Epstein Barr Virus (EBV) is a prevalent viral infection, with an estimated 90% of adults having EBV exposure in their lifetime. EBV has been shown to be lifelong, staying dormant in affected individuals' B lymphocyte cells, salivary gland epithelial tissue, and oropharyngeal epithelial tissue. This dormant virus can be reactivated, leading to chronic acute Epstein Barr Virus, regardless of when the virus was first contracted, which can lead to more similar symptoms and links to more insidious conditions like autoimmune diseases and hematological malignancies.

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CC: Epstein Barr Virus, Extreme Fatigue, Hypothyroidism, Hashimoto's Thyroiditis, Abdominal Bloating, and Constipation

Sara was a 24 yo female who presented with extreme fatigue, chronic digestive issues, brain fog, poor memory, and overall low quality of life. Sara rated her energy as a 2/10 on average. She could not make it through the day without 1-2 naps daily and was not driving herself as she was concerned she would fall asleep at the wheel. She had seen a local doctor one year prior to our first visit for the same symptoms and was diagnosed with Hashimoto's thyroiditis and associated hypothyroidism. Treatment to reduce her elevated thyroid antibodies had not provided improvement for her energy or other symptoms.

She has had digestive issues since childhood and frequently suffers from abdominal pain due to passing a bowel movement every 3-5 days.

Additional History

Three years ago, the patient moved to Los Angeles, California, to begin working a high-stress job with long hours. A few months into her new job, she started noticing overwhelming fatigue and increased digestive symptoms, and she began having sleeping issues of frequent and recurrent night waking.

One year prior, she was diagnosed with Hashimoto's and began a gluten-free diet, bringing her TPO antibodies down from 250 to 30 IU/mL.

Her diet was very clean, with a high intake of whole foods and limited dairy, processed foods, and refined sugar. She had been on oral birth control since she was 15 and has not had a period in over five years.

Lab Work

Comprehensive Stool Test Results

• Fecal Secretory IgA: mild elevation
• Short Chain Fatty Acids (SCFA) (Total): Low
• N-butyrate Concentration: Low
• Beta-glucuronidase: High
• Low beneficial bacteria: Akkermansia muciniphila: below detectable level

Nutrient Evaluation

• Normal Range: Riboflavin, Molybdenum
• Moderate Deficiency: Vitamin A, Vitamin C, Vitamin E, Glutathione, Thiamin, Niacin, Cobalamin, Magnesium, Manganese, Omega 3 Fatty Acids
• Severe Deficiency: Alpha lipoic acid, Pyridoxine, Biotin, Folate
• High Toxic elements Elevated: Mercury  

Lab Analysis

Epstein Barr Virus

Sara's lab work shows a reactivation of her dormant EBV infection as seen through the positive value EBV Early Antigen IgG. The additional positive EBV Viral Capsid and Nuclear AG IGG values indicate a past infection. At the same time, EBV Viral Capsid IgM was negative, indicating a first-time or initial infection of EBV.

The link between heavy metal toxicity and chronic EBV was confirmed with an elevated mercury level noted along with low levels of all her antioxidants, B vitamin, minerals, and glutathione, indicating a taxed system with oxidative damage.

TSH

Other sources contributing to her fatigue are her low TSH- a full thyroid panel was not performed as one was run one month before our visit, and free T3/freeT4 were within normal range.

Gut Health

The comprehensive stool analysis indicates a low level of inflammation but a high toxic load with a heavily increased beta-glucuronidase. Again with the patient on birth control, her estrogen output is well controlled through synthetic hormone contraceptive, so another toxin exposure is likely. A comprehensive detox approach is warranted to limit ongoing exposure and support her body's detoxification ability. This is especially important when taking her high mercury level into account. Mercury is a known neurotoxin linked to Hashimoto's thyroiditis and other autoimmune and neurodegenerative diseases.

A slow detox protocol is warranted so as not to stress out the patients already taxed system, and establishing healthy bowel movements is vital to properly eliminating the mercury once it is mobilized out of her system.

