Chronic Fatigue Syndrome

Background Information

Chronic Fatigue Syndrome (CFS) is a debilitating and poorly understood disorder where a patient experiences profound fatigue to the extent of not being able to perform daily activities. This fatigue is aggravated by physical and mental activities that the patient can ordinarily perform with ease. They often function at substantially lower level than in their pre-morbid state.

Epidemiology

The prevalence of CFS varies from population to population due to differences in the definition used. It has been reported to be as high as 3% in certain countries. In the US, it has been estimated that up to 1 million Americans may have CFS (CDC data) . It affects all ages, gender, ethnicity and socio-economic groups. There seem to be a predilection for female gender (65 – 80% females), aged 40 – 50s and mostly adults and teenagers. In Western countries, young white females form the largest groups. There is data to suggest genetic predisposition as this is sometimes seen in families and blood relatives. Some authorities have suggested causality related to a shared environment as well.

Clinical

The diagnosis of CFS is based on criteria and exclusion of other diseases. CFS International Panel (1994) criteria includes:

  1. More than 6 months of severe chronic fatigue
    AND
  2. Having 4 or more of the following symptoms:
    • Impairment of short term memory/concentration
    • Sorethroat/tender lymph nodes
    • Myalgia
    • Arthralgia (without swelling/redness)
    • Headache (new type, pattern, severity)
    • Unrefreshed sleep
    • Post-exertional malaise ≥ 24 hours

Associated symptoms include: (20 – 50%)

  • Abdominal pain / pelvic pain
  • Alcohol intolerance
  • Chest pain
  • Chronic cough/sorethroat
  • Dry eyes/mouth
  • Diarrhoea/bloating
  • Dizziness
  • Irregular heartbeat
  • Earaches
  • Tingling skin sensation
  • Night sweats
  • Shortness of breath
  • Jaw pain
  • Nausea/vomiting
  • Mood change
  • Panic attacks

Differential Diagnoses

  • Fibromyalgia Syndrome
  • Myalgic Encephalomyelitis
  • Neuroasthenia
  • Multiple chemical sensitivities
  • Chronic EBV Infection
  • Lyme Disease
  • Multiple Sclerosis
  • Vitamin D deficiency
  • Bipolar disorder
  • Diabetes Mellitus
  • Cancers
  • Somatoform disorders
  • Autoimmune disease
  • Sleep Apnoea
  • Narcolepsy
  • Major depressive Illness
  • Hypothyroidism
  • Anemia
  • Hormonal disorders

Many of these conditions are treatable and should not be missed. There are also studies that have found association of CFS with EBV and Mycoplasma infections. As many as 50-80% of these patients have concomitant positive serologies to Mycoplasma and EBV, although no convincing explanation of causal relationship.

Treatment

If a diagnosis of CFS is confirmed, treatment approach should be based on symptoms. Studies have shown that early intervention results in better outcome. The patient should be put on Graded exercise therapy which is a form of physical therapy. The aim is to adjust the level of physical activities according to tolerance and to prevent over-exertion. Prevention of deconditioning is important as this impairs recovery. The patient is advised to target a lower baseline of activity , say 60-70% of previous functional level and reset to a new baseline.

Points to Note

Some people do not believe that CFS is a real condition. Others have classified it under psychiatric or neuroasthenia conditions. There is a lot of controversy regarding diagnosis and treatment of CFS as well as its physiology, psychology and psychosocial aspects. Suffice to say that we do not completely understand the basis of CFS and the aetiology of this disease. Some researchers have theorized that that there may be a failure of feedback mechanisms which has resulted in cytokines dysregulation at the cellular level. These inflammatory cytokines are responsible for some of the symptoms experienced by CFS sufferers. In layman terms, cytokines are chemicals secreted by cells when they are involved in cell communication (cell to cell talk).

Click here for Appointment