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=== Dysbiosis === {{main| page_name =Dysbiosis}} There is strong evidence that [[dysbiosis]] or an imbalance in the microbial ecology of the gut plays a role in the symptoms of [[ME/CFS]]. On average, ME/CFS patients have lower levels of ''[[Bifidobacteria]]'', ''[[Escherichia coli]]'' and higher levels of [[aerobic bacteria]],<ref name=":0">{{Cite journal | last = Logan | first = Alan C | last2 = Venket Rao | first2 = A | last3 = Irani | first3 = Dinaz | date = Jun 2003 | title = Chronic fatigue syndrome: lactic acid bacteria may be of therapeutic value | url =http://www.medical-hypotheses.com/article/S0306-9877(03)00096-3/abstract|journal=Medical Hypotheses|language=English|volume=60|issue=6 | pages = 915β923|doi=10.1016/S0306-9877(03)00096-3|issn=0306-9877}}</ref> in particular ''[[Enterococcus]]'' and ''[[Streptococcus]]'' species.<ref>{{Cite journal | last = Sheedy | first = John R. | last2 = Wettenhall | first2 = Richard E.H. | last3 = Scanlon | first3 = Denis | last4 = Gooley | first4 = Paul R. | last5 = Lewis | first5 = Donald P. | last6 = McGregor | first6 = Neil | last7 = Stapleton | first7 = David I. | last8 = Butt | first8 = Henry L. | last9 = DE Meirleir | first9 = Kenny L. | date = Jul 2009 | title = Increased d-lactic Acid intestinal bacteria in patients with chronic fatigue syndrome | url =http://www.ncbi.nlm.nih.gov/pubmed/19567398|journal=In Vivo (Athens, Greece)|volume=23|issue=4 | pages = 621β628|issn=0258-851X|pmid=19567398}}</ref> The latter produce [[D-lactate]], a form of lactic acid only produced by non-human cells that is poorly metabolized in humans. [[D lactate]] is associated with a wide variety of cognitive and neurological symptoms, such as in patients who suffer from [[Lactic acidosis|D-lactic acidosis]]. A study found that higher levels of enterococcus bacteria in CFS patients were associated with more severe neurological and cognitive dysfunction.<ref>https://getinfo.de/en/search/id/BLCP%3ACN055885616/%60Bacterial-Colonosis-in-Patients-with-Persistent/</ref> CFS patients may suffer from [[small intestinal bacterial overgrowth]] (SIBO).<ref name=":0" /> One hypothesized consequence of dysobiosis is an overproduction of [[hydrogen sulfide]] (H2S) by pathogenic bacteria. H2S can inhibit [[Mitochondrion|mitochondria]]l respiration by blocking [[cytochrome c oxidase]].{{Citation needed}} A study of Norwegian and Belgian patients found significantly decreased proportions of [[Firmicutes]] genera ''[[Holdemania]]'' and increased proportions of [[Bacteroidetes]] genera ''[[Alistipes]]'' in the Norwegian but not the Belgian sample. Significantly increased proportions of [[Firmicutes]] genera ''[[Lactonifactor]]'' were found in both.<ref>{{Cite journal | date = 2013-08-01 | title = High-throughput 16S rRNA gene sequencing reveals alterations of intestinal microbiota in myalgic encephalomyelitis/chronic fatigue syndrome patients| url = https://www.sciencedirect.com/science/article/pii/S1075996413000929|journal=Anaerobe|language=en|volume=22 | pages = 50β56|doi=10.1016/j.anaerobe.2013.06.002|issn=1075-9964}}</ref>
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