Chronic Fatigue Syndrome

Aka: Chronic Fatigue Syndrome, Chronic Fatigue Immune Deficiency Syndrome

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II. Epidemiology

  1. Incidence: 37 cases per 100,000 (difficult to assess)
    1. Fatigue is common complaint (20% of all patients)
    2. Higher Incidence may be in age 20-50 year old women
    3. Case reports include children as young as age 5 years
  2. Outbreaks have been known to occur for centuries
    1. Los Angeles County Hospital (1934)
    2. Akureyri, Iceland (1948)
    3. Royal Free Hospital, London (1955)
    4. Punta Gorda, Florida (1945)
    5. Incline Village, Nevada (1985)

III. Etiology

  1. Idiopathic, likely multifactorial
  2. Genetic predisposition in some patients
  3. Childhood Trauma increases chronic Fatigue risk 6 fold
    1. Heim (2009) Arch Gen Psychiatry 66(1):72-80 [PubMed]
  4. Various viruses have been implicated (with possible chronic immune activation)
    1. Epstein Barr Virus (Mononucleosis)
      1. EBV titers no higher than in healthy controls
      2. Linde (1992) J Infect Dis 165:994-1000 [PubMed]
    2. Mycoplasma pneumoniae
    3. Coxsackie virus
    4. Human Herpes Virus 6
    5. Cytomegalovirus
    6. Measles
    7. HTLV-II

IV. Pathophysiology

  1. T-Cell Activation
  2. Cytokine release
    1. Related to alpha-intrusion sleep disorder

V. Symptoms

  1. See Fatigue

VI. Diagnosis

  1. See Chronic Fatigue Diagnosis

VII. Differential Diagnosis

  1. See Fatigue Causes
  2. See Fatigue Red Flags

VIII. Labs (base on other likely possible Fatigue Causes)

  1. See Fatigue Diagnostic Testing

IX. Course

  1. Most patients partially recover within 2 years
  2. All Chronic Fatigue patients are prone to relapse

X. Management: Nonpharmacologic

  1. Understanding physician
    1. Listen
    2. Counsel
    3. Empathy
  2. Cognitive behavior therapy
    1. Identify unhealthy coping mechanisms
  3. Consider support group
  4. Avoid Caffeine
  5. Avoid Alcohol
  6. Graded Aerobic Exercise
    1. Duration: 30 minutes per session
    2. Repeat five Exercise sessions per week
  7. References
    1. Fulcher (1997) BMJ, 314:1647-52 [PubMed]

XI. Management: Pharmacologic

  1. Symptomatic therapy
  2. Insomnia Management
  3. Major Depression Management
  4. Pain Management
    1. NSAIDS
    2. Selective Serotonin Reuptake Inhibitors (SSRI)
    3. Duloxetine (Cymbalta)
    4. Tricyclic Antidepressants
      1. Elavil 10-25 mg PO qhs and increase as tolerated
  5. Avoid empiric therapies which are not yet supported by good evidence
    1. Nicotinamide-adenine dinucleotide (NADH)
    2. Hydrocortisone 5-10 mg PO qd

XII. Resources

  1. CDC: Chronic Fatigue Syndrome
    1. http://www.cdc.gov/cfs/

XIII. References

  1. Gantz in Noble (2001) Primary Care Medicine, p. 1325
  2. Craig (2002) Am Fam Physician 65(6):1083-95 [PubMed]
  3. Morrison (2001) Obstet Gynecol Clin North Am 28:225-40 [PubMed]
  4. Yancey (2012) Am Fam Physician 86(8): 741-6 [PubMed]

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