• Are they all three autoimmune diseases?
• Fibromyalgia aches and pain as a "Symptom" of hypothyroidism?
• Hashimoto's, FMS, CFS: relationship with chronic bacterial infections
The similarity of the symptoms in those three diseases is probably not just a coincidence: fatigue, low exercise tolerance, exhaustion, anxiety, depression, concentration difficulties, poor sleeping, widespread pain, gastrointestinal problems. There is no clinical or biological test to make a firm diagnosis of chronic fatigue syndrome (CFS). Doctors typically rule out other underlying illnesses before making a CFS diagnosis. Fibromyalgia (FMS) can be diagnosed via a detailed 11 to 18 "tender point" examination, but no biological test to point to the diagnosis. As for Hashimoto's autoimmune thyroiditis (HAIT), it is often overlooked due to a "normal" TSH.
The majority of diagnosed cases of CFS occur in women, most of whom are 25 to 45 years old. FMS strikes mostly women between the ages of 20 and 50. And HAIT is known to affect women 5-10 times more often than men. Hormonal relationships may explain the higher incidence in women.
● Are CFS, FMS and HAIT all autoimmune diseases?
While HAIT is known to be an autoimmune illness, researchers are beginning to believe that there is a strong autoimmune component to CFS and FMS. Ultimately, the three diseases may, in fact, be found to be varying manifestations of the same underlying autoimmune problems. HAIT and FMS can run in families.
A publication of a research which shows an immunological basis of fibromyalgia has been presented at the Paris international meeting of rheumatology in June 2008: "high plasma levels of MCP-1 and eotaxin provide evidence for an immunological basis of fibromyalgia" (City of Hope, Dr. St. Amand et al.). The research has identified in FMS abnormal elevations of various cytokines and chemokines. Similar cytokine profiles found in family members of fibromyalgics support the idea that FMS has a genetic component.
Research reported in the Journal of Clinical Investigation: "New evidence for role of autoimmune factors in CFS", indicates that approximately 52% of CFS patients develop autoantibodies indicative of a clear autoimmune component in CFS. In a 1994 article in the German medical journal Wien Med Wochenschr, "Chronic fatigue syndrome: immune dysfunction", a study of 375 patients with CFS showed an increased occurrence of autoantibodies in the CFS patients, especially microsomal thyroid antibodies (anti-TPO). According to these researchers, "This suggests a relationship between CFS and an autoimmune disease, including diseases with thyroid antibodies. This suggests that CFS is associated with an autoimmune disorder or is a manifestation."
The linkage between all three diseases is discussed in a 1996 article in the Canadian of Medical Association Journal (Neuroimmune mechanisms in health and disease). Researchers found that defects in the hypothalamus-pituitary-adrenal axis have been observed in autoimmune thyroid diseases, chronic inflammatory rheumatic diseases, chronic fatigue syndrome and fibromyalgia. They also found that levels of thyroid hormone are decreased during severe inflammatory diseases.
Studies have shown that up to 25% of women with rheumatoid arthritis, lupus, and Crohn's disease, all of them autoimmune diseases, meet the American College of Rheumatology diagnostic criteria for FMS. Other systemic illnesses with immunological abnormalities are associated with FMS, such as Sjogren's syndrome, Behcet's disease, ulcerative colitis, and Hashimoto's disease. Others researchers have suggested that the development of an autoimmune disorder, such as rheumatoid arthritis or lupus, may precipitate the onset of HAIT, FMS or CFS.
A study published in Eur J Med Res. 1995 Oct 16;1(1):21-6 has demonstrated similar humoral immune-reactivity in FMS and CFS ("High incidence of antibodies to serotonin (5-hydroxytryptamine), gangliosides and phospholipids in patients with chronic fatigue and fibromyalgia syndrome and their relatives: evidence for a clinical entity of both disorders", Klein R, Berg PA, Department of Internal Medicine, University of Tubingen, Germany). The observation among family members of patients with CFS and FMS of the presence also of anti-serotonin, anti-gangliosides and anti-phospholipids antibodies is an argument in favor of a genetic predisposition. They conclude: "These data support the concept that CFS and FMS may belong to the same clinical entity and may manifest themselves as psycho-neuro-endocrine autoimmune diseases".
