On this page: Viral Research

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*O* PRESS RELEASE: From: The Department of Neurology ,Institute of Neurological Sciences, Glasgow University 1992, Dr Behan Introduction The Chronic Fatigue Syndrome (known in the United Kingdom an Myalgic Encephalomyelitis or Postviral Fatigue Syndrome) is a relapsing illness which occurs in epidemics and sporadically.It in now being recognized worldwide and is of apparent increasing prevalence. It's main clinical feature is overwhelming fatigue, made worse by exercise and cited associated with a wide variety of other symptoms including sleep disturbances, muscle aches and pains;, atypical depression, difficulties with concentration and with memory, and symptoms of gastrointestinal upset. We, in this unit, have had a particular interest in the syndrome and have studied It over the past 15 years or more- We have been able to detect clinically a relationship between the onset of this illness and viral infection, the viral infection being most commonly with Enteroviruses. This possibility that Enteroviruses might be involved in this disorder has long been suspected particularly because of the relationship of previous epidemics of the syndrome to that of poliomyelitis outbreaks. Recent studies have shown that patients with the syndrome may excrete enterovirus in stool, and preliminary investigations detected enterovirus specific RNA sequence. in samples of muscle biopsies from patients in which a fifth were found to be positive using a nucleic hybridisation technique. We extended these studies using the highly sensitive polymerase chair reaction and demonstrated that it was possible to examine for low copy numbers of viral nucleic acid sequences in cells and tissues from patients. The technique was applied to muscle biopsies where 53% of patients were found to be positive and their muscle cells to contain enteroviral RNA sequences. NEW DATA TO BE REPORTED: We will report at the 1st International Research Conference on Chronic Fatigue Syndrome to be held at Albany, New York, 2 - 4 October 1992, our new findings relating particularly to Enteroviral infection. We have now extended our PCR data to now cover hundreds or patients together with controls and have continued to find a very significant proportion of the patients' muscle biopsies to contain enterovirus on PCR. In addition, we have used several different types of enteroviral primers and have obtained Identical result; in the patients with these primers; the control muscle biopsies from healthy subject; and patient; with other muscle diseases being entirely negative. We furthermore have isolated RNA from patients and probed this with large enterovirus probes which demonstrated that full length 7.4 kilobase virus was present in these patients. Indeed, detailed studies including Northern Blot Analysis showed that the material was true virus, as did specific studies implying antibody to enterovirus as an aid to augmentation to electronmicroscopy. Furthermore, this virus was shown to be replicating normally at the level of transcription. Sequence analysis of this isolated material showed that it had 80% homology with coxsackie B viruses and 76% homology with Poliomyelitis virus, demonstrating beyond any doubt that the material was enterovirus. We were able to extend these studies; in a unique way by being able to study post mortem material from a definite case of Chronic Fatigue Syndrome who died as a result of drug overdose. This showed that Enterovirus was present in skeletal muscle in, heart muscle, but particularly was abundant in brain. Detailed studies of the brain enterovirus revealed that it was most prevalent in diencephalic particularly hypothalamic, regions. *O* Three Babuska Clusters of Enteroviral-Associated Myalgic Encephalomyelitis by Byron Hyde MD Although physicians associated with Nightingale have been studying both M.E. and CFS patients since 1984, it was only in 1995 that we began to include in the investigation of each new Nightingale M.E. patient, an evaluation by PCR for chronic persisting enteroviral infection. The material employed was frozen blood serum that was evaluated by the research team of the viral laboratory of Ruchill Hospital in Glasgow. These patients were re-evaluated approximately once or twice a year for a period of three years. Blood serum from control patients of similar age and sex were submitted with serum from M.E. patients. Blood from other patients with various autoimmune diseases or neurological illnesses were also submitted along with our samples. The names were changed in repeat samples. The serum received at Ruchill Hospital was divided into reserves and two blinded samples of this serum were investigated by PCR in different laboratories. Only when each sample source was found to be positive for the same enteroviral code was the serum accepted as having a specific circulating enterovirus. Are Myalgic Encephalomyelitis and Chronic Fatigue Syndrome Synonymous Terms? by Byron Hyde MD Enterovirus infections have an incubation period identical to incubation periods noted in most of the M.E. epidemics, that is, of 4-6 days. *O* The impact of persistent enteroviral infection by Dr Elizabeth Dowsett By 1972, a distinguished group of clinicians and scientists had set out to share information, form research groups and hold national and international conferences related to the problems of ME. Following successful vaccination against the three polio viruses during the early 1960s over 60 epidemics of atypical, non paralytic polio had been recorded in the UK alone. It was obvious that (since Nature abhors a vacuum) the non polio enteroviruses were naturally filling the gap(6), and demonstrating their potential for inducing a serious neurological disease of considerable chronicity, mainly affecting school children and middle aged adults in the most important and productive years of their lives. Most of the famous London teaching hospitals were involved, at that time in investigating epidemics and in subsequent research while links were forged with international institutions in USA, Canada, Europe and Australasia, facing the same problems. *O* Research into ME - 1988-1998 Too much PHILOSPHY and too little BASIC SCIENCE! by Dr Elizabeth Dowsett Virology finally emerged from the dark ages of technical difficulty in which viral infection could be guessed at but seldom proved.  From 1948, when tissue culture permitted some viruses to be grown, electron-microscopy enabled others to be seen and the techniques of molecular biology permitted virtually all microbes to be studied (by the amplification and identification of their genetic fragments, even if hidden in internal body organs) the sequence of events in related diseases such as poliomyelitis and ME became clear.  During an outbreak of polio and ME in the 1950s, isolation of a whole range of polio and non polio enteroviruses from clinical and asymptomatic patients, indicated that there were some 69 related viruses in this group associated with a wide range of common acute and chronic infections of children and adults including paralytic poliomyelitis (mainly but not exclusively caused by polioviruses) and with acute viral meningitis, encephalitis, myocarditis, Epidemic Bornholm Disease and Hand Foot and Mouth Disease, infections of the middle ear, skin and eye, to say nothing of chronic myocarditis Juvenile onset diabetes, Myalgic encephalomyelitis and other chronic neurological and motor neurone conditions, caused by a wide range of non polio enteroviruses (Coxsackie, ECHO and enterviruses 68-71)(5).  Echo 9 virus was actually isolated from patients during an outbreak of ME in Lancashire during the 1955-56 epidemic years(6.).  The rediscovery of the Post-Polio Syndrome (first described in 1870) but brought to the attention of doctors in the USA by patient sufferers one hundred years later, indicated that the polio viruses could persist silently for some 25-40 years after the initial infection.  