Monday, November 8, 2010

Fibromyalgia can be experienced concurrently with hepatitis B and C

Presented below is a collection of studies and abstracts from 2009-2010; which lends merit to the connection between the hepatitis c virus and fibromyalgia.

The association between chronic hepatitis C virus infection and fibromyalgia still remains controversial. Studies have shown that Hepatitis C can be associated with arthritis ; it can also cause arthralgias, which is joint pain without swelling. There are also many other illnesses which can be associated with so-called secondary fibromyalgia.

The fact remains in rare cases several forms of arthritis have been linked to HCV infection. One of the most commonly types of arthritis associated with hepatitis C is rheumatoid arthritis (RA). The relationship between RA and the hepatitis c virus results in antibodies starting to attack normal body tissue, although some physicians feel it may be more closely related to liver damage and share the argument the condition usually affects people with cirrhosis.
Treating arthritis with some anti-inflammatory drugs can suppress the immune system and may lead to increased viral replication of the virus. The other concern is many of the drugs used to treat RA are metabolised by the liver; if the liver is damaged toxins may build up. However evidence shows that treating HCV with antiviral medications which reduces the viral load can decrease arthritic symptoms.
From Fibromyalgia Frontiers • 2010 (Volume 18, Number 1
2010 Fibromyalgia Pathophysiology and Treatment
There is a strong association between fibromyalgia and many diseases rheumatologists treat (RA, osteoarthritis, Sjogrens syndrome, lupus and certain infections Hepatitis C and lyme disease.
Fibromyalgia Searching for an Answer /2010

