Chronic Fatigue Syndrome: Diagnosis And Treatment
JOSEPH R. YANCEY, MD, Fort Belvoir Community Hospital, Fort Belvoir, Virginia
SARAH M. THOMAS, MD, Fairchild Air Force Base, Washington
Am Fam Physician. 2012 Oct 15 86:741-746.
Patient information: See related handout on chronic fatigue syndrome, written by the authors of this article.
Chronic fatigue syndrome is a widespread problem. It is estimated that more than 2 million Americans have CFS, many of whom have not been diagnosed.1 Women are twice as likely as men to have CFS,1 and it is more common in persons older than 40 years.1,2 There is not an established racial or educational predilection.1,2 CFS is often mentally and emotionally debilitating, and persons with this diagnosis are twice as likely to be unemployed as persons with fatigue who do not meet formal criteria for CFS.3 In 2002, the estimated annual cost of lost productivity was $9.1 billion dollars in the United States.4 In addition to economic hardships, persons with CFS are more likely to report subjective functional impairment than those with chronic fatigue.3
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Persons with chronic fatigue should have an evaluation, including history, physical examination, and initial laboratory testing .
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Persons with chronic fatigue should have an evaluation, including history, physical examination, and initial laboratory testing .
Can Chronic Lyme Disease Complex Or Infectious Disease Effect Hpa
In the etiology of chronic infectious disease, the traumatic event is a trigger but not the cause of autoimmune disease, Chronic Fatigue Syndrome or fibromyalgia. Nevertheless, treating these triggers is critically important to patient care. It seems that infection, rather than genetic defects, is the progenitor of HPA axis disruption, psychiatric or emotional conditions.
Fibromyalgia Lupus Or Lyme
There exists a disease that is extremely common that people dont realize they have it. It is the most incorrectly diagnosed malady and is not adequately treated because the medications that are prescribed treat only the symptoms without addressing the root cause of your not feeling well.
Highly contagious, this disease can be communicated by close contact among individuals or effectively transmitted by an insect bite. Once infected, the patient may demonstrate symptoms that could represent any one of over 300 different diseases while experiencing any one or more of as many symptoms.
Most families are already living with this aggressive bacterium in their home and it is common for house pets to be carriers of the disease.
The vast array of symptoms covers a wide spectrum and some of them could have you or your doctor questioning ones sanity. In fact, in many cases, a well-meaning physician might suggest that your symptoms are psychosomatic .
My wife and I were diagnoses with everything from lupus to fibromyalgia and multiple sclerosis to celiac disease while stumping the most sophisticated symptom checker.
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What About Your Diagnosis With Ra
Here is what research says: studies show cross-reactivity between EBV and human self-proteins , presence of the EBV genome in synovial membrane, and a cell-mediated response to the EBV within the joint The cross-reactivity EBV encoded proteins share antigenic and sequence similarity to proteins found in the synovial tissues. Moreover, lymphocytes from patients with RA have decreased ability to limit outgrowth of autologous EBV infected lymphocytes. Basically, EBV is the reason why your immune system is confused attacking the wrong cells.
Common Questions To Expect
Your doctor will ask you a series of questions to understand what may be causing your fatigue. These questions may be followed up with blood work or other tests to rule in or rule out related conditions called comorbidities. Common questions include:1
- How well do you sleep?
- How many hours can you work before you hit the wall?
- What do you try to do every day?
- How often do you feel exhausted? How long does it last?
- Is there something you want to do but cant because of how tired you feel?
- Have you had to give up activities you enjoy because youre too tired?
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Treat Underlying Conditions That May Cause Fatigue
âFatigue with lupus is sometimes caused by an underlying medical problem, such as anemia, fibromyalgia, depression, or a kidney or thyroid problem. And in some cases, it can be a side effect of medication,â says Meenakshi Jolly, MD, MS, director of the Rush Lupus Clinic and assistant professor of medicine and behavioral medicine at Rush University. âIn these cases, we can often treat the fatigue by treating the condition or changing the patientâs medication.â
Ask your doctor to check if your fatigue may be related to another condition or a medication. If it is, find out about treatment.