Enterovirus related metabolic myopathy: a postviral fatigue syndrome. Lane RJ, Soteriou BA, Zhang H, Archard LC.Division of Clinical Neurosciences and Psychological Medicine, Imperial College, London SW7, UK. r.lane@imperial.ac.uk OBJECTIVE: To detect and characterise enterovirus RNA in skeletal muscle from patients with chronic fatigue syndrome (CFS) and to compare efficiency of muscle energy metabolism in enterovirus positive and negative CFS patients. METHODS: Quadriceps muscle biopsy samples from 48 patients with CFS were processed to detect enterovirus RNA by two stage, reverse transcription, nested polymerase chain reaction (RT-NPCR), using enterovirus group specific primer sets. Direct nucleotide sequencing of PCR products was used to characterise the enterovirus. Controls were 29 subjects with normal muscles. On the day of biopsy, each CFS patient undertook a subanaerobic threshold exercise test (SATET). Venous plasma lactate was measured immediately before and after exercise, and 30 minutes after testing. An abnormal lactate response to exercise (SATET+) was defined as an exercise test in which plasma lactate exceeded the upper 99% confidence limits for normal sedentary controls at two or more time points. RESULTS: Muscle biopsy samples from 20.8% of the CFS patients were positive for enterovirus sequences by RT-NPCR, while all the 29 control samples were negative; 58.3% of the CFS patients had a SATET+ response. Nine of the 10 enterovirus positive cases were among the 28 SATET+ patients (32.1%), compared with only one (5%) of the 20 SATET- patients. PCR products were most closely related to coxsackie B virus. CONCLUSIONS: There is an association between abnormal lactate response to exercise, reflecting impaired muscle energy metabolism, and the presence of enterovirus sequences in muscle in a proportion of CFS patients. *O* Are echoviruses still orphans? Hill WM. Deparment of Microbiology, Basildon Hospital, Nether Mayne, England, UK. A review of some of the outbreaks of disease caused by echoviruses demonstrates their ability to cause significant morbidity and mortality world-wide. There are now 30 recognised echovirus serotypes; several of the original serotypes have been re-classified. More recently, echovirus 22 has been shown to have significant molecular differences from other types and unusual epidemiological features. Echovirus types 7, 11, 19 and 30 have been associated with significant outbreaks in neonatal units and echovirus types 9, 16 and 25 are more frequently associated with exanthem. Echovirus type 3, although relatively uncommon in the UK, was associated with large outbreaks in China. Since the decline in poliomyelitis, the increase in reports of non-polio enteroviruses has revealed a corresponding increase in associated cases of myalgic encephalomyelitis and post-viral fatigue syndrome.     *O*  Myalgic encephalomyelitis--a persistent enteroviral infection? Dowsett EG, Ramsay AM, McCartney RA, Bell EJ. Basildon Hospital, Essex, UK. Myalgic encephalomyelitis is a common disability but frequently misinterpreted. Amongst 6,000 patients referred for general microbiological diagnosis between 1975 and 1987, 420 cases were recognized. Coxsackie B neutralization tests, in 205 of these, demonstrated significant titres in 103/205 (50%), while of 124 additionally investigated for enteroviral IgM, 38/124 (31%) were positive. This illness is distinguished from a variety of other post-viral states by an unique clinical and epidemiological pattern characteristic of enteroviral infection. Prompt recognition and advice to avoid over-exertion is mandatory. Routine diagnosis, specific therapy and prevention, await further technical advances.     *O*  Postviral fatigue syndrome: persistence of enterovirus RNA in muscle and elevated creatine kinase. Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D. Department of Biochemistry, Charing Cross and Westminster Medical School, London. Enterovirus-specific probes have been prepared by reverse transcription of conserved sequences in purified Coxsackie B2 virus genomic RNA and molecular cloning techniques. These probes were used in quantitative slot blot hybridizations to test for the presence of enterovirus-specific RNA in skeletal muscle biopsy specimens from 96 patients who had suffered from the postviral fatigue syndrome myalgic encephalomyelitis for up to 20 years. Biopsy specimens from 20 patients were positive for the presence of virus-specific RNA with hybridization signals more than three standard deviations greater than the mean of the normal muscle controls. Biopsies from the remaining 76 patients were indistinguishable from the controls. These data show that enterovirus RNA is present in skeletal muscle of some patients with postviral fatigue syndrome up to 20 years after onset of disease and suggest that a persistent virus infection has an aetiological role.   Evidence for enteroviral persistence in humans. Galbraith DN, Nairn C, Clements GB. Journal of Genenal Virology 1997; 78(2): 307-12. Abstract: We have sought evidence of enteroviral persistence in humans. Eight individuals with chronic fatigue syndrome (CFS) were positive for enteroviral sequences, detected by PCR in two serum samples taken at least 5 months apart. The nucleotide sequence of the 5' non-translated region (bases 174-423) was determined for each amplicon. Four individuals had virtually identical nucleotide sequences ( > 97%) in both samples. The sequence pairs also each had a unique shared pattern indicating that the virus had persisted. In one individual (HO), it was clear that there had been infection with two different enteroviruses. In the remaining three individuals, the lack of unique shared features suggested that re-infection had occurred, rather than persistence. With the exception of HO, the sequences fell into a subgroup that is related to the Coxsackie B-like viruses. Phylogenetic analysis of short enteroviral sequences from patients with chronic fatigue syndrome. Galbraith DN, Nairn C, Clements GB. Journal of General Virology 1995; 76: 1701-1707. Abstract: This study used phylogenetic analysis based on a region of the 5' non-translated region (5'NTR) of a variety of enteroviral sequences to compare sequences associated with chronic fatigue syndrome (CFS) and those from enteroviruses causing acute infections. Direct sequencing of PCR products was used to obtain the nucleic acid sequences from CFS patients. The inferred phylogenetic tree identified three groupings, one correlating with the diagnosis of CFS. The analysis identified a close relationship between the chronic fatigue enteroviral sequences, and showed that 19/20 were distinct from previously described enteroviruses. These results suggest there is persistence of enterovirus infection in some CFS patients and indicate the presence of distinct novel enterovirus sequences. Enteroviral RNA sequences in muscle in patients with chronic fatigue syndrome. Gow RJ, Behan PO. British Medical Journal 1991; 302: 692-6. Abstract: OBJECTIVE-To determine the presence of enteroviral sequences in muscle of patients with the postviral fatigue syndrome. DESIGN-Detection of sequences with the polymerase chain reaction in a well defined group of patients with the syndrome and controls over the same period. SETTING-Institute of Neurological Sciences, Glasgow. SUBJECTS-60 consecutive patients admitted to the institute with the postviral fatigue syndrome who had undergone extensive investigation to exclude other conditions. 41 controls from the same catchment area without evidence of fatigue, all undergoing routine surgery. MAIN OUTCOME MEASURES-Routine investigations, serological screen for antibodies to a range of viruses, and presence of enteroviral RNA sequences in muscle biopsy specimens. RESULTS-15 (25%) patients and 10 (24.4%) controls had important serological findings. 12 patients had neutralising antibody titres of greater than or equal to 256 to coxsackieviruses B1-5 (six positive for enteroviral RNA sequences, six negative); three were positive for Epstein-Barr virus specific IgM (two positive, one negative). Six controls had similar neutralising antibody titres to coxsackieviruses (all negative); one was positive for Epstein-Barr virus specific IgM (negative); and three had titres of complement fixing antibody greater than or equal to 256 to cytomegalovirus (all negative). Overall, significantly more patients than controls had enteroviral RNA sequences in muscle (32/60, 53% v 6/41, 15%; odds ratio 6.7, 95% confidence interval 2.4 to 18.2). This was not correlated with duration of disease, patient and age, or to raised titres of antibodies to coxsackieviruses B1-5. CONCLUSIONS-Persistent enteroviral infection of muscle may occur in some patients with postviral fatigue syndrome and may have an aetiological role. Some long term sequelae of Coxsackie B virus. Gray JA. Journal of the Royal College of General Practitioners 1984; 34: 3-6. Are echoviruses still orphans? Hill WM. British Journal of Biomedicine Science 1996; 53(3): 221-6. Abstract: A review of some of the outbreaks of disease caused by echoviruses demonstrates their ability to cause significant morbidity and mortality world-wide. There are now 30 recognised echovirus serotypes; several of the original serotypes have been re-classified. More recently, echovirus 22 has been shown to have significant molecular differences from other types and unusual epidemiological features. Echovirus types 7, 11, 19 and 30 have been associated with significant outbreaks in neonatal units and echovirus types 9, 16 and 25 are more frequently associated with exanthem. Echovirus type 3, although relatively uncommon in the UK, was associated with large outbreaks in China. Since the decline in poliomyelitis, the increase in reports of non-polio enteroviruses has revealed a corresponding increase in associated cases of myalgic encephalomyelitis and post-viral fatigue syndrome. Disturbance