From an article in LHT

The Mysterious Condition of Fibromyalgia

It sneaks in unannounced and makes itself completely at home. It affects every aspect of life, turning days into challenges. This unwelcome arrival frequently manages to hide so it is almost invisible, yet it shows little sign of leaving. This is fibromyalgia (FM), often referred to as “fibro,” and it affects millions of Americans every year. The vast majority of those afflicted, an estimated 95 percent, are women.
Ask some physicians to explain fibromyalgia, and they will tell you it is a condition that exists in the minds of hysterical females; others will claim it is an unidentified health problem that requires additional sleep and an occasional pain reliever. A growing number of medical professionals, however, will tell you what the American College of Rheumatology (ACR) determined in 1990. They would confirm it is an actual medical syndrome that affects all four body quadrants, causes widespread pain for at least three months, and involves at least 11 “tender points” among 18 sites on the body.
The sites are overly sensitive to stimuli that typically would not cause pain. Fibromyalgia is a real condition creating real problems for people of all ages and ethnic backgrounds and can be experienced concurrently with hepatitis B and C. Viral infections often appear in the medical backgrounds of those suffering from fibromyalgia. It is not known how the occurrence of a viral disease, such as hepatitis, is specifically linked to the condition.
Studies have explored various potential triggers of the syndrome, including trauma, stress and hepatitis infections. For example, research findings published in a 2005 study suggested having chronic hepatitis B appeared to increase the risk of FM and its associated symptoms. According to the ACR, the American Medical Association, the National Institutes of Health, the Food and Drug Administration (FDA), and the American Pain Society, this condition is real. So why does it take an average of five years for a patient to get an accurate diagnosis? Unfortunately, as powerful as fibromyalgia can be, it is just as elusive.
It does not show up on a blood test or X-ray. It doesn’t have a defining hallmark of symptoms but has generalized ones that can fit the parameters of other conditions. “Fibromyalgia has no specific physical abnormalities to see, just elevated tenderness,” explains Dr. Philip Mease, director of Rheumatology Research at the Swedish Medical Center in Seattle, Washington. Dr. Jacob Teitelbaum, medical director of Fibromyalgia and Fatigue Centers and author of “From Fatigued to Fantastic,” adds that there is no fancy test for the condition. “Doctors will say it doesn’t exist,” he notes. “If your physician tells you this, just say ‘goodbye,’ and walk out the door. You don’t want a doctor you have to educate.”
Head to Toe The name fibromyalgia means pain in the muscle fibers. From mild annoyances to completely debilitating, the pain element only paints a limited picture of this pervasive condition. There are numerous other common complaints associated with fibro. (See Common Complaints.) A thorough medical history is the best way to discover most of these issues, although some doctors will order thyroid panels and complete blood counts to look for abnormal numbers. Dr. Eric Braverman, director of the Place for Achieving Total Health, has been working with fibro patients for more than 20 years.
“Technology has come a long way, so we have more effective ways of finding and treating fibro,” he says. “There have been more cases of fibromyalgia in recent years because of lack of health care in the U.S. Many people are finding they can’t visit their doctors as often so it goes untreated.” Any combination of these symptoms can play havoc with a person’s life, not only physically, but also emotionally, socially and mentally. As Teitelbaum describes it, “Imagine you’re a busy mother of several children and suddenly you experience brain fog, so people see you as dumb.
You gain the typical 32.5 pounds, your libido drops the typical 73 percent, you have no energy and you feel like you have a toothache throughout your entire body. Your medical tests come back normal—so now your friends, family and doctors think you’re crazy.” Braverman agrees. “Physically, the pain can be excruciating and force a person to the confinement of their beds. Mentally, fibro has been proven to cause depression due to the pain and anguish that people experience. Socially, it definitely has an effect. Many people find that they cannot go out as much as before, to run errands, go to dinner, or attend social gatherings. It is an all-encompassing disease.” Searching for an Answer Scott, a former education student and now author of a children’s book called “Johnny the Phoenix” knows this feeling. He was diagnosed with the condition in 2006, after searching for an answer for two years.
Constant headaches had resulted in four sinus surgeries and a battery of neurological tests. Nothing helped. Then a friend handed him a book about fibromyalgia. After a sleep study that showed apnea, he went to a new doctor and was diagnosed immediately. A husband and father, Scott’s days often depend on the weather. “I find that barometric pressure has a large impact, as well as extreme heat and cold,” he says. “I get as much sleep as possible, usually over nine hours. I look ahead to what needs to be done, and I try to use no more than 90 percent of the energy that I have available. It is a very frustrating disease, because there is no way to plan for good or bad days.” Today, Scott is on disability because it is impossible for him to work. “If you find that you have severe fibro as I do, fight for your disability,” he advises. “Sit down and take stock of what you have left. For me, it is my ability to tell stories, so I write. Just because you have fibromyalgia doesn’t mean that your life has ended. It simply means you need to go to your back-up abilities.”
To Make Matters Worse Just as the condition does not have a definitive test, it does not have a distinct cause or treatment either.
Over 150 clinical trials are being conducted at any one time trying to determine the answers. So far, researchers have proposed that fibromyalgia may be an abnormality in brain chemicals. An imbalance in neurotransmitters, such as norepinephrine, serotonin and dopamine, directly affects how pain is experienced and how it is blocked. “A person with fibro is like a house with a thermostat that is off kilter,” explains Mease. “There is an alteration in sensory processing in the individual. There is an excess of sensory input and a deficiency in the body’s ability to inhibit or block it. Too much comes in and not enough protects it.” Teitelbaum compares it to an energy crisis. “With fibro, the body blows a fuse,” he explains. “And that fuse is the hypothalamus.” Other theories are that fibro is a genetic condition (it tends to run in families) or that it comes along as a “fellow traveler” as Mease calls it, with other infectious or autoimmune diseases, such as hepatitis. Regardless of the cause, what many patients want most, once they have their diagnosis, is help.
Unfortunately, treatment is as complex an issue as the condition itself. Patients may take a variety of medications designed to battle specific symptoms, including pills to combat pain, diarrhea, and depression. They may need pills to increase energy or sleep at night. Prescription costs easily run into the hundreds or even thousands of dollars. The FDA has approved several drugs for the condition including milnacipran (Savella®), duloxetine (Cymbalta®) and pregabalin (Lyrica®). As with most medications, however, there are side effects to consider. Other possible treatments include massage, acupuncture, chiropractic care and heat applications.
Some fibro patients also have had trigger point (spots that are tender to palpation) injections in which an anesthetic is injected into the muscle, which is then gently stretched. The problem with this method is that the injections are usually quite painful, and it can take days for the patient to feel relief. Teitelbaum recommends treatment through what he calls the SHINE Protocol. “Ninety-one percent of fibro patients show improvement after following these steps,” he says. In the protocol, “S” stands for sleep.

