With the recent COVID-19 pandemic, the impact of viruses on long-term immunity and energy levels has been bought into sharp focus. Research shows that viruses can persist in the body, evading host immune and inflammatory defences, in addition to impacting mitochondrial function.^[i] The outcome of viral persistence is physical and mental fatigue along with immune system dysfunction presenting as a decreased resistance to infection.  This case reveals the impact that multiple viral infections can have on many aspects of the patient’s health. 

Initial Consultation

A 37-year-old female presented with a 12-month history of nausea, fatigue, sore throat, lymphadenopathy, and chills. She had also been experiencing a high level of work-related and personal stress, which she rated 5-10/10. The patient also reported feeling anxious most of the time, which manifested as shaking, overthinking, shallow-breathing, and loose bowel movements.  

A case history revealed:

• Headaches occurring 3 times weekly behind the eyes
• Two nose bleeds in the past month
• Poor sleep - waking 5 times nightly due to an overactive bladder since the birth of her son 8 years ago
• Energy levels 5/10, down from a usual 10/10
• Frequent infections
• Sugar cravings
• Asthma - managed with daily use of budesonide/formoterol preventative inhaler
• Herpes simplex virus causing genital lesions
• Excessive thirst
• Visual floaters
• Daily use of marijuana
• A history of vitamin B12 deficiency - treated with 3 monthly vitamin B12 injections
• Diet high in pre-packaged foods and takeaway meals
• Consumes 1 to 2 coffees/day

Previous blood tests showed:

• Ferritin 43 μg/L (25-290)
• TSH 0.89 mIU/L (0.5-4.0)

Initial Prescription

The initial prescription aimed to support the immune system, calm the nervous system and support nutritional insufficiencies. Her prescription included:

• A herbal liquid containing (Dosage: 7.5 ml twice daily with breakfast and lunch): 
  • Passiflora incarnata (Passionflower)       20 ml
  • Scutellaria lateriflora (Skullcap)               15 ml
  • Withania somnifera (Withania)                 15 ml
  • Rhodiola rosea (Rhodiola)                        20 ml
  • Echinacea spp. (Echinacea)                     25 ml 
  • Thuja occidentalis (Thuja)                        10 ml. 
• An anti-viral tablet containing Astragalus membranaceus (Astragalus) 2.0 g, lysine hydrochloride 800 mg, ascorbic acid 250 mg, zinc (as sulfate) 12 mg. Dosage: 1 tablet twice daily, increasing to 2 tablets, 3 times daily with any sign of a herpes outbreak;
• A nutritional powder providing 310 mg magnesium as a blend of phosphate, citrate and orotate, along with vitamins and minerals to support energy production. Dosage: 1 teaspoon, twice daily
• An iron capsule containing iron 24 mg (as glycinate) and ascorbic acid 120 mg. Dosage: 2 capsules taken on an empty stomach, every second evening.

Dietary and lifestyle advice included:

• Reduce coffee to 1 shot daily (maximum)
• Rub magnesium oil into soles of feet (for transdermal magnesium absorption)
• Seek out the support of a psychologist to address the cognitive aspects of her stress

The patient was also referred to her general practitioner (GP) for further blood work to assess her immune, nutritional and hormonal status.

2-Week Follow-Up

The patient reported a reduction in the intensity and frequency of her nausea as well as an improvement in her energy levels (7/10). She had not come down with any infections since her last consultation and felt that her lymphadenopathy had reduced. Her stress levels had reduced to 5/10, however, she reported she had been experiencing ‘gut churning’, indicating that her anxiety was still present.  The patient did not report any herpes outbreaks, headaches or nosebleeds. Additionally, the patient reported poor appetite, as such, her diet had not improved. Her compliance with supplements was around 80%.

Follow-up blood tests revealed:

• Positive Epstein-Barr virus VCA and EBNA IgG antibodies indicating previous exposure.
• Positive cytomegalovirus IgG antibodies indicating previous exposure.
• Ferritin 20 μg/L (25-290).
• Cortisol 250 nmol/L (220-660).

Her prescription was continued with the addition of:

• Replacement herbal liquid containing (Dosage: 7.5 ml twice daily with breakfast and lunch): 
  • Hypericum perforatum (St. John’s Wort)     20 ml 
  • Glycyrrhiza glabra (Licorice)                         15 ml
  • Thuja occidentalis (Thuja)                             10 ml
  • Rhodiola rosea (Rhodiola)                             20 ml
  • Scutellaria lateriflora (Skullcap)                    20 ml
  • Withania somnifera (Withania)                      15 ml. 
• A nutritional powder containing vitamin C, 2.4 g (as ascorbic acid and sodium, calcium, magnesium and zinc ascorbate), Reynoutria japonica (Polygonum) 2.4 g, along with co-factors for immune support. Dosage: 1 teaspoon, twice daily in water.

Diet and lifestyle advice:

• Prioritise a healthy breakfast such as a smoothie including oats, pepitas and sunflower seeds for improved energy and mineral intake.

7-Week Follow-Up

The patient was feeling unwell. She had a sore throat and was feeling nauseous. She described a ‘gnawing’ feeling in her stomach. The patient reported she experienced a stressful incident in her workplace the week prior and attended party over the weekend, both of which she felt were contributing to her current symptoms. She reported feeling an improvement in her emotional wellbeing despite these symptoms. Her energy had been steadily improving prior to the weekend party, after which, had declined again.

Her previous prescription was continued with additions aimed at reducing upper gastrointestinal inflammation and providing additional antiviral and immune support. These included:

• Matricaria chamomilla (Chamomile) tea made with two teabags. Dosage: 2-3 times daily;
• Ulmus Rubra (Slippery Elm) powder. Dosage: 1 teaspoon in water or smoothie daily;
• A herbal tablet containing Artemesia annua (Sweet Wormwood) 8.0 g and Smilax officinalis (Sarsaparilla) 800 mg. Dosage: 1 tablet, 3 times daily.

She was referred her back to her GP for further assessment due to suspected Helicobacter pylori infection.

12-Week Follow-Up

The patient reported feeling much better, despite dealing with some recent family conflict. Her energy remained steady at 7-8/10. She had experienced one cold over the winter but had recovered within one week. Her stress levels reduced significantly when she resigned from her job and moved to an island. She was still suffering from anxiety, but at a lower level than previous and had thought that it was perhaps exacerbated by marijuana smoking. The ‘gnawing’ feeling in her stomach had abated and she had not seen her GP for further investigation. The patient had not returned to appointments after she moved.

Clinical Take-Aways

The fatigue that many patients experience following a viral infection can be both frustrating and debilitating. Thankfully, post-viral fatigue is well recognised clinically and in scientific research, giving patients validation, hope and useful medicines to assist their convalescence. Herbal and nutritional medicines combine to offer unique benefits to the patient as they combat residual viruses while supporting a fatigued immune system.  By understanding viral factors as cause of the fatigue, the practitioner can apply appropriate medicines to support the patient through their path to recovery. 

References

[i] Lidbury BA. Ross river virus immune evasion strategies and the relevance to post-viral fatigue, and myalgic encephalomyelitis onset. Front Med (Lausanne). 2021;8:662513.