of hypothalamic function and evidence for persistent enteroviral infection in patients with chronic fatigue syndrome. Richardson J. Journal of Chronic Fatigue Syndrome 1995; 1(2): 59-66. Abstract: It has been suggested that one of the major effects of persistent virus infections in the production of disorders such as the chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is on the hypothalamus (1). Buspirone, which is one of the anxiolytic drugs of the azapyrone group, causes a release of prolactin by stimulation of serotonin 5-hydroxytryptamine (5-HT) receptors. The buspirone-prolactin response was studied in a subgroup of patients with CFS/ME and evidence of persistent enteroviral infection, as shown by the repeated detection of the group-specific protein of enteroviruses, VP1, in the blood. Family controls who were asymptomatic were studied at the same time. In addition to the response to buspirone, diurnal variations in cortisol and prolactin levels were studied. It was found that the patients with CFS/ME had much greater rises in prolactin levels one hour after buspirone compared to controls. Cortisol levels were elevated in the patients, but the rise was not significantly different between the two groups. There was a significant association between the pattern of sleep disturbance, which we speak of as the OWL syndrome, and the ratio of pre- and post-buspirone prolactin levels. This study shows that there is a hypothalamic disturbance in the patients who also had evidence of enteroviral infection as part of the disorder of CFS/ME. It represents a quantifiable biochemical alteration to be found in this group of patients. Chronic enterovirus infection in patients with postviral fatigue syndrome. Yousef G, Bell E, Mann G, et al. Lancet 1988; 1: 146-50. Abstract: 76 patients with the postviral fatigue syndrome (PVFS) and 30 matched controls were investigated. Virus isolation was attempted from concentrated faecal samples by direct culture and after acid dissociation of virus from antibody. Positive cultures of enteroviruses were obtained from 17 (22%) patients and 2 (7%) controls. An enterovirus-group-specific monoclonal antibody, 5-D8/1, directed against the VP1 polypeptide, was used to detect enteroviral antigen in the circulation, either free or complexed with antibody. VP1 antigen was detected in the serum of 44 (51%) of a further group of 87 PVFS patients. The number of patients positive for VP1 antigen was greater (42/44) when IgM complexes were detectable than when they were no (2/23). 1 year later, the 17 patients of the first group of 76 with positive cultures were again studied. The same virus was again isolated from 5 (29%), 13 (76%) had detectable IgM responses to enteroviruses, and 9 (53%) were positive from VP1 antigen in the serum. These results show that chronic infection with enteroviruses occurs in many PVFS patients and that detection of enterovirus antigen in the serum is a sensitive and satisfactory method for investigating infection in these patients. Enteroviruses and postviral fatigue syndrome. Behan PO, Behan WM, Gow JW, Cavanagh H, Gillespie S. Ciba Foundation Symposium 1993; 173: 146-54. Abstract: Postviral fatigue syndrome (PFS) occurs both in epidemics and sporadically. Many of the original epidemics were related to poliomyelitis outbreaks which either preceded or followed them. The core clinical symptoms are always the same: severe fatigue made worse by exercise, myalgia, night sweats, atypical depression and excessive sleep. The other common symptoms include dysequilibrium disorders and irritable bowel syndrome. We have detected enteroviral genome sequences in muscle biopsies from cases of PFS, using specific enteroviral oligonucleotide primers in the polymerase chain reaction (PCR). In addition, whole virus particles can be demonstrated in PCR-positive muscle, using solid-phase immuno-electron microscopy. An increase in the number and size of muscle mitochondria was found in 70% of PFS cases, suggesting an abnormality in metabolic function. Evidence of hypothalamic dysfunction was present, particularly involving 5-hydroxytryptamine metabolism. A putative model of PFS, based on persistent enteroviral infection in laboratory mice, revealed resolving inflammatory lesions in muscle with, however, a marked increase in the production of certain cytokines in the brain. This model may help to explain the pathogenesis of PFS.   Enteroviral RNA sequences detected by polymerase chain reaction in muscle of patients with postviral fatigue syndrome. Gow JW, Behan WM, Clements GB, Woodall C, Riding M, Behan PO. Department of Neurology, University of Glasgow. OBJECTIVE--To determine the presence of enteroviral sequences in muscle of patients with the postviral fatigue syndrome. DESIGN--Detection of sequences with the polymerase chain reaction in a well defined group of patients with the syndrome and controls over the same period. SETTING--Institute of Neurological Sciences, Glasgow. SUBJECTS--60 consecutive patients admitted to the institute with the postviral fatigue syndrome who had undergone extensive investigation to exclude other conditions. 41 controls from the same catchment area without evidence of fatigue, all undergoing routine surgery. MAIN OUTCOME MEASURES--Routine investigations, serological screen for antibodies to a range of viruses, and presence of enteroviral RNA sequences in muscle biopsy specimens. RESULTS--15 (25%) patients and 10 (24.4%) controls had important serological findings. 12 patients had neutralising antibody titres of greater than or equal to 256 to coxsackieviruses B1-5 (six positive for enteroviral RNA sequences, six negative); three were positive for Epstein-Barr virus specific IgM (two positive, one negative). Six controls had similar neutralising antibody titres to coxsackieviruses (all negative); one was positive for Epstein-Barr virus specific IgM (negative); and three had titres of complement fixing antibody greater than or equal to 256 to cytomegalovirus (all negative). Overall, significantly more patients than controls had enteroviral RNA sequences in muscle (32/60, 53% v 6/41, 15%; odds ratio 6.7, 95% confidence interval 2.4 to 18.2). This was not correlated with duration of disease, patient and age, or to raised titres of antibodies to coxsackieviruses B1-5. CONCLUSIONS--Persistent enteroviral infection of muscle may occur in some patients with postviral fatigue syndrome and may have an aetiological role.     A study of Coxsackie B virus infections, 1972-1983. Bell EJ, McCartney RA. The results of a twelve-year study of Coxsackie B virus (CBV) infections in patients with a variety of acute and chronic illnesses are reported. CBVs were isolated from only 123 patients most of whom were children with respiratory illness. Virus diagnosis in adults was based mainly on the detection of significant rising or static high neutralizing antibody titres. Between 1972 and 1979 most investigations centred on patients with suspected viral heart disease, 12% of whom were found to have diagnostically significant CBV titres. In studies on patients with definite myo-pericarditis the number positive increased to 33%. In 1980 clinical interest switched to the possible role of CBV in myalgic encephalomyelitis (ME), an illness of diverse symptomatology. Investigation of suspected cases of ME in 1983 showed that 16% were serologically positive compared to 4% of normal adults in the West of Scotland. In patients with well-documented ME this figure rose to 41%. The demand by clinicians for CBV neutralizing antibody tests has increased over the past twelve years and continues to escalate annually, especially in patients with chronic relapsing illness.     *O*  Phylogenetic analysis of short enteroviral sequences from patients with chronic fatigue syndrome. Galbraith DN, Nairn C, Clements GB. Regional Virus Laboratory, Ruchill Hospital, Glasgow, UK. This study used phylogenetic analysis based on a region of the 5' non-translated region (5'NTR) of a variety of enteroviral sequences to compare sequences associated with chronic fatigue syndrome (CFS) and those from enteroviruses causing acute infections. Direct sequencing of PCR products was used to obtain the nucleic acid sequences from CFS patients. The inferred phylogenetic tree identified three groupings, one correlating with the diagnosis of CFS. The analysis identified a close relationship between the chronic fatigue enteroviral sequences, and showed that 19/20 were distinct from previously described enteroviruses. These results suggest there is persistence of enterovirus infection in some CFS patients and indicate the presence of distinct novel enterovirus sequences.   Chronic enterovirus infection in patients with postviral fatigue syndrome. Yousef GE, Bell EJ, Mann GF, Murugesan V, Smith DG, McCartney RA, Mowbray JF. Lancet. 1988. Department of Pathology, St Mary's Hospital Medical School, London. 