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Chronic fatigue syndrome: Fact or fiction?

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From page B10 | April 14, 2012 |

Doctors and patients alike sometimes struggle to affix a meaningful diagnosis to nonspecific symptoms. When a patient develops a number of symptoms that seem to go together, we sometimes call this a syndrome.

Syndromes often are described when neither doctor nor patient really understands what is going on.

Perhaps a quintessential example of such a situation is what we encounter in the so-called chronic fatigue syndrome.

Let us consider how best to struggle with symptoms of fatigue.

As an internist, I prefer to always consider the possibility that what a patient calls “fatigue” may be something else altogether.

One fatigue mimicker is actual muscular weakness. This can occur in a variety of conditions including muscular dystrophy, muscle inflammation conditions, deconditioning following hospitalization or stroke, depression, nutritional deficiencies or glandular disorders.

I typically test muscle strength by examination procedures (such as squeezing a device called a Jamar Dynonometer). If the muscles are really weak, various tests can sort out a specific diagnosis.

In addition to blood work, studies of neurological function of muscles or even muscle biopsies may on occasion prove necessary.

If a patient is strong physically, but describes a pervasive lack of energy, we may need to consider fatigue as a distinct entity and there is yet another “laundry list” of possible explanations.

For example, does the patient have iron-deficiency anemia? So-called “iron-poor blood,” as it was once referred to in vitamin advertisements, can result from conditions ranging from menstruation to colon cancer, and an appropriate evaluation is necessary before simply prescribing an iron supplement.

Does the patient have an under-active thyroid gland, and if so what is the cause?

Is the patient clinically depressed, or suffering from a sleep disorder, or side effects of prescribed medications?

All of these conditions can be specifically diagnosed and treated.

For example, thyroid hormone can be supplemented with pills, sleep disorders can be treated and medication side effects can be addressed by prescribing better-tolerated alternative medications.

Sometimes fatigue responds to an exercise program and lifestyle changes, if no specific cause emerges.

In general, I like to tailor the treatment to the specific diagnosis, however.

In some cases, no cause of fatigue is specifically identifiable. In recent decades, these patients on occasion have been diagnosed with “chronic fatigue syndrome.” Patient support groups have emerged to advocate for sufferers of this malady and a variety of practitioners purport to treat chronic fatigue syndrome.

The underlying cause is felt to be unknown, but chronic fatigue syndrome criteria for diagnosis often are described as including fatigue, swollen lymph nodes and blood tests revealing antibodies to common viruses. A specific offending virus that is often cited as causative is Epstein-Barr virus.

Treatments undertaken for chronic fatigue syndrome include pain killers, antidepressants, psychotherapy, and nutritional support, but symptoms tend to be chronic.

The axiom Primum Non Nocere, or “first do no harm,” should guide physician and patient toward relatively benign therapies, if at all possible.

The Epstein-Barr that is purported to cause chronic fatigue syndrome is also widely described in nonfatigued hosts. Moreover, I rarely find objective physical examination findings in chronic fatigue syndrome patients to suggest an ongoing infection of any sort.

We also know that the history of medicine is replete with diagnoses that were once popular and now are discredited. Neurasthenia, for example, was a 19th century condition that bore similarity to chronic fatigue syndrome, albeit in a different historical and cultural context.

I recognize, however, that medical research is always advancing and forcing us to reconsider our entrenched opinions.

Perhaps further research on viruses and physiology will shed light on the chronic fatigue syndrome. In medicine, the only thing that stays the same is change.

Scott Anderson, M.D., Ph.D. (stamdphd@comcast.net) is Clinical Professor of Rheumatology, Allergy, and Clinical Immunology at UC Davis. This article is informational, and does not constitute medical advice.

Scott Anderson

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Discussion | 5 comments

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  • Huh?April 14, 2012 - 1:30 pm

    An article, by a medical professional, that suggests that Chronic Fatigue Syndrome might be fiction...and doesn't even mention Myalgic Encephalomyelitis. That in itself is indefensible--that is, if one has an interest in knowing the subject they're writing about--but unfortunately not even all that uncommon. An article that mentions Neurasthenia, and not ME...that takes some doing. I don't suppose it would hurt to take a look at this. http://www.virology.ws/2011/11/23/chronic-fatigue-syndrome-and-the-cdc-a-long-tangled-tale/

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  • KALApril 14, 2012 - 3:23 pm

    Dr. Anderson writes a thoughtful article. However he fails to mention that the "fatigue" in myalgic encephalomyelitis (ME), sometimes called chronic fatigue syndrome, is a rather rare and specific form. According to the latest clinical diagnostic definition published in 2011 (Carruthers B et al) post exertional malaise lasting 24-hours or more, unrelieved by rest and upon minimal exertion such as doing the dishes is considered mandatory as is part of a specific pattern of symptoms and signs. Researchers at the University of the Pacific, Stanford University, the University of Utah, Harvard University, Mt Sinai and others are all adding to the nearly 5,000 biomedical research papers on ME and CFS demonstrating the pathological changes in the different physiological systems in such patients. Harvard professor and ME and CFS researcher, Dr. Anthony Komaroff states that these include changes in the autonomic nervous system, the immune system, energy metabolism and mitochondria, as well as the active process of “gene expression” in the illness and, as Dr Anderson notes, links to an infectious process. Because multiple definitions selecting very different cohorts are used the literature is very mixed. Researching apples and calling them peaches doesn't work from a scientific standpoint. Currently, Dr. Ian Lipkin direction of the Columbia University Center for Infection and Immunity is coordinating a large study of 200 very narrowly defined patients using cutting edge deep sequencing methods to look for pathogens as well as biomarkers in such patients.

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  • Barba BrightApril 17, 2012 - 2:30 pm

    At least the comments are worth reading.

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  • Phoebe SnowdenApril 17, 2012 - 2:57 pm

    While I do appreciate much of Dr. Anderson's article, I believe that he is misinformed about true CFS, also called myalgic encephalomyelitis. I hope that he will investigate Dr. Jose Montoya's work at Stanford (Stanford Chronic Fatigue Initiative) so that he gets a better idea of what constitutes a CFS patient. CFS is now often used as a "garbage can diagnosis" by physicians who don't know any better, and the CDC has not helped the situation with their increasingly vague & inaccurate definitions. True CFS patients have chronic, quantifiable infections, including EBV, CMV, HHV-6, Parvovirus, Coxsackie B, and mycoplasma & chlamydia pneumoniae along with other very specific biomarkers. Until the CDC definitions are changed (or myalgic encephalomyelitis is once again recognized as a disease in the US) and physicians are better educated, people will continue to be incorrectly diagnosed with CFS and true CFS patients will continue to pay the price for medical ignorance.

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  • MystyApril 18, 2012 - 4:42 am

    Acquired immune deficiency syndrome or acquired immunodeficiency syndrome (AIDS) is a disease of the human immune system caused by the human immunodeficiency virus (HIV). Sjögren's syndrome, also known as "Mikulicz disease" and "Sicca syndrome", is a systemic autoimmune disease in which immune cells attack and destroy the exocrine glands that produce tears and saliva. Down syndrome or Down's syndrome, also known as trisomy 21, is a chromosomal condition caused by the presence of all or part of an extra 21st chromosom CFS is a collection of people. ME is a World organisation recongised neurolgical disease that has been recorded as such since 1969. Many people have died from ME. About 3 cases have already been reported by the press this year. Chronic fatigue syndrome is a fiction without any science applied. ME is a fact with a wealth of scientific evience behind it including brains scans. When GPs can be bother to read the literature may be they will be qualified to write articles.

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