Myalgic Encephalomyelitis/Chronic Fatigue Syndrome
Julie Adkins, Jill C. Cash, Beverly R. Byram, Cheryl A. Glass, Kristin Ownby, and Pat Obulaney
Definition
A.Fatigue is one of the most common symptoms confronting the practitioner in an office practice. A patient with chronic fatigue is characterized as having fatigue with multiple associated symptoms for longer than 6 months in which these symptoms have a profound impact on daily activities.
Incidence
A.Fatigue accounts for 1% to 3% of visits to generalists as an isolated symptom or diagnosis. Psychiatric disorders are involved in less than 50% of cases. Myalgic encephalomelitis/chronic fatigue syndrome (ME/CFS), formerly known as chronic fatigue, has a reported frequency in excess of 20%. Fatigue is seen predominantly in women, four times more than in men, and the highest prevalence is among people aged 40 to 60; however, it can affect people of all ages, including teens and children.
Pathogenesis
A.Fatigue is a sensitive but nonspecific indicator of underlying medical and/or psychological pathology. It is reportedly more often due to unknown cause or to psychiatric illness than to physical illness, injury, medications, drugs, or alcohol.
Predisposing Factors
A.Hyperthyroidism.
B.Hypothyroidism.
C.Cardiac disease: Congestive heart failure.
D.Neurally mediated hypotension.
E.Infections: Endocarditis, hepatitis, Epstein–Barr virus, Coxiella burnetii.
F.Respiratory disorders: Chronic obsturactive pulmonary disease (COPD) and sleep apnea.
G.Anemia.
H.Arthritis and related disorders.
I.Cancer.
J.Alcoholism.
K.Side effects from drugs such as sedatives and beta blockers.
L.Psychologic conditions such as insomnia, depression, anxiety, and somatization disorder.
M.Female gender.
N.Race/ethnicity: Whites over other races and ethnicities.
Common Complaints
A.Lack of energy.
B.Listlessness.
C.Fatigue that interferes with participation in family, work, or even leisure activities; not improved with rest.
Other Signs and Symptoms
A.Weakness.
B.Postexertional malaise.
C.Poor physical conditioning.
D.Unrefreshing sleep.
E.Undernutrition and poor appetite.
F.Stress.
G.Obesity.
H.Emotional problems: Depression, anxiety, and somatization disorder.
I.Myalgia and arthralgia.
J.Problems with thinking and memory.
K.Orthostatic intolerance.
Subjective Data
A.Review history for onset, duration, and course description of the fatigue.
B.Perform thorough mental status exam. Ask the patient about significant losses, low self-esteem, and occurrence of crying spells and suicidal thoughts. Utilize a depression screening tool. High prevalence of depression and suicide is present in this patient population.
C.Ask the patient about a history of any abuse of hypnotic drugs, alcohol, or tranquilizers.
D.Review medications, both over-the-counter (OTC) and prescription drugs.
E.Review the patient’s medical history for cardiac, thyroid, and other medical conditions.
F.Review sleep and insomnia history.
G.Review history for family illness, new baby, or postpartum.
H.Establish last menses to rule out pregnancy.
I.Review exercise patterns.
J.Review diet with 24-hour recall.
K.Elicit history of fever, night sweats, weight loss, and enlarged lymph node(s).
L.Inquire about recent major life changes, such as moving or a change in job.
M.Establish usual weight, and review recent weight gain or loss, over what period.
N.Review any recent infections.
O.Review high-risk sexual practices and intravenous (IV) drug use to rule out HIV exposure.
P.Review recent history for transfusion of blood products to rule out hepatitis or HIV exposure.
Q.Obtain history of the patient’s daily living and working habits.
Physical Examination
A.Check temperature, pulse, respirations, blood pressure, and weight; check for postural hypotension.
B.Inspect:
1.Observe general overall appearance.
2.Skin: Conduct dermal exam for changes in pigmentation, purpura, dryness, rashes, jaundice, pallor, splinter hemorrhages, or petechiae.
3.Eyes: Conduct a funduscopic exam to rule out Roth’s spots and tuberculoma.
4.Check sclerae for icterus.
5.Throat: Inspect pharynx for petechiae at the junction of the hard and soft palate to rule out mononucleosis.
6.Extremities: Inspect joints for inflammation.
C.Palpate:
1.Palpate the neck to rule out goiter.
2.Palpate all lymph nodes (neck, axilla, and groin) for size, degree of tenderness, and distribution.
3.Complete clinical breast exam for masses.
4.Palpate the abdomen for organomegaly, masses, and ascites.
5.Palpate the joints for tenderness.
6.Assess the genitalia for masses and tenderness to rule out infection.
D.Percuss: Percuss the abdomen for organomegaly, masses, ascites, and hepatic tenderness.
E.Auscultate: Auscultate the heart and lungs.
F.Neurologic exam: Complete mental status assessment.
G.Rectal exam: Assess for masses, prostatic pathology, and occult blood.
Diagnostic Tests
A.Complete blood count (CBC) with differential and peripheral smear.
B.Erythrocyte sedimentation rate (ESR).
C.Calcium, phosphate, albumin, sodium, potassium, chloride, bicarbonate.
D.Fasting glucose.
