-lead ECG showed an inverted T-wave in standard lead II but was otherwise normal. An HCMV ELISA IgM antibody titer was positive, and the IgG titer was 498 [18]. EBV VCA IgM and EBV EA tests were negative. Herpesvirus 6 IgM was negative; the herpesvirus 6 IgG ELISA was 160. Holter monitoring on September 4, 1993 showed oscillating, abnormal flat or inverted T-waves appearing with the onset of sinus tachycardias and alternating with the reappearance of normal upright T-waves when tachys resolved. A 2-D echocardiogram showed minimal right ventricular hypertrophy consistent with bronchial asthma.

     A myocardial perfusion rest/stress test TC-99 sestamibi on October 19, 1993 showed reversible "ischemia" of the anterior, apical, and inferior walls, but at cardiac catheterization the coronary arteries were patent on October 21, 1993. A stress MUGA study on October 11, 1993 revealed abnormal left ventricular function. Resting EF was 40% (normal 50%). The maximal exercise tolerance was 600 kg/min, at which time the EF increased to 54%. Myocardial biopsy on October 21, 1993, at electron microscopic study showed focal myofiber disarray and hypertrophy.

     Beginning on October 20, 1993, the patient was given daily IV ganciclovir (5 mg/mg q12h) for 30 days. Nearly 5 months later, on March 8, 1994, the stress MUGA study was repeated, and his resting EF had increased from 14% to 54% and with exercise (600 kg/min), the EF increased to 68%. On Mar 10, 1993 a repeat myocardial perfusion study during exercise was normal. Left ventricular dysfunction was no longer present. Fatigue disappeared, he resumed work as a millwright. At follow-up 2.5 years after treatment, the left ventricular function remained normal.

DISCUSSION:

This preliminary open trial of IV ganciclovir in patients with CFS, abnormal T-wave oscillations at Holter monitoring, and significant HCMV ELISA antibody titers was conducted to identify a possible subset of patients who may benefit from this therapy. A significant HCMV ELISA IgG antibody titer (>120 U) with or without the presence of an HCMV IgG antibody titer, plus an absence of EBV VCA IgM antibody titer, along with an EBV EA antibody titer of <40 may help describe a CFS cohort of patients who may derive benefit from ganciclovir. This study as not blinded, randomized, or placebo-controlled, and the efficacy of ganciclovir has not been determined. The use of a single 30-day course of intravenous ganciclovir is arbitrary.

     During the EBV infectious lytic cycle, antigen is expressed and can be divided into a diffuse (EA-D) complex and a cytoplasmic restricted (EA-R) complex. Here, we assayed EA-D. The 52/50 kDa EA-D protein complex neutralizes EBV-encoded DNA polymerase activity. Elevated EBV VCA IgM and EBV EA antibody titers indicate recent EBV multiplication (e.g., within 90 days). Buffy coats from blood samples, urine samples, and cardiac biopsies did not contain infectious HCMV. It appears that we report a nonlytic, nonpermissive, persistent HCMV infection [24].