“It’s essential that the body gets at least eight hours of sleep, even if it means helping it by using herbs, medication or other techniques,” explains Teitelbaum. “H” stands for hormonal support, as in taking supplements to support the thyroid and adrenal glands. “I” stands for infection because fibro patients often deal with a variety of infections. “N” stands for nutritional support, indicating the importance of a healthy diet, and “E” stands for exercising as able. While exercise typically helps, it is hard to do when dealing with intense exhaustion and muscles that are already complaining.

Cutting off Sleeves Lee’s life hasn’t been easy for some time. After a full life as an educator and syndicated newspaper columnist, he began to experience health problems. In 1990, he was diagnosed with multiple sclerosis. Later, he developed several types of arthritis. Everything got worse in 1995 when a speeding semi-truck loaded with a payload of stone broadsided him, burying him under 75 tons of rubble. “The police thought I was dead,” he admits. He almost was. It took six hours to extricate him. He spent a month in intensive care and six months in the hospital. When he appeared in the courtroom, he was still in a wheelchair and hooked up to an IV. “I was so out of it, I had no idea what was even going on. I got absolutely nothing.” It wasn’t until 2004 that Lee was diagnosed with fibro. Amazingly, after all his health problems, it is fibro that has had the most profound effect on his life. “This pain supersedes everything else,” he states. “There are spots on my arms that hurt so much I have had to cut off all the sleeves on my shirts. I can’t stand the touch of the fabric.”
Not much makes Lee feel better. He uses a massage pad in his chair but says he has to put several towels or blankets between the rollers and his skin or he can’t stand the pressure.
Each month Lee’s medications cost $3,000. After being unemployed for more than 14 years, this is money he simply does not have so he stopped taking most of the medication. “Each night I plan to do things the next day, but then it gets here, and I just can’t shake the exhaustion,” he explains. “I try to go out, but I can’t . . . often for days or even weeks on end. Fibromyalgia saps all my energy.” Lee lives alone and depends on his friends and daughter to stop by and help with chores. He spends a great deal of time in bed. “Mentally, there is so much I want to do,” he says, “but physically, it isn’t possible.”
Fibromyalgia is an unwelcome visitor that creeps in the body. It brings pain, fatigue, fog, and insomnia. Noticing it doesn’t take long; identifying it can take what seems like forever. Treatment is often a hit and miss process. Eviction is rarely possible, but sometimes, with a skillful doctor and appropriate treatments, a truce can reached.


*Excerpt : In addition to the genetic associations, various external stimuli such as infection, trauma and stress may contribute to development of the syndrome (see Table 3). Bennett and colleagues provided an Internet survey of 2,596 people with FM.[32] Approximately 21% of responders indicated that they could not identify any triggering events of their illness. Over 73% of those who indicated some triggering event made attributions to emotional trauma or chronic stress. The next most common attribution was acute illness (26.7%), followed by physical stressors (surgery, motor vehicle collisions, and other injuries). Various infectious agents have been linked to the development of FM as well as to that of the closely related chronic fatigue syndrome.

Viral agents, including hepatitis C and HIV, have been associated with FM on epidemiological and clinical grounds.[33,34] In particular cases, such as Lyme disease and HIV, obvious overlap of clinical manifestations can be described; nonetheless, evidence of the utility of antibiotic or antiviral treatment in FM or chronic fatigue syndrome is lacking.[35]
Various forms of physical trauma have been implicated as triggering events in the pathogenesis of FM. Increased rates of FM have been demonstrated among patients undergoing cervical trauma during motor vehicle accidents.[36] Most recently, Wynne-Jones and colleagues found a 7.8% frequency of widespread pain within 12 months among a cohort of patients who underwent a motor vehicle collision.[37] Emotional trauma and stress have also been implicated as triggers of FM. Post-traumatic stress disorder may precipitate the development of FM, and both conditions share similar pathogenic mechanisms.[38]

Clin Rheumatol. 2010 Dec;29(12):1373-80. Epub 2010 Apr 22.