Genetic Predisposition And Premorbid Phenotype
There is evidence for a strong genetic component in some autoimmune diseases, such as complement component deficiencies in SLE which may lead to reduced self-antigen elimination. Likewise, in ME/CFS, autoimmune diseases, for example, thyroid disease , SS , and SLE , often occur among relatives and sometimes among the patients themselves.
Presence of an HLA association is a hallmark of many autoimmune diseases. It indicates an aberrant immune presentation to either cytotoxic T cells or T helper cells which predisposes for autoimmunity. One study found an overrepresentation of HLA Class II DQA1*01, with an odds ratio of 1.93 .
Specific cytokine gene polymorphisms were observed an increase of one, for TNF, and a decrease of one, for IFN, were found in CFS .
Recent genome-wide association studies showed an increased frequency in ME/CFS of single-nucleotide polymorphisms , some isolated, some concentrated to three gene regions: microtubule associated protein 7, CCDC7 and a T-cell receptor alpha chain gene . The latter may confine an increased tendency to autoimmunity. The comorbidity with autoimmune disease or disease having an increased prevalence of autoantibodies, e.g., FM , IBS , POTS , and hypothyroidism , also indicate a tendency for autoimmunity in ME/CFS patients . SS and SLE often occur among relatives and sometimes among the patients themselves.
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Factors Associated With Fatigue
- SLE patients aerobic capacity is often decreased compared to healthy controls and studies have shown improved health outcomes including decreased fatigue from increasing physical activity.
- Obesity is prevalent in the SLE population, with a BMI above 30 kg/m2 associated with worse depression and fatigue.
- A bidirectional relationship exists between fatigue and poor sleep, with SLE cohorts usually experiencing more sleepwake disturbances and unrestorative sleep.
- Depression has been consistently associated with fatigue and anxiety and mood disorders have been correlated with fatigue in SLE patients compared to healthy controls.
- Suboptimal levels of vitamin D have been reported in the SLE population, with vitamin D deficiency correlating with worse fatigue.
- There is a positive correlation between pain intensity and fatigue in the SLE population.
- No significant associations were found between corticosteroids or NSAID use and fatigue severity.
- Coexisting fibromyalgia, thyroid disease and anemia may also affect fatigue in SLE.
- Conflicting theories exist, with one side showing positive correlation between SLE disease activity and fatigue, and the other arguing for weak or no association.
Autoreactive B Cell Clones And Autoantibodies In Me/cfs
Several autoantibodies have been found in ME/CFS , and some of its comorbidities . This is circumstantial evidence for ME/CFS being an autoimmune condition. Especially interesting are the results where an increased frequency of antibodies to certain hormone receptors was found . Several ME/CFS symptoms may be explainable by receptor interference from such autoantibodies.
Table 4. Occurrence of autoantibodies in ME/CFS and some of its comorbidities.a
In autoimmune conditions with pathological autoantibodies, erroneously activated and mutated B cells are the root of the evil . These should be studied in detail . One can envisage large scale sequencing of immunoglobulin gene variable domains of such clones to define aberrant specificities, with autoreactivity. A characteristic variation in B cell subsets has been described in ME/CFS.
This should be studied systematically. At which time point did these diseases manifest themselves, before or after the ME/CFS started? How large is the frequency of autoantibodies in patients with these conditions, preferably measured simultaneously in an antigen matrix? Maybe there are autoimmunity biomarkers which could be used for ME/CFS diagnosis?
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Me/cfs: What Do We Know
Researchers have long believed that ME/CFS could involve chronic inflammation. Studies reveal several biomarkers of inflammation and a sustained immune response in the blood of ME/CFS patients. Some researchers now consider ME/CFS to be a neuroimmune or neuroendocrineimmune disease.
However, we’re still learning about the specific role of inflammation in the condition. Recent research paints a growing picture of autoimmunity as well. And when autoimmunity is involved, the major question is: what is its target?
