Dr. Charles Balis San Francisco, CA 94104 August 24, 1996 Dear Dr. Balis: I have just examined a patient of yours, Cassandra Evans. Her case is somewhat puzzling, but I think we have several leads. We reviewed her medical history and I am sending her for a blood work-up. The patient is a 24 year old white female. She complains of impairments in concentration and short-term memory, sleep disturbances, musculoskeletal pain, prolonged fatigue, occassional sore throat, multijoint pain, headaches, unrefreshing sleep, post-exertion malaise, tender axillary lymph nodes. Physically, she presents an extremely ragged and run down appearance. She reports no history of substance abuse. No psychomotor retardation was observed. I've requested lab tests for complete blood count with leukocyte differential, erythrocyte sedimentation rate, serum levels of alanine aminotransferase, total protein, albumin, globulin, alkaline phosphatase, calcium, phosphorus, glucose, blood urea nitrogen, electrolytes, creatinine, determination of thyroid-stimulating hormone, and urinalysis. Although preliminary, I suspect a failure of immunologic function and therefore believe that further tests may be appropriate. Although many of these tests were performed before by her other physicians, I believe it appropriate to start anew. I would suggest testing for Epstein-Barr virus, retroviruses, human herpesvirus 6, enteroviruses, Candida albicans. I would test for immunologic function, including cell population and function studies and would consider imaging studies. Although the symptoms presented do not fit such a diagnosis, I believe it would be appropriate to rule out hepatitis B or C, hypothyroidism, sleep apnea and narcolepsy and any iatrogenic condition. I would also consider fibromyalgia as a possibility, as well as Lyme disease and syphilis. I would also look for an elevated antinuclear antibody titer for possible discrete connective tissue disorder. I also plan on discussing her case with a collegue who specializes in infectious diseases to see what he might suggest. While I would like to conduct the full battery of tests outlined above, I am concerned about her emotional well being and thus believe it necessary to minimize extraneous testing. She has given me permission to discuss her case openly with you. I would appreciate it if you could seek her similar permission so that you can keep me apprised of her progress. Thank you for the referral. Very truly yours, Doug Halsey, MD

Doctor Balis' Notes on this Letter