Prevalence of rheumatologic manifestations of chronic hepatitis C virus infection among Egyptians/2010

Mohammed RH, Elmakhzangy HI, Gamal A, Mekky F, El Kassas M, Mohammed N, Hamid MA, Esmat G.Department of Rheumatology and Rehabilitation, Faculty of Medicine, Cairo University Hospitals, Cairo, Egypt,
Chronic hepatitis C virus (HCV) viremia has been known to provoke a plethora of autoimmune syndromes referred to as extrahepatic manifestations of chronic HCV infection. Aim of the current study was to assess the prevalence of rheumatologic manifestations among Egyptians with hepatitis C infection and its' association with cryoglobulin profile.

The current research represents a cross-sectional study where patients with chronic HCV infection attending the outpatient clinic of the National Hepatology and Tropical Medicine Research Institute over a period of 1 year were interviewed.

Patients with decompensated liver disease, on interferon therapy, having end-stage renal disease or coexisting viral infection like hepatitis B surface antibody positive patients were all excluded from the research. Laboratory investigations as well as serological assay including cryoglobulin profile, rheumatoid factor, antinuclear antibody, HCV-PCR were performed.

Three hundred and six patients having chronic HCV infection were interviewed in this research.

The overall estimated prevalence of rheumatologic manifestations in the current research was 16.39%

chronic fatigue syndrome 9.5%,
sicca symptoms 8.8%
arthralgia 6.5%
fibromyalgia 1.9%
myalgia 1.3%, arthritis 0.7%
cryoglobulinemic vasculitis 0.7%
autoimmune hemolytic anemia 0.7%
thrombocytopenia 0.7%.

Xerophthalmia was significantly present in male population (p = 0.04), whereas fibromyalgia, cryoglobulinemic vasculitis, arthritis, and autoimmune hemolytic anemia were significantly present in female population under study (p less then 0.05).

In chronic HCV genotype 4 infection, the prevalence of rheumatologic manifestations was 16.3% with chronic fatigue syndrome and sicca sysmptoms being the most common with no significant correlation to the degree of elevation of liver disease or viral load.
PMID: 20411290 [PubMed - in process]

Current Opinion in Rheumatology:
January 2010 - Volume 22 - Issue 1 - p 91-96
doi: 10.1097/BOR.0b013e328333ba5d
Systemic disorders with rheumatic manifestations:

Edited by Jonathan Kay

Rheumatic manifestations of hepatitis/2010
Vassilopoulos, Dimitrios; Manolakopoulos, Spilios


Purpose of the review: Rheumatic manifestations are commonly encountered in patients with hepatitis B virus (HBV) or C (HCV) infection. In this review the most common clinical rheumatic manifestations of HBV or HCV infection and their management will be critically presented with a special emphasis on the efficacy and safety of the new biologic agents.

Recent findings: Recent significant advances in the antiviral therapy of chronic hepatitis B and C as well as the emergence of new biologic therapies (anti-TNF agents, rituximab) for the treatment of rheumatic diseases have changed significantly the therapeutic approach for patients with rheumatic disorders in the setting of hepatitis B or C. For patients with hepatitis B, prophylactic antiviral therapy with oral antiviral agents (nucleoside or nucleotide analogues) is recommended for all cases in which immunosuppressive therapies are administered, whereas for severe hepatitis C-associated mixed cryoglobulinemia, a number of recent studies have shown the short-term safety and efficacy of rituximab.

Summary: Rheumatologists in collaboration with hepatologists have today an array of efficacious therapeutic options to explore for patients presenting with rheumatic disorders in the setting of a co-existent HBV or HCV infection. Appropriate pretreatment screening and close monitoring are essential for these difficult-to-treat patients.

Understanding fibromyalgia/2009

Rev Salud Publica (Bogota). 2009 Aug;11(4):662-74.

Restrepo-Medrano JC, Ronda-Pérez E, Vives-Cases C, Gil-González D.
Facultad de Enfermería, Universidad de Antioquia.


This study was aimed at describing the main features of articles published in scientific journals between 1992 and 2007 addressing the analysis of the etiological factors associated with this condition.


This consisted of a systematic review of scientific articles regarding this association using the following health and social science databases: Medline, Cinhal, Web of Science, Lilacs, Sociological Abstracts, Embase, Psycoinfo and ISI web of Knowledge.


