Case Study: Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)

Client: 44-year-old female

Initial presentation

The client, a 44-year-old female, presents with persistent fatigue that has progressively worsened over the past three years after contracting glandular fever.  She has been diagnosed with Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) by her GP after appropriate medical investigations excluded alternative causes of fatigue.

Her primary concern is post-exertional malaise (PEM), where even moderate physical or mental activity results in a marked worsening of symptoms lasting between 48 and 72 hours.  She reports significant reductions in work capacity and now works two days per week from home.

Additional symptoms include:

·         Unrefreshing sleep despite sleeping 8-10 hours nightly

·         Cognitive dysfunction (‘brain fog’), including poor concentration and short-term memory lapses

·         Orthostatic intolerance with dizziness on prolonged standing

·         Generalised muscle pain and heaviness

·         Mild headaches occurring several times per week

·         Increased sensitivity to bright lights and loud environments.

Medical history includes seasonal allergic rhinitis and iron deficiency during pregnancy, now resolved.  Current medications include occasional paracetamol for headaches.  She takes a generic multivitamin intermittently.

Diet consists mostly of foods that don’t require much preparation, including fresh fruits and vegetables, nuts, seeds and ready-made meals.  Her appetite fluctuates due to fatigue.  Water intake averages 1.5 litres daily.  She consumes two coffees each morning to try improve energy and occasionally skips meals when symptoms flare.  Physical activity is inconsistent as she often experiences symptom exacerbation following attempts to exercise. 

Recent investigations ordered by GP:

Test	NZ reference interval	Clients result
Ferritin	Female 20–200 µg/L	58 µg/L
Vitamin B12	170–800 pmol/L	250 pmol/L
Serum folate	Serum folate 5-45 nmol/L	15.5 nmol/L
Vitamin D (25-OH)	Deficient: <25 nmol/L; Mild deficiency: 25–50 nmol/L; Sufficient: >50 nmol/L	75 nmol/L
Thyroid function	TSH adult 0.27–4.2 mIU/L	2.3 mIU/L
Coeliac screen	Tissue transglutaminase (tTG-IgA): Negative	Negative

 

Naturopathic assessment

44-year-old female presents with diagnosed ME/CFS following Epstein-Barr infection.  Her symptoms are characterised by post-exertional malaise, cognitive dysfunction, dizziness, generalised muscle pain, frequent headaches and persistent fatigue.  Likely exacerbated by mitochondrial dysfunction, neuroimmune dysregulation, autonomic dysfunction, poor sleep quality and neuroinflammation.

The primary therapeutic goals are to support quality of life, improve resilience, optimise nutritional status, minimise inflammatory burden, encourage nervous system regulation and reduce factors that may contribute to symptom exacerbation, while recognising there is currently no curative treatment for ME/CFS.

Key factors considered

·         Post-exertional malaise (PEM) – PEM is considered the hallmark feature of ME/CFS and differentiates it from many other fatigue disorders.  Even relatively minor physical, cognitive or emotional exertion may trigger prolonged symptom worsening.  Supporting appropriate pacing and energy management is therefore central to care.

·         Mitochondrial dysfunction – Reduced capacity for oxidative phosphorylation, altered fatty acid metabolism and impaired adenosine triphosphate (ATP) generation have been associated with ME/CFS pathology.  This limits cellular energy availability and contributes to the profound fatigue and reduced exercise tolerance that characterise the disease.

·         Neuroimmune dysregulation – Post-infectious ME/CFS occurs in up to 80% of diagnosed individuals.  It is theorised that the acute infection initiates persistent immune danger signalling that prevents normal recovery and maintains a chronic state of immune activation.

·         Autonomic nervous system dysfunction – Symptoms of dizziness upon prolonged standing and exercise intolerance suggest dysregulation of autonomic function, which commonly contributes to fatigue and reduced exercise capacity.

·         Sleep dysregulation – Although the client sleeps for an adequate duration, sleep remains non-restorative.  Poor sleep quality may further impair immune regulation, cognition and pain perception.

·         Neuroinflammation – Activation of glial cells, specifically microglia and astrocytes, has been proposed as a key mechanism linking peripheral immune activation with fatigue, cognitive impairment and sensory hypersensitivity.

Herbal medicine

Ashwagandha (Withania somnifera) – Traditionally used as an adaptogenic herb to support resilience during periods of stress and fatigue.  Its actions are particularly relevant where ME/CFS is accompanied by poor stress tolerance, sleep disturbance and fatigue.  Its withanolides have demonstrated immunomodulatory effects through regulation of cytokine activity and enhancement of natural killer (NK) cell function.  They have also displayed influence on inflammatory signalling, oxidative stress, mitochondrial function and neuroplasticity in experimental studies. 

Cordyceps (Cordyceps militaris) – Traditionally used as a restorative tonic to support convalescence and improve resistance to fatigue.  Its effects on cellular energy metabolism are mainly attributed to its primary constituent cordycepin.  Cordycepin may enhance ATP production, improve mitochondrial efficiency, reduce oxidative stress and improve oxygen utilisation.  Its polysaccharides exert immunomodulatory effects by activating macrophages, dendritic cells and NK cells to enhance both innate and adaptive immunity.  Cordyceps generally supports energy without producing abrupt increases in sympathetic activation, making it suitable for clients with autonomic instability. 