76 patients with the postviral fatigue syndrome (PVFS) and 30 matched controls were investigated. Virus isolation was attempted from concentrated faecal samples by direct culture and after acid dissociation of virus from antibody. Positive cultures of enteroviruses were obtained from 17 (22%) patients and 2 (7%) controls. An enterovirus-group-specific monoclonal antibody, 5-D8/1, directed against the VP1 polypeptide, was used to detect enteroviral antigen in the circulation, either free or complexed with antibody. VP1 antigen was detected in the serum of 44 (51%) of a further group of 87 PVFS patients. The number of patients positive for VP1 antigen was greater (42/44) when IgM complexes were detectable than when they were not (2/23). 1 year later, the 17 patients of the first group of 76 with positive cultures were again studied. The same virus was again isolated from 5 (29%), 13 (76%) had detectable IgM responses to enteroviruses, and 9 (53%) were positive for VP1 antigen in the serum. These results show that chronic infection with enteroviruses occurs in many PVFS patients and that detection of enterovirus antigen in the serum is a sensitive and satisfactory method for investigating infection in these patients.   Myalgic Encephalomyelitis - a persistent enteroviral infection? Dowsett E, Ramsay AM, McCartney RA and Bell EJ. Postgraduate Medical Journal 1990; 66: 526-530. Abstract: Myalgic encephalomyelitis is a common disability but frequently misinterpreted. Amongst 6,000 patients referred for general microbiological diagnosis between 1975 and 1987, 420 cases were recognized. Coxsackie B neutralization tests, in 205 of these, demonstrated significant titres in 103/205 (50%), while of 124 additionally investigated for enteroviral IgM, 38/124 (31%) were positive. This illness is distinguished from a variety of other post-viral states by an unique clinical and epidemiological pattern characteristic of enteroviral infection. Prompt recognition and advice to avoid over-exertion is mandatory. Routine diagnosis, specific therapy and prevention, await further technical advances. Post viral fatigue syndrome: persistence of enteroviral RNA in skeletal muscle and elevated creatine kinase. Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D. Journal of the Royal Society of Medicine 1988; 81: 326-9. Abstract: Enterovirus-specific probes have been prepared by reverse transcription of conserved sequences in purified Coxsackie B2 virus genomic RNA and molecular cloning techniques. These probes were used in quantitative slot blot hybridizations to test for the presence of enterovirus-specific RNA in skeletal muscle biopsy specimens from 96 patients who had suffered from the postviral fatigue syndrome myalgic encephalomyelitis for up to 20 years. Biopsy specimens from 20 patients were positive for the presence of virus-specific RNA with hybridization signals more than three standard deviations greater than the mean of the normal muscle controls. Biopsies from the remaining 76 patients were indistinguishable from the controls. These data show that enterovirus RNA is present in skeletal muscle of some patients with postviral fatigue syndrome up to 20 years after onset of disease and suggest that a persistent virus infection has an aetiological role.   Evidence for persistent enterovirus infection of the central nervous system in patients with previous paralytic poliomyelitis. Muir P, Nicholson F, Sharief MK, Thompson EJ, Cairns NJ, Lantos P, Spencer GT, Kaminski HJ, Banatvala JE. Department of Virology, UMDS St. Thomas' Hospital, London, United Kingdom. It has been suggested that late onset neurological deterioration after poliomyelitis may be due in some cases to persistent poliovirus infection of the central nervous system. In view of this, we decide to determine whether polioviruses and other enteroviruses can persist in the central nervous system. In a previous study, one of us (M.K.S.) reported serological evidence of persistent poliovirus infection of the central nervous system (CNS) in a proportion of these patients. We have now studied cerebrospinal fluid (CSF) from these patients for the presence of enterovirus RNA sequences using the polymerase chain reaction (PCR). Enteroviral RNA was detected in 3 of 24 patients with a clinical diagnosis of post-polio syndrome, but in none of 36 patients with stable poliomyelitis, and none of 36 patients with other neurological conditions of noninfective origin. All 3 patients in whom viral RNA was detected had high intrathecal levels of poliovirus-specific oligoclonal IgM bands. In a second study we examined formalin-fixed postmortem CNS tissue from 7 patients with a history of paralytic poliomyelitis. Enterovirus RNA was detected in tissue from the spinal cord from 3 patients, but not in the cerebral cortex. We are now conducting a larger prospective, blind study of patients with evidence of late deterioration. Analysis of the first 30 patients studied revealed the presence of enterovirus RNA in CSF of 1 of 4 patients with unexplained late-onset post-polio weakness, 1 of 6 with some evidence of clinical deterioration, but none of 20 without inexplicable signs of post-polio weakness. Enteroviral RNA was also detected in spinal cord from 2 of 3 patients who died from other causes during this study. These studies provide virological evidence that enteroviruses may persist in the CNS of man. Further study is required in order to understand fully the biological and clinical significance of these findings. [Enterovirus infections in new disguise] [Article in Swedish] Fohlman J, Friman G, Tuvemo T. Infektionskliniken, Akademiska sjukhuset, Uppsala. Enteroviruses (Coxsackie A and B, echovirus, poliovirus) belong to a group of small RNA-viruses, picomavirus, which are widespread in nature. Enteroviruses cause a number of wellknown diseases and symptoms in humans, from subclinical infections and the common cold to poliomyelitis with paralysis. The development of polio vaccines is the greatest accomplishment within the field of enterovirus research and the background work was awarded the Nobel prize in 1954. New knowledge implies that enteroviruses play a more important part in the morbidity panorama than was previously thought. Chronic (persistent) enteroviruses were formerly unknown. Serologic and molecular biology techniques have now demonstrated that enteroviral genomes, in certain situations, persist after the primary infection (which is often silent). Persistent enteroviral infection or recurrent infections and/or virus-stimulated autoimmunity might contribute to the development of diseases with hitherto unexplained pathogenesis, such as post polio syndrome, dilated cardiomyopathy, juvenile (type 1) diabetes and possibly some cases of chronic fatigue syndrome.   Persistence of enterovirus RNA in muscle biopsy samples suggests that some cases of chronic fatigue syndrome result from a previous, inflammatory viral myopathy. Bowles NE, Bayston TA, Zhang HY, Doyle D, Lane RJ, Cunningham L, Archard LC. The Journal of Medicine 1993; 24(2-3): 145-60. Abstract: Molecular hybridization using an enterovirus group specific probe detected virus RNA in muscle biopsy samples from 25 of 96 cases of inflammatory muscle disease and similarly from 41 of 158 cases of postviral fatigue syndrome (PFS). Enterovirus RNA was detected in only two of 152 samples of control muscle. The inflammatory myopathy group comprised patients with polymyositis (PM), juvenile dermatomyositis (JDM) or adult dermatomyositis (DM), and all showed the presence of an inflammatory infiltrate and fiber necrosis on histological examination of a muscle biopsy sample. In contrast, muscle samples from the PFS group were histologically normal except for non-specific changes such as occasional single fiber atrophy. By analogy with enteroviral myocarditis, which can progress to a post-inflammatory disease with persistence of virus in myocardium and disposes to the rapid development of dilated cardiomyopathy, we propose that PFS syndrome may be a sequela of a previous inflammatory viral myopathy. Persistence of enteroviral RNA in chronic fatigue syndrome is associated with the abnormal production of equal amounts of positive and negative strands of enteroviral RNA. Cunningham L, Bowles NE, Lane RJ, Dubowitz V, Archard LC. Journal of General Virology 1990; 71 (6): 1399-402. Abstract: A subgenomic restriction fragment from cDNA prepared from Coxsackie B2 virus (CVB2) RNA was subcloned into a riboprobe vector allowing the production of enteroviral group-specific RNA probes complementary to either the positive (genomic) or negative (template) strand of enteroviral RNA. These riboprobes were used to follow productive infection of cultured cells by CVB2; as expected, positive strand RNA was synthesized in approximately 100-fold excess over negative strand. RNA was extracted from muscle biopsy samples from patients with chronic fatigue syndrome and probed for the presence of enteroviral RNA. In cases where enteroviral RNA was detected the amounts of positive and negative strands of enteroviral RNA were approximately equal, in contrast to the situation in lytic infection of cultured cells. This suggests that enterovirus persistence in muscle is due to a defect in control of viral RNA synthesis.   