throat culture

Diagram by Blausen Medical;

There are many different triggers for ME/CFS. In most people, the illness starts with an infection, often viral, but others report a vaccination or immunisation as the initial event. Although there has been very little research on this particular aspect, one Belgian report from 2002 found a small cluster of cases (around 5% of more than 1500 patients) where hepatitis B vaccination could have been involved in the initiation of ME/CFS  (read abstract), and there have been reports of ‘CFS-related’ adverse events after flu vaccinations  (read abstract).

Recently, there have been suggestions that vaccination against human papillomavirus (HPV) can lead to “patterned illness” involving chronic pain, headaches, fatigue, and problems on standing – very like the symptoms suffered by people with ME/CFS (read more). While HPV vaccination is considered beneficial overall, and there is little evidence of serious adverse effects in most recipients, the European Medicines Agency announced the launch of a ‘safety review’ of HPV vaccines in 2015 that will hopefully encourage healthcare professionals to look for unusual but potentially serious adverse effects (read more).

A Japanese study published this month in Immunological Research reports a possible association between HPV vaccination, chronic epipharyngitis (inflammation of the back of the nose and throat), and chronic symptoms. The researchers from the Hotta Osamu Clinic in Miyagi, Japan examined the nasopharynx in 41 young women (average age 17.3 years) who had developed ME/CFS-like symptoms following HPV vaccination. Their symptoms included headache (in 97.6 %), general fatigue (95.1 %), sleep disturbance (87.8 %), stiffness of neck and upper back (85.3 %), photophobia (80.5 %), muscle weakness (75.6 %), and cognitive impairment (68.3 %). As a result, most of them (83%) were unable to attend school. They had been been treated using a number of approaches, but their condition had not significantly improved with any of these.

On closer examination, almost half of the patients had mild pharyngeal symptoms, but abrasion of the epipharyngeal mucous membrane with a cotton swab (which, the researchers say, tests for inflammation as chronic epipharyngitis is often not obvious by eye) and smear analysis showed that all 41 of them had severe epipharyngitis, identified by severe bleeding during the examination. Sixteen patients were willing to come into hospital for treatment, consisting of a very dilute zinc chloride solution thoroughly applied to the epipharyngeal wall. While this treatment reduces the pain and inflammation at the back of the nose and throat, the most interesting finding was that in 13/16 patients there was also a marked reduction in symptoms overall after the procedure, with 4 patients eventually achieving a ‘cure’. As the authors say, “Given the degree of impairment of quality of life previously observed in these patients, the degree of response to this treatment was quite remarkable….” They point out that the extremely high incidence of severe epipharyngitis (100%) and dramatic improvement in patients’ general and multisystem symptoms after treatment strongly suggest an association between chronic epipharyngitis and the ME/CFS-like symptoms that developed after HPV vaccination.

Interestingly, the Japanese researchers outlined their results at a conference earlier this year, at the 4th International Symposium on Vaccines in Leipzig Germany (see the video presentation). In it, they point out that chronic epipharyngitis may have an important role in the development of various autoimmune diseases and disorders. They say that the epipharynx has high levels of immunologic activation and that, because of its anatomic location, chronic inflammation in the epipharynx can have systemic effects via autoimmunity and the autonomic nervous system.

It’s important to remember, however, that ‘chronic epipharyngitis’ is poorly recognised, and that the term is rarely used in the modern medical literature, particularly outside of Japan. For that reason, other studies need to validate and confirm these findings – in people with other medical conditions (autoimmune diseases and autonomic nervous disorders) as well as ME/CFS patients – and extend them to determine, for instance, the prevalence of chronic epipharyngitis in the population at large.

Are these results be relevant to the majority of ME/CFS patients whose illness began with other triggers, mainly viral or other infections? Well, an accompanying Editorial in Immunological Research suggests so. Certainly, ‘sore throat’ at the early stages of illness had a prominent part  in descriptions of epidemics of myalgic encephalitis (read more), and the symptom is part of some definitions of ME/CFS, such as the Holmes criteria, and the International Consensus Criteria of 2011 as part of the ‘flu-like symptoms’ that may be recurrent (read more). A study examining the nasopharynx mucosa in a mixed-onset group of ME/CFS patients would well be revealing; if frank inflammation is present, a treatment trial could explore whether improvements occur in chronic symptoms as well as local inflammation.