E.Renal function: Blood urea nitrogen (BUN), creatinine, glomerular filtration rate (GFR).
F.Liver function: Bilirubin, alkaline phosphatase (ALP), gamma glutamyl transaminase (GGT), alanine transaminase (ALT), aspartate transaminase (AST).
G.Thyroid panel to rule out hyperthyroidism or hypothyroidism.
H.Iron studies: serum iron, iron-binding capacity, ferritin.
I.Vitamin B12, serum folate, and 25-hydroxycholecalciferol (vitamin D).
J.Sleep study.
K.Creatine kinase (CK).
L.Urinalysis.
M.Additional tests as clinically indicated: Rheumatoid factor, antinuclear antibodies (ANA), Epstein–Barr virus, HIV serum test, creatine phosphokinase (CPK) if muscle weakness.
Differential Diagnoses
A.ME/CFS:
1.The Centers for Disease Control and Prevention (CDC) and Institute of Medicine (IOM) include these three criteria for ME/CFS syndrome diagnosis:
a.Unexplained, persistent fatigue present for 6 months or more that is not due to ongoing exertion; is not substantially relieved by rest, is of new onset (not lifelong) and results in a significant reduction in previous levels of activity
; postexertional malaise; unrefreshing sleep.
b.Four or more of the following symptoms present for 6 months or more:
i.Cognitive impairment (impaired memory or concentration).
ii.Postexertional malaise (extreme, prolonged exhaustion and sickness following physical or mental activity).
iii.Unrefreshing sleep.
iv.Orthostatic intolerance (symptoms worsen when a person stands but improve when individual reclines).
v.Multijoint pain without swelling or redness.
vi.Headaches of a new type or severity.
vii.Sore throat that is frequent or recurring.
viii.Tender cervical or axillary lymph nodes.
ix.Myalgia and arthralgia.
B.Hypercalcemia.
C.Renal disease.
D.Early diabetes mellitus.
E.Hypothyroid or hyperthyroidism.
F.Cardiac disease.
G.Anemia.
H.Liver disease.
I.Connective tissue diseases.
J.Lyme disease.
K.Disturbed sleep or obstructive sleep apnea.
L.Occult neoplasm.
M.Infection: History of fever, sweats, weight loss, and diffuse adenopathy. These symptoms also suggest HIV, especially with high-risk behaviors (see section HIV
in this chapter).
N.Mononucleosis.
O.Psychiatric disorder.
P.Vitamin deficiency (vitamin D, B12).
Plan
A.General interventions:
1.Treatment goal—decrease symptoms and increase quality of life.
2.Determine patient’s view of his or her illness before proceeding with patient education.
3.Manage underlying disease (refer to specific chapters).
4.Treat the patient with nutritional or vitamin supplementation, as indicated.
5.Provide activity management guidance and dietary recommendations.
6.Strong patient–provider alliance is essential.
7.Evaluate the patient for the possibility of confusing focal neuromuscular disease with generalized lassitude.
8.Consider a sleep study to determine if obstructive sleep apnea is a contributor to fatigue.
B.Patient teaching:
1.Discuss and review the evidence for the diagnosis and offer a careful explanation of symptoms. Provide encouragement and review symptom management plan.
2.Review the diagnostic criteria for depression (see Chapter 25), and describe the neurochemical mechanisms by which depression relates to fatigue. Refer for individual counseling or group therapy.
3.Review the idiopathic nature of ME/CFS and its nonprogressive nature. The clinical course includes gradual improvement with the hope of full recovery (10% to 15% of adults fully recover). Illness severity varies from patient to patient. Over time, patients may improve to the point that the diagnosis is removed. Relapses are common.
4.Encourage mild exercise not to exceed patient’s energy level. Refer to physical therapy for exercise plan development.
5.Provide nutritional education.
6.Discuss and promote sleep hygiene.
C.Pharmaceutical therapy:
1.For postural hypotension:
a.Increase dietary sodium.
b.Antihypotensive agent: Fludrocortisone 0.1 mg daily.
2.Low-dose antidepressant therapy for disordered sleep:
a.Amitriptyline HCl 25 mg at bedtime.
b.Doxepin HCl 10 to 20 mg every bedtime.
c.Short-term hypnotic: Zolpidem (Ambien) 5 to 10 mg at bedtime (use cautiously with elderly).
3.Nonsteroidal anti-inflammatory drugs (NSAIDs) for symptomatic relief of myalgia, arthralgia, or headache.
4.Correct anemia with iron supplements, if applicable.
5.Cyclobenzaprine 5 to10 mg at bedtime as needed
D.Nonpharmacologic interventions:
1.Massage therapy for muscle aches and pains.
2.Tai Chi or yoga to improve balance.
3.Encourage relaxation interventions such as meditation or mindfulness.
4.Recommend memory book.
Follow-Up
A.Follow up in 2 weeks to reevaluate status and then monthly, depending on signs and symptoms.
B.Follow closely if the patient is depressed.
Consultation/Referral
A.Consult a physician if no improvement is seen with therapies. Emphasize the legitimacy of the patient’s symptoms and summarize the workup, its rationale, and its findings.
B.Refer the patient to a mental health professional as indicated by depression and/or suicidality.
C.Refer to occupational therapy and/or physical therapy
Individual Considerations
A.Adults: