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. ([email protected]) is Clinical Professor of Rheumatology, Allergy, and Clinical Immunology at UC Davis. This article is informational, and does not constitute medical advice.