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The Real Reason for Chronic Fatigue in Mono?

Posted Feb 03 2009 1:00am
A recent article in the New York Times reports on the widespread incidence of mononucleosis in teens and young adults. The Epstein-Barr virus is thought to be the cause, with most Americans infected by their 30s. It’s thought that up to 50% of people infected develop severe fatigue or other symptoms. The article points out the fact that "mono," or "the kissing disease" has been trivialized due to it’s widespread nature and that trials of new drugs and vaccines are lacking.
 
My take on this article: Most people who are infected with mono experience little more than your typical cold symptoms, but there are a small, but significant number of people who suffer a variety of potentially life-threatening complications, if not extreme fatigue that can be quite debilitating. Mononucleosis infects your body’s lymphoid system, most of which are found in your lymph nodes and spleen. These lymph glands educate your body about any infections and respond appropriately by making more immune cells. As a result, the glands can swell to various degrees—sometimes, to dangerous levels. 
 
Besides the many lymph glands in your neck, your tonsils (and adenoids) are also made of lymphoid tissue. So if you are a teen or a young adult and still have relatively large tonsils, then being infected with mono will cause your tonsils to swell. 
 
As I’ve stated before, anything that causes either temporary or permanent narrowing in your throat will cause your throat structures to obstruct when you are sleeping, especially when you are on your back (due to gravity), and when in deeper levels of sleep (due to muscle relaxation). Even a simple cold can aggravate temporary sleep-breathig problems, causing you to toss and turn all night long. Once your cold goes away, you’re fine again. 
 
However, if you have larger tonsils than normal, then the enlarged tonsils will cause you to stop breathing more often, and in certain people, the vacuum effect created in the throat causes a suctioning of stomach juices into your throat, which causes more swelling. This irritates your tonsils further and the vicious cycle continues. 
 
One little appreciated piece of information is that if you have large tonsils (or eve if you’ve had your tonsils taken out), you could still have lingual tonsils remaining. Lingual tonsils are lymphoid tissue at the base of the tongue in the midline, just above your voice box. So any degree of swelling will narrow the space behind the tongue significantly. It’s also been shown recently that persistently enlarged lingual tonsils are associated with laryngopharyngeal reflux disease. 
 
I’ve also alluded to my sleep-breathing paradigm (in my book  Sleep, Interrupted: A physician reveals the #1 reason why so many of us are sick and tired ) where many people with sleep-breathing problems have relatively narrow jaws and dental crowding, which leads to chronic low-grade obstructions preventing deep sleep, and constant low-grade inflammation of the throat from microscopic stomach contents. 
 
In my practice, every time I see someone with severe mono, their tonsils are infected and extremely large, sometimes almost touching in the midline. Antibiotics usually don’t work (because it’s a viral infection), and in fact, is not recommended due to a potential reaction to certain antibiotics. The one medication that usually helps patients feel better is a short course of oral steroids, like prednisone. It’s thought to be due to its’ anti-inflammatory effects, significantly reducing swelling. 
 
Anytime there is inflammation in the throat, by definition, there will also be inflammation in the nose. This occurs via a combination of gastric juice regurgitation into the nose, ears and sinuses, as well as through an imbalance of the involuntary nervous system. People with narrows jaws will also have narrow nasal side-walls, since the the width of the nasal cavity follows the width of the upper jaw.
 
If there is any degree of nasal congestion, then vacuum forces are created downstream, aggravating even more throat or tongue narrowing and collapse. 
 
The well-known residual symptoms of severe chronic fatigue after mono can last from weeks to months. Sometimes, the fatigue doesn’t go away at all. Eventually, some of these people will be diagnosed with chronic fatigue syndrome. 
 
The chronic physiologic stress state that’s created can lead to metabolic and hormonal changes. For example, elevated cortisol levels due to stress can suppress thyroid function and raise glucose levels. 
 
It can even affect reproductive hormones adversely. In women, stress can suppress progesterone, elevating the estrogen to progesterone ratio. Interestingly, progesterone is known to promote upper airway muscle tone, so the lower the level of progesterone, the more your tongue is likely to fall back and obstruct, leading to less efficient sleep.
 
It’s been suggested that there are many different reasons for chronic fatigue syndrome, but upper airway narrowing due to to anatomic reasons and swelling is one logical explanation that encompasses all other explanations. Ultimately, swelling of the upper airway structures can be from anything that causes inflammation, from the common cold to allergies, to acid reflux. The tonsils are one dramatic example of swelling due to infection or inflammation, but other areas of the throat can become swollen, such as the soft palate and tongue. If you look at mono from a sleep-breathing perspective, the chronic fatigue that results sometimes makes a lot more sense.
 

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