Nutrients

Sara's labs also indicate a borderline low iron and ferritin level. She has been on birth control and has had no menstrual cycle in many years, so directly focusing on gut health, subsequent iron absorption, and iron conversion cofactors should support an increase in this level.

Cortisol Support

Sara's DHEA-s were low, indicating her adrenals are likely being taxed. Yet, her cortisol output is mostly within normal limits minus a low morning output, indicating a delayed cortisol awakening response but not quite an adrenal fatigue diagnosis. Lifestyle interventions and nutrient support should be able to support this as her level was just outside of the reference range.

Interventions

Epstein Barr Virus Support

• Foods to avoid that promoted viral replication: red meat, egg yolks, and sugar.
• Food list provided of antiviral/immune stimulating foods to eat 3 x daily.
• Zinc Sulfate 15 mg 2x daily: high zinc foods also reviewed.
• Liquid Liposomal Vitamin C 1,000 mg 3x daily.
• Lysine capsules 500 mg 3x daily.

Digestive Support

• L Glutamine (Klaire Labs): 5 grams nightly to support the integrity of her gut lining.
• Butyrate Complex to support low butyrate/SCFA levels and support the health of her gut lining.
• Calcium D glucarate 500 mg 2x daily to inhibit high beta-glucuronidase levels.
• Microbiome support for low beneficial microflora: pomegranate/cranberry juice, matcha green tea powder, collagen powder, acacia powder.

Nutrient Restoration and Mitochondria Support

• Mitocore by Ortho Molecular was recommended with a slow increase of capsules to a total dosage of 4 pills daily.
• High omega-3 fatty acid foods were also reviewed.

Mercury Detox

• Cilantro tincture 2x daily before food for one week, then two weeks off, then resume.
• Activated Charcoal capsules were taken mid-day between the first and second dose of cilantro tincture. Take charcoal continually as it also helps bind to viral byproducts and prevents die-off reaction symptoms from the EBV antiviral protocol.
• Mercury sources in food, cosmetics, and environmental reviewed
• Infrared sauna 2x weekly for increased detoxification support and improved immune system function.

Cortisol Support

• Lifestyle factors reviewed: regular sleep/wake times, outdoor walk within 45 minutes of waking for sunlight exposure, avoiding intense workouts after 2 pm, morning meditation starting with 5 minutes.
• Avoid toxin exposure: Berkey water filter, all organic produce, organic & free-range meat, wild-caught fish, clean body care, and household products.

Follow Up Labs 3 Months Later

3 Months Follow Up Visit

At the follow-up visit, Sara was doing significantly better. Her energy had improved to a 5-8/10, and she was feeling more energy in the morning and about to begin working a new, less stressful job three days a week.

She was taking 1-2 naps a week but didn't feel the overwhelming need to nap as long as she stuck to a regular sleep schedule providing 9 hours nightly.

1.5 months into the protocol, she was able to begin exercising again without the side effects of fatigue.

Initially, she responded poorly to the gastrointestinal support and began experiencing diarrhea 3-4 times a day for the first week, we reduced the dosage of the butyrate complex and took it with meals, which resulted in her having 1-2 daily bowel movements that were well formed and easy to pass, and her bloating had resolved one month into the digestive support.

She also noticed her skin health and hair had improved, her symptoms of brain fog and memory issues had almost entirely diminished, and she had lost 6 pounds of the excess weight she had gained due to lack of activity.  

Summary

This case is an excellent example of the complexity of chronic infections and their systemic effects on even a young, healthy person.

The contributing factors, such as heavy metal toxicity and nutrient deficiencies, can contribute to a weakened immune system, allowing an underlying, latent infection like Epstein Barr to reactivate.

Checking for a reactivated viral infection in adults with fatigue is essential for their long-term health. As Sara continues to follow the protocol and allows her body more time to heal, my professional opinion is that she will be able to regain her energy levels without the need for weekly naps. However, the long-term effects of chronic viral infections are a genuine concern, and reactivation is possible due to stress, lifestyle factors, etc.

Patients who suffer from chronic fatigue and or are known to have past viral infections such as EBV should work with a functional medicine provider who can check for these levels annually and help make an individualized healthcare plan tailored to that patient's needs.