What Are Fibromyalgia Chronic Fatigue Syndrome And Lupus
By | Submitted On December 30, 2011
There are millions of people in America, most of them women, who are suffering with fibromyalgia, chronic fatigue syndrome, and/or lupus. All three of these syndromes are classified as autoimmune diseases. That means that the immune system has turned against a specific part or parts of the body and is attacking and destroying those tissues and organs. For years, doctors have been trying to get answers regarding these illnesses, their causes, treatment options, and symptom-attacks called episodes or flares. Here’s why…
Fibromyalgia Syndrome– A chronic condition causing: intense widespread pain, painful points on specific parts of the body, extreme fatigue that doesn’t go away with sleep or rest, muscle stiffness and weakness, cognitive and memory problems, mental fog, insomnia and other sleep disturbances, gastrointestinal issues including irritable bowel syndrome, depression and anxiety, mood swings, hypersensitivity to heat/cold/ noises/ odors/foods/medications, unexplained vision changes and blind spots, dry eyes, vertigo and dizziness, endometriosis, migraines and headaches…and dozens of other symptoms.
Symptoms of lupus may manifest suddenly or develop slowly over time. They may be mild or severe, temporary or permanent. No two cases of lupus are alike. Most people with lupus have a mild form of the disease until severe episodes erupt. Then, symptoms get worse for a time… then may improve… or even disappear indefinitely!
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Common Symptoms Of Chronic Fatigue
If you suffer from a chronic illness, then its highly likely that youll experience fatigue from time to time. Fatigue is different than just feeling tired, and generally its not something that can be fixed with an early night or by resting for a little while.
With tips from the pros at prevention.com, weve put together a list of six ways that chronic fatigue can affect sufferers on a daily basis.
You feel extremely exhausted.
Everyone experiences feeling tired and worn out from time to time but chronic fatigue takes this a step further. People will often avoid doing things they enjoy because they dont have the energy to go out or even get off the sofa. Getting through a day at work or school will leave them feeling extremely exhausted as though they have gone through their energy reserves and have nothing left.
You cant get a good nights sleep.
You would imagine that fatigue could be solved with sleep, but patients who suffer from chronic fatigue often have trouble falling asleep or wake constantly throughout the night. This lack of sleep only adds to the problem and makes the fatigue worse. Even if you do get to sleep, many find that they dont feel any better when they wake up.
You cant concentrate.
Simple tasks zap your emotional energy.
You cant balance.
Youre constantly in pain.
Infection Could Trigger Lasting Immune Response
The Columbia team says their research supports the hypothesis that CFS may be triggered in a hit-and-run fashion following a common infection, such as infectious mononucleosis.
The cross-sectional study, published in the journal Science Advances, involved analyzing the blood plasma samples of 298 CFS patients and 348 people without the disease.
The researchers found distinct biomarkers created by the immune system in those with the disease. They also found differences in those who have had the disease for less than three years and those who have had it more than three years.
Those who had the disease for a shorter extent of time had higher amounts of different types of cytokines, or molecules that regulate your bodys defensive response to inflammation and infection.
Specifically, the Columbia team reports, early-stage CFS patients have elevated levels of interleukin-17A, a known biomarker of a faulty immune system.
The researchers added the elevated biomarker levels seem to subside after three years because the immune system has become exhausted after failing to calm itself after an infection. They compared it to an engine running at high gear for an extended period of time.
Our results should accelerate the process of establishing the diagnosis after individuals first fall ill as well as discovery of new treatment strategies focusing on these early blood markers, Hornig, lead author of the study, said.
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What Are The Signs & Symptoms Of Chronic Fatigue Syndrome
There’s a long list of possible symptoms that someone with fatigue syndrome can have. The most common ones include:
- severe fatigue, which can make it hard to get out of bed and do normal daily activities
- sleep problems, such as trouble falling or staying asleep, or not having a refreshing sleep
- symptoms getting worse after physical or mental effort
- symptoms or dizziness that get worse after standing up or sitting upright from a lying down position
- problems with concentration and memory
- headaches and stomachaches
Get Enough Rest To Prevent Fatigue
Most people do best with at least seven to eight hours of sleep each night. If you have lupus you may need even more sleep.