21 articles were obtained during the study period, distributed as follows: 7 theoretical reviews (33.3 %), 6 cross-sectional studies (28.5 %), 4 cohort studies, (19.0 %) 2 case-control studies (9.5 %) and 1 systematic review (4.7 %). Of these, 7 (33.3 %) considered the following to risk factors to be associated with the emergence of other factors such as silicone implants, socio-demographic and hormonal factors: 3 on stress (14.3 %), 4 on hepatitis C (19.0 %), 3 on traumatic antecedents (14.3 %) and 4 on occupation (19.0 %). The most productive time was 2000-2004. There was broad thematic dispersion in the published journals.


Available empirical evidence about risk factors related to fibromyalgia is still scarce and scattered. Future studies should focus on generating more knowledge about the risk factors studied so as to help improve fibromyalgia care, diagnosis and treatment.
PMID: 20169222 [PubMed - indexed for MEDLINE]Free Article


Study Highlights New Way to Diagnose Fibromyalgia
And It Doesn’t Include a Tender Point Exam

Researchers found that testing for fibromyalgia using a widespread pain index and a measurement of the number and severity of symptoms leads to a more accurate fibromyalgia diagnosis than the commonly used tender point examination.
Researchers sought to develop updated criteria for diagnosing fibromyalgia that does not warrant a tender point examination, and their findings were published in the May 2010 issue of Arthritis Care & Research.
To create the new diagnostic criteria, the researchers developed a widespread pain index (WPI). The WPI is a 19-item checklist that tracks where a patient feels pain. Additionally, the researchers created a symptom severity scale to measure the amount and intensity of the patient’s symptoms.

The researchers hoped that by understanding the painful areas, in addition to the number and severity of the symptoms, they would create a more comprehensive diagnostic method that can detect fibromyalgia more accurately than the tender point exam that’s traditionally used.
To test the new criteria, the researchers conducted a multi-center study of 829 people who had fibromyalgia and a control group of people who had other pain disorders. The researchers found that the combination of the pain index, number of symptoms, and severity of symptoms provided the most accurate fibromyalgia diagnosis.
The researchers reported that the new criteria will correctly diagnose more than 88% of people with fibromyalgia—and that’s without a tender point examination.

Getting a solid fibromyalgia diagnosis is still a fairly new concept, as much of the medical community had once dismissed the disorder as merely a figment of the imagination. But the new diagnostic criteria, which have the support of the American College of Rheumatology, help legitimatize fibromyalgia.

If you would like to learn more about the updated fibromyalgia diagnosis criteria, read the study abstract here.
A new study found that there are significant benefits of Tai Chi for individuals with all types of arthritis, including fibromyalgia, rheumatoid arthritis and ...
The Hepatitis C Connection/2009
*Excerpt: Although not yet confirmed, many experts believe that Hepatitis C may act as a trigger to the onset of fibromyalgia. The documented links between the two conditions include: · Symptom Specificity – Fibromyalgia and chronic Hepatitis C infection share many clinical features including musculoskeletal pain and fatigue. While the two conditions do not always accompany each other, some symptoms may be unique when a person has both fibromyalgia and Hepatitis C. One study found that people dually diagnosed with fibromyalgia and Hepatitis C exhibit symptoms such as inflammation around a joint, bursa and/or tendon, and vasculitis (blood or lymph vessel inflammation) that are not seen in Hepatitis C negative people with fibromyalgia.
· Immune Proteins – Cytokines are proteins that regulate immune response. Interleukins are a specific type of cytokine that cause a person to feel pain. Several interleukins have been found to be dramatically elevated in fibromyalgia patients. Harvard researchers found those same interleukins increased in production when exposed to the Hepatitis C virus.· Hepatitis C and Pain – Many people infected with Hepatitis C virus infection complain of myalgias, arthritis and widespread pain. When compared to other liver diseases, the frequency of musculoskeletal pain clearly favors Hepatitis C. The frequencies of musculoskeletal pain for the following isolated conditions are as follows: Alcoholic liver disease = 48 percent, Hepatitis B = 59 percent and Hepatitis C = 91 percent. As fibromyalgia’s most prominent symptom, it is not surprising that musculoskeletal pain may represent the link to Hepatitis C.

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