Lemon balm (Melissa officinalis) – Traditionally used to calm the nervous system, improve sleep quality, support post-viral recovery and reduce nervous tension without excessive sedation.  Its effects on GABAergic signalling may contribute to its calming and sleep-supportive actions.

Reishi (Ganoderma lucidum) – Reishi occupies a unique position with ME/CFS management due to its broad actions across immune regulation, sleep quality, anxiety and inflammation.  Its polysaccharides demonstrate immunomodulatory effects by stimulating IL-1, TNF-α, NK cells and T-lymphocytes, thereby enhancing protection against recurrent infections and helping regulate chronic immune dysregulation. 

Herbal formula – 500 mL

·         Ashwagandha (Withania somnifera) 3:2 – 50 mL

·         Cordyceps (Cordyceps militaris) 1:2 – 150 mL

·         Lemon balm (Melissa officinalis) 1:2 – 100 mL

·         Reishi (Ganoderma lucidum) 1:2 – 200 mL

Dosage: 2.5 mL twice daily (BD), morning and night, for the 1^st week.  If well tolerated, increase to 5 mL BD.

Note: The client was advised to drink one glass of water with each dose of herbal medicine, to support the liver and kidneys natural processing of alcohol.

Additional recommendations

Dietary modifications

·         Increase protein intake – Choose pre-prepared protein options where possible to limit energy expenditure.  Options may include tinned fish, pre-cooked poultry, Greek yogurt, cottage cheese and pre-sliced cheese.  Adequate protein intake improves satiety, regulates blood glucose responses, stabilises energy levels throughout the day and supports immune function.

·         Stabilise blood sugar – Pair carbohydrates with protein and or/fat and fibre to reduce blood sugar fluctuations.  Combinations may include fruit with nut butter or Greek yogurt, vegetables with hummus and seeded crackers with cheese.  Stable glucose availability may support more consistent energetic, metabolic and neurochemical activity throughout the day.

·         Ensure adequate hydration – Aim for 2 – 3 L of fluid daily, always keeping a water bottle close by as a reminder to hydrate.  Consider adding ¼ tsp mineral salt to each litre of water.  Sodium helps the body retain water, which increases blood volume, improves blood circulation and helps maintain healthy blood pressure.

·         Reduce reliance on caffeine as a substitute for rest – Excessive intake may contribute to disrupted sleep and fluctuating energy.

Lifestyle modifications

·        Energy pacing – Education regarding energy pacing is a cornerstone of ME/CFS management.  The client was encouraged to monitor physical, cognitive and emotional exertion, schedule regular rest periods and avoid the ‘push-crash’ cycle that frequently perpetuates symptom exacerbation.  A key strategy for preventing this cycle is to avoid overexertion on days when symptoms are less severe.  Instead, the client was advised to function at 50% of their perceived capacity for the day, helping to conserve energy and reduce the risk of PEM.

·         Prioritise restorative rest – Incorporate scheduled quiet rest before symptoms become overwhelming rather than waiting until exhaustion develops.

·         Sleep hygiene – Maintain consistent sleep and wake times, avoid blue light exposure one hour before bed and avoid caffeine after midday to improve sleep quality. 

·         Gentle vagus nerve stimulation – Humming, gargling, singing and massaging the outer ear are all effective methods for stimulating the vagus nerve.  Vagus nerve stimulation activates the parasympathetic nervous system, which supports autonomic regulation and may help improve orthostatic intolerance symptoms.

·         Orthostatic intolerance management – Consider wearing compression garments and avoid prolonged standing where possible.  Lying down with legs elevated against a wall promotes venous blood flow back to the heart and brain, helping to reduce dizziness.

Supplements

·         Magnesium glycinate (300-400 g/day) – To support muscle relaxation and sleep quality.

·         Coenzyme Q10 (100-300 mg/day) – Functions as a mitochondrial cofactor to support cellular energy production.  CoQ10 in combination with nicotinamide adenine dinucleotide (NADH) supplementation was shown to reduce cognitive fatigue and quality of life in a small clinical study with ME/CFS patients.

·         NADH (10 mg/day) – A coenzyme that plays a key role in cellular energy metabolism.  It helps replenish depleted ATP stores and participates in essential redox reactions involved in energy production.

·         Cease taking the multivitamin – The client was advised to stop taking their generic multivitamin as they often contain sub-therapeutic levels of nutrients, with minimal bioavailability.   

Follow up

At the four-week follow-up, the client reported that overall fatigue remains present, but daily symptom variability has improved.

She has successfully implemented pacing strategies and notes fewer severe post-exertional crashes after recognising her personal activity limits.  Brain fog remains present but episodes are shorter and less disruptive.

Sleep quality has modestly improved from 3/10 to 5/10, with fewer overnight awakenings. Muscle pain has reduced in intensity, although orthostatic symptoms continue during prolonged standing.

She reports improved consistency with meals and has increased her daily protein intake with ease after including more pre-packaged protein options in her weekly shop.  Staying hydrated throughout the day has become easier since always keeping a water bottle with her.  She had reduced her coffee intake to one cup each morning and has greater confidence in planning her week around energy availability.

The herbal formula was well tolerated without adverse effects.  The current protocol was continued with ongoing review every six to eight weeks in conjunction with her GP. Continued emphasis was placed on symptom monitoring, pacing strategies and maintaining realistic expectations regarding gradual improvement and long-term symptom management.