● Fibromyalgia aches and pain as a "Symptom" of hypothyroidism
The fibromyalgia syndrome is one of the most frequent rheumatic disorders. It is a condition typically characterized by musculoskeletal pain, fatigue and a wide spectrum of different symptoms.
Dr. John C. Lowe is Director of Research for the Fibromyalgia Research Foundation, and one of the innovators in the diagnosis and treatment of hypothyroidism. In a 1997 research study, reported in the Clinical Bulletin of Myofascial Therapy: "Thyroid status of 38 fibromyalgia patients: implications for etiology of fibromyalgia", Dr. John C. Lowe found clear relationships between thyroid function and fibromyalgia, and believes that some form of hypo-metabolism, including thyroid dysfunction, may in part explain FMS. Approximately 64% of fibromyalgia patients had thyroid hormone deficiencies (those who had normal TSH levels were subsequently also given a TRH stimulation test to more thorough evaluation of hypothyroidism). And interestingly, the level of primary hypothyroidism found among these FMS patients was 10.5 times higher than what we would expect to find in the general population.
Dr. Lowe's years of practice have led him to the conclusion that fibromyalgia is, for many people, a symptom of an underlying thyroid problem, and not necessary a disease unto itself. He feels that the typical patient's fibromyalgia is actually evidence of too little thyroid hormone regulation of certain tissues. According to Dr. Lowe, in some patients, the inadequate tissue regulation by thyroid hormone results from cellular resistance to thyroid hormone, in others, the inadequate regulation results from a thyroid hormone deficiency. He writes: "So, when I refer to fibromyalgia, I'm referring to a certain set of symptoms and signs of too little thyroid hormone regulation of tissues."
Dr. Lowe theorizes that hypothyroidism underlies most patients' fibromyalgia symptoms. I support this opinion for a long time. Dr. Lowe writes: "If you meet the criteria for fibromyalgia, then you've likely been hypothyroid all along… It is important to recognize that of fibromyalgia patients with primary hypothyroidism, fibromyalgia symptoms and signs are a product of the thyroid hormone deficiency… An elevated titer of anti-thyroid antibodies indicates impaired thyroid gland function, even when thyroid function test results do not show a thyroid hormone deficiency. Before hormone deficiency is detectable in the serum by thyroid function tests, slight reductions in thyroid hormones levels may be causing fibromyalgia symptoms in a patient whose cells are highly responsive to minor reductions in thyroid hormone levels. In this subset of patients, the elevation of anti-thyroid antibodies is a clue that reduced thyroid hormone levels may account for fibromyalgia symptoms". I will show in the chapter on treatment that the control of thyroid metabolism is performed individually in each tissue and therefore a tissue, an organ, or a group of organs or systems may be deficient in thyroid hormone and no others, explaining the selectivity of the symptoms of hypothyroidism and thus fibromyalgia or chronic fatigue syndrome, before the clinical picture is complete. This also explains normal thyroid blood tests for months, even for years. The implication of this concept in the management of these patients is, in my opinion, capital.
This aspect linking thyroid autoimmunity with fibromyalgia is supported by a study by Aaarflot and Bruusgaard, two Scandinavian researchers, on 737 men and 771 women. They found that those with chronic widespread musculoskeletal pain (often diagnosed as fibromyalgia) had a higher incidence of thyroid antibodies than those without pain. But thyroid function test results did not differ between the two groups. This means that the antibody test showed thyroid disease while the TSH and thyroid hormone levels failed to show it. They conjectured that evidence of thyroid autoimmunity is more important than thyroid function tests in patients with widespread musculoskeletal pain. [Aaarflor, T. and Bruusgaard, D.: Association of chronic widespread musculoskeletal complaints and thyroid autoimmunity: results from a community survey, Scandinavian Journal of Primary Health Care, 14(2):1-111-115, 1996.]
Several studies have shown that thyroid autoimmunity is especially common in people with fibromyalgia, and some researchers theorize that some thyroid problems may contribute to the development of fibromyalgia in some cases. A 2007 study in Clinical Rheumatology found that having signs of autoimmune thyroid disease was associated with worse fibromyalgia symptoms.
