Infection Associated Chronic Illness, Drs. Ruhoy & Kaufman, Clinician's Roundtable, March 2024

Two leading clinicians outline a practical framework for infection-associated chronic illness (including ME/CFS, dysautonomia/POTS, MCAS, and hypermobility/EDS). They stress exhaustive history-taking and a tailored exam, and describe a recurring “septad” of overlapping domains: autonomic dysfunction/orthostatic intolerance (using a liberal definition and favoring NASA Lean or tilt), GI dysmotility/SIBO, connective tissue/EDS traits, mast cell activation, chronic/persistent infections, autoimmunity, and hormonal imbalance. Workups commonly include immunology (quantitative immunoglobulins and function), viral studies (e.g., EBV PCR/serology), MCAS mediators, SIBO testing, cortisol and sex hormones, vitamins, and targeted autoantibodies (including ganglionic AChR when appropriate), plus neurologic evaluation, pain and neuroinflammation assessment, vessel/endothelial imaging when indicated, and evolving coagulation/microclot testing. Management is individualized: diagnose and treat OI/POTS, address MCAS, treat infections or immune deficits, and consider endothelial dysfunction and hypercoagulability as contributors to brain fog and fatigue. Q&A touches on handling chronic inflammation (“inflammaging”), links between syringomyelia, MCAS, and dysautonomia, experience with rapamycin, and thoughtful sex hormone assessment (including low testosterone in females). Overall, the message is to recognize common clusters, test strategically, and treat multimodally rather than siloed by specialty.