Transcript of Telephone Conversation between Charles Balis, M.D. and Douglas Halsey, M.D., Monday, September 9, 1996 at 9:30 am.

Dr. Halsey: Dr. Balis please.
Dr. Balis: Speaking.
Dr. Halsey: This is Doug Halsey over at UCSF. I am calling in regards to Cassandra Evans, a mutual patient.
Dr. Balis: Yes. I am very interested in hearing the progress on her case.
Dr. Halsey: I must admit I have put quite a bit of time and research on this one. Very intriguing, and I love a challenge. Especially if I can help a patient. I assume you received the letter I sent after her initial visit?
Dr. Balis: Yes, I appreciated it.
Dr. Halsey: Very well then. I spent some time digging through the medical journals and speaking to colleagues. I also spoke to some people down at the Centers for Disease Control. I started with a thorough search of computerized databases and health indexes for unusual immune disorders based on her symptoms. Her blood results came back pretty much as expected. Her magnesium and calcium levels were suspiciously low. She has elevated titers for Human Herpes Virus 6. I believe this is significant. Also, the results showed a lower than average white blood cell count. During my physical exam of Cassie, I found...wait, let me grab her chart. Okay, here we go. She had tender and swollen lymph glands, low blood pressure, slightly abnormal heart rhythms. However, Cassie has seen a cardiologist who explained to her that there is nothing wrong with the heart's pathology or anatomy. She reported that a previous EEG study found non-functional dysrethmia. She tested positive for trigger points, and thus I believe fibromyalgia plays a role in her condition. The waning and intensifying of major symptoms seemed reminiscent of MS. Nonetheless, it was the mentioning of Epstein Barr that turned out to be the biggest clue in identifying a possible cause for her ailments.
Dr. Balis: Really? How intriguing. Please go on.
Dr. Halsey: I did a full search on Medline for all related peer reviewed journal articles and studies on Epstein Barr. I fell upon an editorial about the Yuppie Flu. Are you familiar with that at all?
Dr. Balis: I seem to recall reading about it back in the 80's. Something about a disease which seemed to attack white woman predominantly and was associated with hypochondriasis and malingering, yes?
Dr. Halsey: Well, that is pretty much the way the mass media portrayed it. Medicine pretty much ignored the phenomena, claiming it was all in the head, and so forth. Anyway, Cassie complained of constant flu-like symptoms. When I spoke to the CDC, I inquired about the Yuppie Flu--any information as to the subsequent diagnosis and prognosis of patients. I had them fax me a sheet on all related maladies, especially those just reaching epidemic proportions. I weeded through a list of possibilities and narrowed it down to a likely candidate. I hypothesize Cassie is suffering from a condition known as Chronic Fatigue Syndrome.
Dr. Balis: Is this a physical malady or a psychological one?
Dr. Halsey: Oh, no. Apparently it is quite physical.
Dr. Balis: Then why don't you test her for it to be certain?
Dr. Halsey: Unfortunately, it is not quite that simple. There is no specific diagnostic test for CFS. It's primarily a negative diagnosis, after everything else has been ruled out. That is probably why none of her previous physicians picked up on this before. The CDC has a set of guidelines and diagnostic criteria. First, anything and everything that could be a problem must be ruled out. For instance, I originally suspected a thyroid disorder. The tests results show borderline normal for the entire endocrine system. Thus, we can rule out thyroidism. Fortunately for Cassie, she has been tested for just about everything under the sun, with relatively normal results. However, one of the things that must be ruled out are any psychological factors which could account for her condition. What about it, Doctor?
Dr. Balis: Well, I've only seen Cassie about six times now, but in my opinion her health problems have a primarily physical origin. She's suffering from depression now, but I believe that depression is exogenous primarily resulting from the health problems. I found no evidence in Cassie's recent personal or family history to support a diagnosis of primary depression. I would say Cassie's current depression is not endogenous. As such, I think I can rule out a psychological causation for Cassie's physiological problems.
Dr. Halsey: During her next visit, I'll review the criteria and make sure things match up, but given what you've just told me I think it likely that she will finally have a diagnosis.
Dr. Balis: I think that will be a huge relief for her. I think it's appropriate to put her on an antidepressant, if that is all right with you.
Dr. Halsey: I see no problem with doing so at this juncture. Try something mild, and start her on a low dose. If she does indeed have this disease, she probably suffers from multiple chemical sensitivity, including negative drug reactions.
Dr. Balis: Very good. I was considering a serotonin reuptake inhibitor just because the onset time seems to be better. But we could try the tricyclics if you had a particular preference.
Dr. Halsey: No, the serotonin reuptake inhibitors should work fine. I think they're more appropriate than the tricyclics for CFS patients. As in any other case, you will probably have to try a few before settling on a dosage.
Dr. Balis: Of course. What is the prognosis, treatment, etc. that can be expected if she does indeed have this?
Dr. Halsey: Do you want the good news or the bad news first?
Dr. Balis: Oh dear.
Dr. Halsey: I know. The good news is that as of now, there are no documented cases that have resulted in death except for suicides. The bad news is the scientific community has yet to figure the cause or cure for CFS. In fact, relatively little is known. Some research is being done, but it's moving slowly. Most physicians are treating symptoms and leaving it at that. I am going to call some international folks. In countries like Japan and France they seem to have more insight into CFS than we do.
Dr. Balis: Have you informed Cassie yet?
Dr. Halsey: No. During her next visit, I'll check her against the criteria, and if it all fits, I'll explain it to her. Maybe by then I will have more good news.
Dr. Balis: Yes.
Dr. Halsey: I will messenger the criteria listing for CFS as well as how Cassie measures up, if you'd like. I am going into uncharted territory here, and we are obviously working with an emotional young woman. It would be great if we could work hand in hand on this one.
Dr. Balis: Just let me know. I would be pleased to offer my assistance wherever I can.
Dr. Halsey: Okay. I have got to run. It was good talking to you Doctor. Thanks for your help.
Dr. Balis: Sure, thanks Doctor. Goodbye.
Dr. Halsey: Bye now.
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