Persistence of enteroviral RNA in chronic fatigue syndrome is associated with the abnormal production of equal amounts of positive and negative strands of enteroviral RNA. Cunningham L, Bowles NE, Lane RJ, Dubowitz V, Archard LC. Department of Biochemistry, Charing Cross and Westminster Medical School, London, U.K. A subgenomic restriction fragment from cDNA prepared from Coxsackie B2 virus (CVB2) RNA was subcloned into a riboprobe vector allowing the production of enteroviral group-specific RNA probes complementary to either the positive (genomic) or negative (template) strand of enteroviral RNA. These riboprobes were used to follow productive infection of cultured cells by CVB2; as expected, positive strand RNA was synthesized in approximately 100-fold excess over negative strand. RNA was extracted from muscle biopsy samples from patients with chronic fatigue syndrome and probed for the presence of enteroviral RNA. In cases where enteroviral RNA was detected the amounts of positive and negative strands of enteroviral RNA were approximately equal, in contrast to the situation in lytic infection of cultured cells. This suggests that enterovirus persistence in muscle is due to a defect in control of viral RNA synthesis.     Evidence for enteroviral persistence in humans. Galbraith DN, Nairn C, Clements GB. Regional Virus Laboratory, Ruchill Hospital, Glasgow, UK. We have sought evidence of enteroviral persistence in humans. Eight individuals with chronic fatigue syndrome (CFS) were positive for enteroviral sequences, detected by PCR in two serum samples taken at least 5 months apart. The nucleotide sequence of the 5' non-translated region (bases 174-423) was determined for each amplicon. Four individuals had virtually identical nucleotide sequences ( > 97%) in both samples. The sequence pairs also each had a unique shared pattern indicating that the virus had persisted. In one individual (HO), it was clear that there had been infection with two different enteroviruses. In the remaining three individuals, the lack of unique shared features suggested that re-infection had occurred, rather than persistence. With the exception of HO, the sequences fell into a subgroup that is related to the Coxsackie B-like viruses.     Postviral fatigue syndrome: persistence of enterovirus RNA in muscle and elevated creatine kinase. Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D. Department of Biochemistry, Charing Cross and Westminster Medical School, London. Enterovirus-specific probes have been prepared by reverse transcription of conserved sequences in purified Coxsackie B2 virus genomic RNA and molecular cloning techniques. These probes were used in quantitative slot blot hybridizations to test for the presence of enterovirus-specific RNA in skeletal muscle biopsy specimens from 96 patients who had suffered from the postviral fatigue syndrome myalgic encephalomyelitis for up to 20 years. Biopsy specimens from 20 patients were positive for the presence of virus-specific RNA with hybridization signals more than three standard deviations greater than the mean of the normal muscle controls. Biopsies from the remaining 76 patients were indistinguishable from the controls. These data show that enterovirus RNA is present in skeletal muscle of some patients with postviral fatigue syndrome up to 20 years after onset of disease and suggest that a persistent virus infection has an aetiological role.   Coxsackie B viruses and myalgic encephalomyelitis. Bell EJ, McCartney RA, Riding MH. Journal of the Royal Society of Medicine 1988; 81: 329-31. Abstract: Data collected over the past 6 years suggest that Coxsackie B viruses (CBV) play an important role in myalgic encephalomyelitis (ME). Since psychological upset is a feature of this illness, 247 patients, recently admitted to a psychiatric hospital, were tested for neutralizing antibodies to CBV. A total of 12.5% had significantly raised CBV titres compared with 4-5% of 'well' control groups; the percentage positive was greatest (21%) in those aged 30-39 years. During 1985 and 1986 sera from 290 adults with ME were tested using the newly developed CBV IgM ELISA test; 37% were CBV IgM positive compared with 9% of 500 'well' adult controls. Forty-seven children, with ME were similarly tested during this period; 38% were positive, implying recent or active CBV infection. The combined use of this ELISA test and the virus probe techniques now available should further help to elucidate the exact role of CBV in this disabling illness.   How enteroviruses might evade the immune system. Cunningham et al. J  Gen Virology, 1990, 71, 1399   *O* Redefinitions of ME - a 20th Century Phenomenon by Dr Elizabeth Dowsett   Advantages of the “polio-like” description – general awareness of the entity by physicians; information readily available in standard text books and medical journals.  Supportive evidence:  (a)  a virological distinction between the 2 diseases was not available until the development of virus culture in 1948.  This resulted in the discovery of some 69 related polio and non-polio enteroviruses.  Although the majority of host/virus contacts produce subclinical infections, these agents are extremely versatile with a wide range of overlapping tissue affinities.  They are reliably associated with many acute infections of the respiratory and intestinal tracts;  with middle ear, neurological, skin, muscle, throat and mucous membrane infections; with epidemics of viral meningitis, Bornholm and Hand Foot and Mouth disease and with chronic sequelae affecting the brain, heart muscle, the pancreas and other endocrine glands.  (b) Serological studies in Iceland, following the introduction of oral polio vaccine in 1958, indicated that a 1948 epidemic of Iceland Disease (ME) in the north of the island effectively blocked a 1957 epidemic of polio type I in the south from spreading north.  At the same time the response to polio type I oral vaccine was standard in the south but aberrant in patients who suffered from the 1948 epidemic in the north.  This indicated a close relationship between the agents of both diseases with competition for receptor sites in the bowel and persistence of the 1948 epidemic agent over 7 years.   Elevated Plasma Prolactin and EEG Slow Wave Power in Post-Polio Fatigue: Implications for a Dopamine Deficiency Underlying Post-Viral Fatigue Syndromes Richard L Bruno, Susan Creange, Jerald R Zimmerman and Nancy M Frick HarvestCtr@AOL.COM Journal of Chronic Fatigue Syndrome 1998 vol.4 no.2 page 61-75   To test the hypothesis that plasma prolactin and electroencephalographic (EEG) slow wave activity are correlated with fatigue, 33 polio survivors without medical or psychologic comorbidities were studied. Subjects were administered the Post-Polio Fatigue Questionnaire (PFQ) and had resting measurement of both plasma prolactin and bilateral temporal-occipital power across the EEG frequency spectrum. Typical daily fatigue severity on the PFQ was significantly correlated with daily difficulty with attention, staying awake and motivation, but not with measures of acute polio severity or the number of limbs affected by late-onset Post-Polio Sequelae symptoms. Prolactin was significantly correlated with daily fatigue severity on the PFQ (r = .39; p <0.5). EEG power was equal between the two hemispheres across all frequency bands. However, EEG slow wave power in the right hemispheres was significantly correlated with daily fatigue severity and prolactin level (r = .37; p <.05). Using multiple linear regression, age at acute polio, frequency of difficulty with attention on the PFQ, prolactin and right hemisphere slow wave power predicted 72% of the variance of the daily fatigue severity rating (r = .85; p < .0001). These data suggest that increased prolactin secretion and EEG slowing are related to the severity of post-polio fatigue, findings similar to those in patients with acute paralytic and non-paralytic poliomyelitis and with chronic fatigue syndrome. A primary role is suggested for a dopamine deficiency (versus serotonergic receptor supersensitivity) underlying impaired cortical activation and the symptoms associated with putative post-viral fatigue syndromes. Chronic fatigue syndrome--aetiological aspects  Dickinson CJ  Wolfson Institute , St. Bartholomew's & Royal London School of Medicine & Dentistry, London, UK. Eur J Clin Invest 1997 Apr;27(4):257-67 (ISSN: 0014-2972) "Regional blood flow studies by single photon-emission computerized tomography (SPECT) have been more consistent. They have revealed blood flow reductions in many regions, especially in the hind brain. Similar lesions have been reported after poliomyelitis and in multiple sclerosis--in both of which conditions chronic