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An obvious initiating infection with Epstein-Barr virus and positive IgM tests and/or positive IgG tests shows that there has been exposure to Epstein-Barr in the past and there could well be ongoing non-permissive replication now.
If there is no IgG antibody to Epstein-Barr virus, then this indicates no prior infection and therefore no indication of the treatment.
Lerner also looks at other antigens, namely D (diffuse) and R (restricted) components of EVB early antigen (EA) to indicate non-permissive incomplete virus replication. I am not sure if this test is available and I will make enquiries. However, my view at this stage would be that anybody with a viral trigger, positive IgM and/or IgG antibodies and who has not responded to the above regime would be a candidate for a trial of Valacyclovir.
We then have to ask the question if there is any evidence of cytomegalovirus (CMV) or HHV-6 infection, which would require additional treatment with Valganciclovir. From his paper it does not appear that these two viruses are candidates for non-permissive replication and therefore it should be straightforward to diagnose these simply by doing IgG antibody studies for these two viruses.
As part of his work up, Lerner also does 24 hour ECG monitoring and the abnormalities he most commonly picks up are oscillating T-wave flats and inversions, together with tachycardia at rest. My guess here is that these cardiac abnormalities reflect mitochondrial dysfunction and poor energy delivery to the heart because of the cellular disruption resulting from chronic viral infection.
So to diagnose Epstein-Barr virus subset chronic fatigue syndrome requires the following positives:
- International criteria for CFS
- 24-hour ECG monitor, oscillating T-wave flats and inversions
- Tachycardia at rest
- Epstein-Barr virus, early antigen (diffuse) total antibody with or without viral capsid antigen IgM
- Negative tests for acute co-infections such as Mycoplasma pneumoniae, Babesia microti, borrelia burgdorferi, Anaplasma phagocytophilic IgG, antistreptolysin O.