Viral Infections in CFS/FMS and Long COVID: Part 1—Testing

It is routine that the immune system goes into overdrive (though ineffectually) and then becomes exhausted in CFS, fibromyalgia, and Long COVID (CFS/FMS/LC). This results in many problems, including countless opportunistic infections. By definition, these are infections that do not survive when the immune system is healthy. So, reducing the load on the immune system and giving it added support is critically important.

It isn't necessary to track down and treat every infection. When the immune system is healed up, it knows how to do so itself. But some infections are helpful to treat, especially infectious organisms that are large, such as Candida and parasites. (I will discuss these in upcoming newsletters.)

In this article, I will discuss testing to look for viral infections. Especially important is Epstein-Barr Virus (EBV) Reactivation. Here is how I diagnose it.

Epstein-Barr Viral (EBV) Reactivation

Many infections, including COVID, suppress parts of the immune system. This can result in reemergence of old viruses—a process known as viral reactivation—in the Epstein-Barr virus family (e.g., Mono, HSV 1&2, HHV6, Shingles), which then stress the immune system even further. This is one key reason people develop post infection CFS/FMS, such as Long COVID.

Although we have good tests that can detect these infections the first time they occur in a person, the tests aren't nearly as reliable for reinfections and viral reactivation. In fact, most physicians aren't even trained in how to interpret the test results in that setting, and so they have no idea how to treat it.

So here is what you and your doctor need to know.

When Should You Do the Viral Testing?

It depends on the symptoms. I am more likely to suspect (and test for) an important underlying viral infection if a person's symptoms fit one of the following:

• Their CFS/FMS began with a severe flu-like illness, and symptoms persisted despite having followed the S.H.I.N.E.® Protocol, OR
• They have flu-like symptoms in general or during flare ups, OR
• They have pure CFS with predominantly flu-like symptoms with debilitating fatigue and little to no pain, or with low blood pressure symptoms—a condition that may be NMH/POTS (see "POTS (Postural Orthostatic Tachycardia Syndrome").

Viral Testing and Interpretation in CFS/FMS/LC

The key test to diagnose Epstein-Barr viral reactivation is the EBV EA (early antigen) test. However, 20-30% of healthy people test positive on this test even when nothing is wrong. And 90-95% of healthy adults also test positive on the routine Epstein-Barr virus IgG antibody testing when nothing is wrong. So by themselves, these tests are simply not reliable.

Viral Testing and Interpretation in Suspicious Cases

Below are the viral tests that I check in people who have the above symptoms:

Test for EBV Reactivation. To look for this, I check:

1. EBNA (EBV nuclear antigen). The average level is 235 (levels over 600 are in the top 25% of the population, and therefore suggestive of EBV reactivation).
2. VCA (viral capsid antigen) IgG. The average is 186 (levels over 517 are suggestive of EBV reactivation).
3. EBV EA (early antigen). The average* is 10.7 (levels over 18 are suggestive of EBV reactivation of EBV reactivation).

   *Note: Average—actually median—EBV levels shown above are based on a sample of results in 28 healthy people done by Dr. Nancy Klimas, one of my favorite CFS infectious disease researchers in the world.

Tests 1 and 2 above are positive in almost everyone, and simply indicate that you (like 95% of all healthy adults) had mono at some time in your life. I only consider the possible presence of EBV reactivation if there is an elevated reading in test 3, the EBV EA test. But even then only in the presence of the symptoms I discussed earlier, as 20% of healthy people also show a positive EBV EA.

Other Testing

HSV-1, HHV-6, and CMV IgG antibodies (I don’t check IgM). Levels greater than 4 (or 1:640 or greater, which is another way these tests may be reported), make me suspicious. If positive, the treatment is similar to EBV reactivation (more on this in my next newsletter).

In addition to viral testing, with the symptoms above and severe and stubborn cases, I also check immune function with Total IgG antibody levels along with IgG 1–4 antibody subsets to look for further evidence of immune suppression.

I'll discuss treatments for these conditions in part 2 of this short series in next week's newsletter.