fatigue is characteristically present. In the well-known post-polio fatigue syndrome, lesions predominate in the RAS of the brain stem. If similar underlying lesions in the RAS can eventually be identified in CFS, the therapeutic target for CFS would be better defined than it is at present. A number of logical approaches to treatment can already be envisaged". Thu, 15 Feb 2001 "Dr. Richard L. Bruno" CFSENG@AOL.COM I have received some questions as a result of my recent post to Co-Cure on CFS vs PPS and OPV which I thought might be of interest to the Co-Cure readers. Question: "What, specifically, was it from Sabin's 1947 data that suggests that some of the people with ME/CFS may be survivors of nonparalytic polio? Are there research reports available online?" Answer: They are not available on line. I went through the Sabin Archive in Cincinnati. Take a look at the non-paralytic polio papers and the "Parallels" between polio and CFS paper at: http://members.aol.com/harvestctr/pps/lib2.html Question: "And what about those people who developed the disease as teenagers in the 1990s (and who weren't around in the 1950s)? If any of them have NPP, would they have contracted it from the older patients, or from vaccines, or from some other source?" Answer: They would not have had polio at all. If a virus caused their CFS, it would have been from some other source. Our best guess as a cause is another enterovirus very similar to the poliovirus, e.g., Coxsackie B4, that can cause brain and spinal cord lesions identical to those caused by the poliovirus. Polio only means gray in Latin, referring to damage to unmyelinated neurons. Poliovirus causes "polio," but so do other viruses, e.g., Enterovirus 71 causing "polio" in Brazil. Question: "Is there a way to test for NPP in today's patients?" Answer: You can do an EMG, where needles are inserted into muscles, to look for "silent" denervation. But EMG can give false negatives even in polio survivors. We have found MRI and hormonal correlates of PPS fatigue but they are identical to the findings s in CFS! Question: "Would vaccine programs in place since the 1950s have given everyone so many antibodies to polio that such testing would be futile?" Answer: Probably. By if one had a "natural" poliovirus infection their antibody titre might be higher than if they only had the vaccine. Hope this helps! Dick Bruno Poliovirus induces an early impairment of mitochondrial function by inhibiting succinate dehydrogenase activity.Koundouris A, Kass GE, Johnson CR, Boxall A, Sanders PG, Carter MJ School of Biological Sciences, University of Surrey, Guildford, Surrey, United Kingdom. PMID: 10814509, UI: 20275463 Poliovirus infection of COS-1 and T47D cells caused a rapid decrease in total cell respiration, and this was attributed to an inhibition of mitochondrial respiration. The stimulation of mitochondrial respiration by pyruvate plus malate or succinate was impaired in saponin-permeabilised cells. However, this inhibition could be overcome by the addition of N,N,N',N'-tetramethyl-1, 4-phenylenediamine and ascorbate. The activity of succinate dehydrogenase was impaired in parallel with the inhibition of mitochondrial respiration during poliovirus infection. This shows that mitochondrial function is profoundly altered during poliovirus infection and that this occurs primarily through inhibition of electron flow at complex II of the mitochondrial respiratory chain. Copyright 2000 Academic Press. The Plenocoral Trial by Dr Betty Dowsett Post viral fatigue syndrome: persistence of enteroviral RNA in skeletal muscle and elevated creatine kinase. Archard LC, Bowles NE, Behan PO, Bell EJ, Doyle D. Journal of the Royal Society of Medicine 1988; 81: 326-9. Abstract: Enterovirus-specific probes have been prepared by reverse transcription of conserved sequences in purified Coxsackie B2 virus genomic RNA and molecular cloning techniques. These probes were used in quantitative slot blot hybridizations to test for the presence of enterovirus-specific RNA in skeletal muscle biopsy specimens from 96 patients who had suffered from the postviral fatigue syndrome myalgic encephalomyelitis for up to 20 years. Biopsy specimens from 20 patients were positive for the presence of virus-specific RNA with hybridization signals more than three standard deviations greater than the mean of the normal muscle controls. Biopsies from the remaining 76 patients were indistinguishable from the controls. These data show that enterovirus RNA is present in skeletal muscle of some patients with postviral fatigue syndrome up to 20 years after onset of disease and suggest that a persistent virus infection has an aetiological role. Enteroviruses and postviral fatigue syndrome. Behan PO, Behan WM, Gow JW, Cavanagh H, Gillespie S. Ciba Foundation Symposium 1993; 173: 146-54. Abstract: Postviral fatigue syndrome (PFS) occurs both in epidemics and sporadically. Many of the original epidemics were related to poliomyelitis outbreaks which either preceded or followed them. The core clinical symptoms are always the same: severe fatigue made worse by exercise, myalgia, night sweats, atypical depression and excessive sleep. The other common symptoms include dysequilibrium disorders and irritable bowel syndrome. We have detected enteroviral genome sequences in muscle biopsies from cases of PFS, using specific enteroviral oligonucleotide primers in the polymerase chain reaction (PCR). In addition, whole virus particles can be demonstrated in PCR-positive muscle, using solid-phase immuno-electron microscopy. An increase in the number and size of muscle mitochondria was found in 70% of PFS cases, suggesting an abnormality in metabolic function. Evidence of hypothalamic dysfunction was present, particularly involving 5-hydroxytryptamine metabolism. A putative model of PFS, based on persistent enteroviral infection in laboratory mice, revealed resolving inflammatory lesions in muscle with, however, a marked increase in the production of certain cytokines in the brain. This model may help to explain the pathogenesis of PFS. Persistence of enterovirus RNA in muscle biopsy samples suggests that some cases of chronic fatigue syndrome result from a previous, inflammatory viral myopathy. Bowles NE, Bayston TA, Zhang HY, Doyle D, Lane RJ, Cunningham L, Archard LC. The Journal of Medicine 1993; 24(2-3): 145-60. Abstract: Molecular hybridization using an enterovirus group specific probe detected virus RNA in muscle biopsy samples from 25 of 96 cases of inflammatory muscle disease and similarly from 41 of 158 cases of postviral fatigue syndrome (PFS). Enterovirus RNA was detected in only two of 152 samples of control muscle. The inflammatory myopathy group comprised patients with polymyositis (PM), juvenile dermatomyositis (JDM) or adult dermatomyositis (DM), and all showed the presence of an inflammatory infiltrate and fiber necrosis on histological examination of a muscle biopsy sample. In contrast, muscle samples from the PFS group were histologically normal except for non-specific changes such as occasional single fiber atrophy. By analogy with enteroviral myocarditis, which can progress to a post-inflammatory disease with persistence of virus in myocardium and disposes to the rapid development of dilated cardiomyopathy, we propose that PFS syndrome may be a sequela of a previous inflammatory viral myopathy. Detection of enterovirus-specific RNA in serum: the relationship to chronic fatigue. Clements GB, McGarry F, Nairn C, Galbraith DN. Journal of Medical Virology 1995; 45(2): 156-61. Abstract: The serum of 88 chronic fatigue patients was screened for enteroviral specific sequences by polymerase chain reaction (PCR) assay. The PCR method used was "nested" PCR targetting the 5' nontranslated region of the enteroviral genome which yielded a final fragment length of 264 base pairs. Samples were obtained from patients during 1990-1991. In addition, buffy coat specimens and stool specimens were examined in some patients. Samples from two cohorts of comparison individuals were also obtained. The comparison groups were firstly, acutely ill individuals with symptoms consistent with a presumed enteroviral infection (matched by age, sex, and date of receipt of specimen) and secondly, healthy individuals (matched by age and date of receipt of specimen). Enteroviral specific sequences were detected in 36 of 88 serum samples from chronic fatigue patients, 22 of 82 acutely ill individuals, and 3 of 126 healthy individuals. The enteroviral PCR positivity did not correlate with any one particular feature of chronic fatigue nor did it reflect any history of illness at onset of fatigue, duration of fatigue, or age of patient. These results provide new evidence for the presence of enteroviral specific sequences in serum, buffy coat, and stool samples in many patients with chronic fatigue. This may reflect a persistent enterovirus infection in a proportion of chronic fatigue patients. Persistence of enteroviral RNA