Many hypothyroid patients on hormone replacement therapy which has "normalized" the TSH level find that over time they are developing more and more joint and muscle pain or symptoms resembling of rheumatism or of osteoarthritis. They may be diagnosed as having fibromyalgia "in addition" to hypothyroidism. Dr. Lowe believes that what is happening may actually be a symptom of undertreated hypothyroidism. Dr. Lowe writes: "These symptoms, despite the use of hormone replacement T4 [Euthyrox, Synthroid], will be identified as a" new "disease, such as fibromyalgia or chronic fatigue syndrome, instead of being taken for symptoms resulting from a treatment failure due to inadequate treatment of the existing problem, hypothyroidism".
Dr. Lowe believes that many patients who develop fibromyalgia symptoms after a trauma were already hypo-metabolic (hypothyroid) before the trauma occurred.
In an article in the magazine Alternative medicine titled "Energizing Chronic Fatigue", Dr. Raphael Kellman, M.D., indicates that approximately 40 % of his patients suffering from chronic fatigue had actually a condition called hypothyroidism, "likely initial cause of many cases of chronic fatigue syndrome, as well as certain nutritional deficiencies". He writes: "The thyroid gland fails to meet all its bodily functions which include energy regulation".
● Hashimoto's, FMS and CFS: their relationship to chronic bacterial infections
Given the similarity of their symptoms, their frequent association in the same individual, their occurrence among members of the same family, and their autoimmune character, the question arose as to which the common denominator may disrupt the immune system. Just as a reactivation of some viral infections, including Epstein-Barr virus (EBV), Cytomegalovirus (CMV) and Herpes human virus type 6 (HHV-6), can cause immune dysfunction, researchers have identified a wide variety of chronic bacterial infections involved in the pathogenesis of autoimmune diseases as diverse as rheumatoid arthritis, lupus, scleroderma, ankylosing spondylitis, Sjögren's syndrome, Crohn's disease, multiple sclerosis, Hashimoto's thyroiditis, fibromyalgia, chronic fatigue syndrome, etc...
The bacteria involved are Borrelia (Lyme disease), Mycoplasma, Chlamydia, and Ureaplasma. Others are known as co-infections of Lyme disease: Bartonella, Ehrlichia and Babesia.
These bacteria, unlike other bacteria, have no cell walls and therefore must live inside cells, using energy cells to reproduce. They can invade almost every tissue in the human body, compromise the immune system, and permit opportunistic infections by other pathogens, and even damage or destroy nerve cells. They are covered by a membrane that regulate their permeability and allows them to stick to the membranes of blood vessels and nerve tissue. This membrane contains lipopolysaccharides, which are known to trigger the human immune response and cytokine production, in turn leading to inflammation. These microorganisms have the ability to persist for many years in the body (in different forms during their lifecycle), and trigger, if the immune system becomes less efficient, systemic diseases, which become chronic because the infectious cause often goes unnoticed. The type of disease the bacteria cause seems to depend only on which cells of the body they have migrated to and invaded. Since the thyroid can itself be attacked by borrelia, mycoplasma or chlamydia, these bacteria can cause thyroid disease in several forms, including Hashimoto's disease. As the bacteria slowly invade greater areas of the body and at greater depth, so disease worsens.
A study published in Nov. 2002 in the journal FEMS Immunology and Microbiology Medicine showed that 69% of CFS patients are tested positive for Mycoplasma. A study published in June 1999 in the journal Rheumatology found that 54% of patients with rheumatoid arthritis were positive for Mycoplasma infections.
Regarding fibromyalgia, several studies reveal the presence of Chlamydia pneumoniae in 50-60 % of cases. Dr. Nicolson, professor at the University of Texas at Houston, has found Mycoplasma infections in approximately one half of patients with fibromyalgia as well as arthritis. In Br J Rheumatol. 1997 Oct; 36 (10):1134, Chlamydia pneumoniae antibodies were found in many cases of myalgia (muscle pain) of unknown cause, including fibromyalgia.
In all the above-mentioned diseases, including Hashimoto's disease, the identification of the causative bacteria by serological tests can lead to a remarkable improvement with a long but effective antibiotic protocol, combined with immune therapy. I am part of this therapeutic approach that most physicians are not aware of. I deal in my clinic with Lyme disease and all the other chronic bacterial infections that I just mentioned.