âItâs important to develop good sleeping habits,â says Jolly. âIt can really make the difference in getting a good nightâs sleep.â
- Take time to relax before bedtime. A warm shower or bath can help.
- Avoid alcohol and food or drinks that contain caffeine after dinnertime.
- Donât watch TV right before bedtime because it can be distracting. Read a book instead.
If there are times when you know you wonât get a full nightâs sleep, you may need to plan to make it up the next day.
âI canât go out on a work night like other people my age. If I donât get at least eight hours of sleep, Iâm useless the next day,â says Brown. âSo if thereâs something I want to do in the evening, I have to plan for it by setting aside time to sleep the next day.â
Even with a full nightâs sleep you may need to take several rest periods throughout your day. âSome people may need to plan short periods of rest after each activity,â says Jolly. âThis gives your body time to catch up and can make a big difference in how you feel.â
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How Do You Define Lupus Fatigue
Fatigue is an integral part of living with . When Dr. Berman asked the group to define fatigue, a member said, “No matter how much I rest, I still feel tired. Even if I had a wonderful night’s sleep.”
“That is the perfect description of what fatigue means for those living with lupus,” Dr. Berman told the group. While healthy people will come home from work after a hard day and feel fatigued, she explained, after they sleep and rest, they are refreshed. That isn’t the case for people living with lupus. For people who don’t live with lupus every day, “The best way for them to understand what fatigue and lupus is like to tell them it’s like having the flu.” Dr. Berman added. “Nothing you can do seems to make the fatigue any better. Also, over time the more and more you experience fatigue, the more chronic it becomes.”
Dr. Berman defined fatigue as “an overwhelming, sustained sense of exhaustion and decreased capacity for mental and physical work.” This is in contrast to chronic fatigue, which is defined as “unpleasant, unusual, abnormal or excessive whole-body tiredness, disproportionate to or unrelated to activity or exertion and present for one month.” As a person living with lupus, you may experience fatigue from a slight exertion, such as showering or making breakfast. Fatigue might make it difficult to even perform these tasks. That is what distinguishes the fatigue someone living with lupus experiences from that of other people.
Major Impact Of Epigenetic Changes Gene Involvement
Studies show that gene alterations are caused by infections involving immune function, intercellular communication, and energy transfer.
Researchers have identified many different genes in patients with Chronic Fatigue Syndrome that relate to blood disease, immune system function, and infection. Despite these identifications, however, there is no clear pattern to them and it is quite possible that infection alone that is altering these genes. In the same vein, they are likely responsible for impacting mental and emotional health as well. It is very possible that infections can alter these genes that impact both mental and emotional health as well.
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Many Different Infections Have Been Observed At The Outset Of Me/cfs Like Disease
There is abundant evidence for infection as a trigger of chronic fatigue in a more general sense . But negative evidence also exists . Some of this evidence is inconclusive . Whether all these instances of postinfectious fatigability have identical properties should be systematically investigated. These infections can be traced in the patient history, by direct detection of the microbe , or by detection of antibodies to the microbe , see, however, Ref. .
Table 2. Long-standing fatigue, or fatigability, after an infection.
How often does it happen that spouses are afflicted? This would advocate a transmissible factor rather than inheritance.
Summarizing, EBV is especially interesting as a facilitator of autoreactivity. Some autoantibodies may have an origin in a mimicry between EBV antigen and self-antigens. EBV is a ubiquitous virus. EBV can stimulate thousands of B cells to produce thousands of different antibodies, each with its own unique antigen-binding site. It often occurs as an eliciting factor triggering ME/CFS, in this case referred to as postviral fatigue. As mentioned, it stimulates growth of a wide variety of B cells, and it has viral proteins that can give rise to autoantibodies .
Transmissibility is a microbial property. Most ME/CFS cases are sporadic . However, there are a few recorded outbreaks, where healthy ME/CFS patient contacts developed symptoms of the disease , forming ME/CFS outbreaks in ME/CFS, indicating a transmissible agent.