in chronic fatigue syndrome is associated with the abnormal production of equal amounts of positive and negative strands of enteroviral RNA. Cunningham L, Bowles NE, Lane RJ, Dubowitz V, Archard LC. Journal of General Virology 1990; 71 (6): 1399-402. Abstract: A subgenomic restriction fragment from cDNA prepared from Coxsackie B2 virus (CVB2) RNA was subcloned into a riboprobe vector allowing the production of enteroviral group-specific RNA probes complementary to either the positive (genomic) or negative (template) strand of enteroviral RNA. These riboprobes were used to follow productive infection of cultured cells by CVB2; as expected, positive strand RNA was synthesized in approximately 100-fold excess over negative strand. RNA was extracted from muscle biopsy samples from patients with chronic fatigue syndrome and probed for the presence of enteroviral RNA. In cases where enteroviral RNA was detected the amounts of positive and negative strands of enteroviral RNA were approximately equal, in contrast to the situation in lytic infection of cultured cells. This suggests that enterovirus persistence in muscle is due to a defect in control of viral RNA synthesis. Evidence for enteroviral persistence in humans. Galbraith DN, Nairn C, Clements GB. Journal of Genenal Virology 1997; 78(2): 307-12. Abstract: We have sought evidence of enteroviral persistence in humans. Eight individuals with chronic fatigue syndrome (CFS) were positive for enteroviral sequences, detected by PCR in two serum samples taken at least 5 months apart. The nucleotide sequence of the 5' non-translated region (bases 174-423) was determined for each amplicon. Four individuals had virtually identical nucleotide sequences ( > 97%) in both samples. The sequence pairs also each had a unique shared pattern indicating that the virus had persisted. In one individual (HO), it was clear that there had been infection with two different enteroviruses. In the remaining three individuals, the lack of unique shared features suggested that re-infection had occurred, rather than persistence. With the exception of HO, the sequences fell into a subgroup that is related to the Coxsackie B-like viruses. Phylogenetic analysis of short enteroviral sequences from patients with chronic fatigue syndrome. Galbraith DN, Nairn C, Clements GB. Journal of General Virology 1995; 76: 1701-1707. Abstract: This study used phylogenetic analysis based on a region of the 5' non-translated region (5'NTR) of a variety of enteroviral sequences to compare sequences associated with chronic fatigue syndrome (CFS) and those from enteroviruses causing acute infections. Direct sequencing of PCR products was used to obtain the nucleic acid sequences from CFS patients. The inferred phylogenetic tree identified three groupings, one correlating with the diagnosis of CFS. The analysis identified a close relationship between the chronic fatigue enteroviral sequences, and showed that 19/20 were distinct from previously described enteroviruses. These results suggest there is persistence of enterovirus infection in some CFS patients and indicate the presence of distinct novel enterovirus sequences. Enteroviral RNA sequences in muscle in patients with chronic fatigue syndrome. Gow RJ, Behan PO. British Medical Journal 1991; 302: 692-6. Abstract: OBJECTIVE-To determine the presence of enteroviral sequences in muscle of patients with the postviral fatigue syndrome. DESIGN-Detection of sequences with the polymerase chain reaction in a well defined group of patients with the syndrome and controls over the same period. SETTING-Institute of Neurological Sciences, Glasgow. SUBJECTS-60 consecutive patients admitted to the institute with the postviral fatigue syndrome who had undergone extensive investigation to exclude other conditions. 41 controls from the same catchment area without evidence of fatigue, all undergoing routine surgery. MAIN OUTCOME MEASURES-Routine investigations, serological screen for antibodies to a range of viruses, and presence of enteroviral RNA sequences in muscle biopsy specimens. RESULTS-15 (25%) patients and 10 (24.4%) controls had important serological findings. 12 patients had neutralising antibody titres of greater than or equal to 256 to coxsackieviruses B1-5 (six positive for enteroviral RNA sequences, six negative); three were positive for Epstein-Barr virus specific IgM (two positive, one negative). Six controls had similar neutralising antibody titres to coxsackieviruses (all negative); one was positive for Epstein-Barr virus specific IgM (negative); and three had titres of complement fixing antibody greater than or equal to 256 to cytomegalovirus (all negative). Overall, significantly more patients than controls had enteroviral RNA sequences in muscle (32/60, 53% v 6/41, 15%; odds ratio 6.7, 95% confidence interval 2.4 to 18.2). This was not correlated with duration of disease, patient and age, or to raised titres of antibodies to coxsackieviruses B1-5. CONCLUSIONS-Persistent enteroviral infection of muscle may occur in some patients with postviral fatigue syndrome and may have an aetiological role. Are echoviruses still orphans? Hill WM. British Journal of Biomedicine Science 1996; 53(3): 221-6. Abstract: A review of some of the outbreaks of disease caused by echoviruses demonstrates their ability to cause significant morbidity and mortality world-wide. There are now 30 recognised echovirus serotypes; several of the original serotypes have been re-classified. More recently, echovirus 22 has been shown to have significant molecular differences from other types and unusual epidemiological features. Echovirus types 7, 11, 19 and 30 have been associated with significant outbreaks in neonatal units and echovirus types 9, 16 and 25 are more frequently associated with exanthem. Echovirus type 3, although relatively uncommon in the UK, was associated with large outbreaks in China. Since the decline in poliomyelitis, the increase in reports of non-polio enteroviruses has revealed a corresponding increase in associated cases of myalgic encephalomyelitis and post-viral fatigue syndrome. Disturbance of hypothalamic function and evidence for persistent enteroviral infection in patients with chronic fatigue syndrome. Richardson J. Journal of Chronic Fatigue Syndrome 1995; 1(2): 59-66. Abstract: It has been suggested that one of the major effects of persistent virus infections in the production of disorders such as the chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is on the hypothalamus (1). Buspirone, which is one of the anxiolytic drugs of the azapyrone group, causes a release of prolactin by stimulation of serotonin 5-hydroxytryptamine (5-HT) receptors. The buspirone-prolactin response was studied in a subgroup of patients with CFS/ME and evidence of persistent enteroviral infection, as shown by the repeated detection of the group-specific protein of enteroviruses, VP1, in the blood. Family controls who were asymptomatic were studied at the same time. In addition to the response to buspirone, diurnal variations in cortisol and prolactin levels were studied. It was found that the patients with CFS/ME had much greater rises in prolactin levels one hour after buspirone compared to controls. Cortisol levels were elevated in the patients, but the rise was not significantly different between the two groups. There was a significant association between the pattern of sleep disturbance, which we speak of as the OWL syndrome, and the ratio of pre- and post-buspirone prolactin levels. This study shows that there is a hypothalamic disturbance in the patients who also had evidence of enteroviral infection as part of the disorder of CFS/ME. It represents a quantifiable biochemical alteration to be found in this group of patients. Chronic enterovirus infection in patients with postviral fatigue syndrome. Yousef G, Bell E, Mann G, et al. Lancet 1988; 1: 146-50. Abstract: 76 patients with the postviral fatigue syndrome (PVFS) and 30 matched controls were investigated. Virus isolation was attempted from concentrated faecal samples by direct culture and after acid dissociation of virus from antibody. Positive cultures of enteroviruses were obtained from 17 (22%) patients and 2 (7%) controls. An enterovirus-group-specific monoclonal antibody, 5-D8/1, directed against the VP1 polypeptide, was used to detect enteroviral antigen in the circulation, either free or complexed with antibody. VP1 antigen was detected in the serum of 44 (51%) of a further group of 87 PVFS patients. The number of patients positive for VP1 antigen was greater (42/44) when IgM complexes were detectable than when they were no (2/23). 1 year later, the 17 patients of the first group of 76 with positive cultures were again studied. The same virus was again isolated from 5 (29%), 13 (76%) had detectable IgM responses to enteroviruses, and 9 (53%) were positive from VP1 antigen in the serum. These results show that chronic infection with enteroviruses occurs in many PVFS patients and that detection of enterovirus antigen in the serum is a sensitive and satisfactory method for investigating infection in these patients. CFS May Be Result of Childhood Non-paralytic Polio Infection A layperson-accessible introductory article on this subject by Dr. Richard Bruno appears on-line at www.polionet.org/pen&ink/PI33-Sum00.htm#Childhood in "Pen and Ink," an E-zine of the Polio Experience Network. Some excerpts and notes: "A childhood poliovirus infection may cause chronic fatigue in baby-boomers concludes a paper published in the January, 11, 2000, issue of the American Journal of Physical Medicine and Rehabilitation "Paralytic Versus 'Non-Paralytic' Polio: A Distinction without a Difference," by Dr. Richard L. Bruno, director of The Post-Polio Institute at New Jersey's Englewood Hospital and Medical Center and chairperson of the International Post-Polio Task Force."  Dr. Bruno notes that L. Jason's recent CFS prevalence study, published in the October 11, 1999 issue of Archives of Internal Medicine (available on-line at: www.archinte.ama-assn.org/issues/v159n18/full/ioi90161.html), found that baby-boomers have a higher incidence of CFS: "Potentially half of those diagnosed today with CFS may in fact have had Summer Grippe or undiagnosed non-paralytic polio as children in the years before the polio vaccine became available," said Dr. Bruno. "They may also have brain activating system damage that causes chronic fatigue [syndrome]." *O* The Late Effects Of M.E. - Can they be distinguished from the Post-Polio Syndrome? by Dr Elizabeth Dowsett "The number likely to be affected by the post-polio syndrome has been calculated as between 200-270/100,000 currently[7], but no account has been taken of survivors from non-paralytic polio which could easily double that figure. Possible costing for ME support has been based on 3 times the cost of maintenance for multiple sclerosis on the supposition that ME is 3 times as common[4]. The only costs that we can be sure of are those derived from the failure of appropriate management, and of inappropriate assessments which waste vast sums of money and medical time while allowing patients to deteriorate unnecessarily.[16] Research workers must be encouraged and appropriately funded to work in this field. However they should first be directed to papers published before 1988, the time at which all specialised experience about poliomyelitis and associated infections seem to have vanished mysteriously![11,12,13]" *O* A Rose By Any Other Name by Dr Elizabeth Dowsett Both the earliest definition (HOLMES et al, 1988) and its revision (FUKUDA, 1994) elevated tonsillitis, glandular enlargement and fatigue to unreal importance while overlooking the characteristic encephalitic features of the genuine illness.  These mistakes also inflated the possibility of a psychiatric diagnosis, leading to the incorporation of such a heterogeneous population of psychiatric and non-psychiatric causes later on, that research groups of different persuasions were unable to compare results or evaluate treatment. The tools we can use today to study the brain offer possibilities which were unimaginable 50 years ago2.  These include Molecular Biology: for example PCR – a microbiological technique capable of amplifying and identifying minute fragments of viral genes, hidden away in internal organs (such as brain, heart or muscle 3) while a test for rapid diagnosis (within five hours) is currently available.  These tests indicate that viruses from the polio group, or related to it, are involved both in the late effects of ME and the Post Polio Syndrome 4.  Brain Imaging: the use of CT, MRI, SPECT and PET scans clearly indicates that metabolic dysfunction in the brain stem and the spinal nerve radiations which transverse it, are initially associated with viral (inflammatory) damage and are the major cause of the cardinal symptoms of ME – central fatigue, stress induced weakness, autonomic nervous dysfunction and the breakdown of homoeostasis over hormonal and other vital functions5. National ME / FM Action Network's 1st Annual Symposium on Parallels Between Post-Polio Sequelae, Myalgic Encephalomyelitis/Chronic Fatigue Syndrome. June 15, 2002 Dr. Dowsett believes that the polio vaccine made room for other polio-like viruses (from the family of viruses called enteroviruses) to take over. According to Dr. Dowsett's research and other work, these other viruses may even hit some parts of the brain harder than in polio, judging by the brain fatigue and research on the ME/CFS brain. So, even if people with ME/CFS don't have paralysis and get as physically weak as people who had polio, they may be even more impaired in other ways. This has VERY IMPORTANT implications for assessment of disability and for treatment. Important Treatment Information Dr. Bruno says pacing, NOT cognitive behavioural therapy and NOT graded exercise, is the cornerstone of treatment for people with PPS and ME/CFS. The key message is that people with ME/CFS and PPS have demonstrated brain stem dysfunction. This explains a multitude of symptoms because the brain stem controls so many physical and mental processes. Dr. Dowsett supports this view As the Canadian Newsletter `Quest` reports, both Dr Dowsett`s and Dr Bruno`s presentations are amazing, Dr Dowsett tells of her work throughout the years on ME/CFS linking it up with the Post Polio Sequelae. Dr Bruno, himself a paraplegic after Polio, is admirable in his determination to get over to people the effects of PPS, ME/CFS. and what can be done to allow people to help themselves improve their quality of life. Pleconaril - A New Drug For Enteroviral Infections by Dr Elizabeth Dowsett If the American multicentre placebo controlled randomised trial of  PLECONARIL in neonatal disease is successful, what a chance we have to treat, stop and prevent enteroviral illness now!  Please talk to your MP as soon as possible about why similar studies are not being carried out within the UK despite large amounts of money being provided!!  Polioencephalitis and the brain fatigue generator model of post-viral fatigue syndromes. Bruno RL, Frick NM, Creange S, Zimmerman JR, Lewis T. Journal of Chronic Fatigue Syndrome 1996; 2(2/3): 5-27. Abstract: Fatigue is the most commonly reported and most debilitating Post-Polio Squelae (PPS), affecting millions of polio survivors world-wide. Post-polio fatigue is associated with: (1) subjective reports of difficulty with attention, cognition, word-finding and maintaining wakefulness; (2) clinically significant deficits on neuropsychological tests of information processing speed and attention; (3) gray and white matter hyperintensities in the reticular activating system on magnetic resonance imaging of the brain; (4) neuroendocrine evidence of impaired activation of the HPA axis. Many of these findings are identical to those documented following a variety of viral encephalitides, including acute poliovirus infection, lethargic encephalitis, Iceland Disease, myalgic encephalomyelitis, and, most recently, Chronic Fatigue Syndrome. The clinical, historic, neuropsychologic, neuroanatomic and physiologic parallels between poliovirus infection, post-polio fatigue and post-viral fatigue syndromes (PVFS) will be explored in an attempt to describe the pathophysiology of PVFS. The disinhibition of a putatitve Brain Fatigue Generator will be implicated as a cause of the subjective symptoms and objective signs that accompany PVFS. The results of a pilot placebo-controlled study of a dopamine 2 receptor agonist to treat post-polio fatigue will also be described. Chronic fatigue, fainting and autonomic dysfunction: further similarities between post-polio fatigue and chronic fatigue syndrome? Bruno RL. Journal of Chronic Fatigue Syndrome 1997; 3(3): 109-116. Abstract: To test the hypothesis that fatigue and fainting occur together, 1,047 polio survivors and 419 non-disabled control subjects were asked about the frequency and cause of fainting and asked to rate their typical daily fatigue severity. Fatigue severity was significantly higher in polio survivors as compared to controls, and in both polio survivors and controls who had fainted, as compared to those who had not. Daily fatigue severity also increased in both groups as the number of lifetime faints increased. Fatigue was significantly higher in controls who fainted one time and three times as compared to controls who had never fainted. Daily fatigue severity was significantly higher in polio survivors who had fainted three, four and five times as compared to those who had never fainted. These findings suggest a physiological relationship between fatigue and fainting, possibly attributable to the close proximity of cardiovascular regulation and brain activation centers within the brain stem. Fatigue and hypotension in patients with chronic fatigue syndrome and in polio survivors with late-onset fatigue may result from damage to brain stem and hypothalamic neurons.