Fatigue
In The College Student
To test, or not to test?
Bruce Helming, MD, FAAFP
University of Arizona
Campus Health Service
bhelming@email.arizona.edu
Conflict of interest
statement:
I have NO actual or potential
conflict of interest in relation
to this educational activity or
presentation.
Objectives
Describe clinical fatigue
Identify warning signs for
serious illness
Identify risk factors for iron
deficiency
Identify common infectious
causes of fatigue
Describe screening,
diagnostic and general
treatment options for
depression
Fatigue Facts
6 - 7 % prevalence
$136 billion in lost
productivity
7 million office visits
In primary care:
21 to 33 % report
“Significant fatigue”
1/3 of adolescents report it
Definition – Clinical Fatigue
Inability to initiate activity
perception of generalized weakness, in the
absence of objective findings
Reduced capacity to maintain activity
easy fatiguability with exertion
Difficulty with concentration, memory, and
emotional stability
mental fatigue
Case 1
25 year old male graduate student with about 4
weeks of fatigue with exercise, mild shortness of
breath and cough
Case 2
22 year old female student with about 2 months of
fatigue with exercise, and non-specific leg pain
Case 3
24 year old male graduate student with about 8
weeks of generalized fatigue, worse with
exercise, as well as some motivation and
concentration problems that he attributes to grad
school
Case 4
19 year old female student-athlete with about 2
weeks of fatigue with exercise, diminished
performance in her sport
Case 5
22 year old male student-athlete with about 8
weeks of fatigue with exercise, mild shortness of
breath with exercise, some generalized daytime
fatigue
Fatigue in Athletes
Real or perceived:
Decrease in performance (exercise capacity)
Plateau in performance
Lack of improvement with training
Intolerance to increased training intensity
“Run down” without specific complaint
Patient-driven or from peers, coaches, family
Basic Assumptions
Healthy population
New onset
Reliable historians
No secondary gain
Red Flags
Fever/Chills
Night sweats
Weight loss
Bleeding disorders
Trouble with daily activities
Amenorrhea
Stress fracture
Low BMI
Trouble
Diabetes
Leukemia / cancer
Heart disease
Congenital
Myocarditis
Hypercalcemia
Acute infection
HIV, Hepatitis
Pulmonary embolism
Concussion
Remember to ask about recent head injury
“Follow up accident (MVA)” visits
Many patients are not educated about concussion
Leave ER with lots of normal xrays
Lingering effects on mood, energy, sleep and
concentration are common
CDC Concussion information is excellent:
http://www.cdc.gov/concussion/HeadsUp/physicians_tool_kit.html
Functional
Neuropsych
Grief
Concussion
Exercise
Allergies
Asthma
Depression
Stress
Pregnancy
Sleep
Adjustment Disorder
Celiac
Nutrition
Substance abuse
Domestic violence
Vitamin D
Fatigue
Iron
HIV
Mono
Diabetes
Thyroid
Cocci
Anemia
Metabolic
Chronic Infection
Infectious
History
Onset - abrupt or gradual,
related to event or illness
Course - stable, improving or
worsening
Duration and daily pattern
Factors that alleviate or
exacerbate symptoms
Impact on daily life - ability to
work, socialize, participate in
family activities
Accommodations patient has
made to adjust
History, part deux
Depression/anxiety
Current life stress,
relationships, school, work
Past trauma or abuse
Change in activity or diet
Medications, substance use
History of anemia, iron
deficiency, mood or eating
disorders
Menstrual patterns
Family history
More History...
Sleep habits, quality
Nutrition: meal schedule/size,
restrictions, caloric intake
Digestive: diarrhea, bloating,
discomfort
Exercise: frequency, intensity,
duration, effect on symptoms
Social history: interest in
school, social
activities/support system,
hours in work/school
Physical Exam
General
Alertness, appearance, mood/affect
Neck
Lymphadenopathy, goiter, thyroid
nodules
Chest
Murmurs, crackles, wheezing
Neurologic
Tone, bulk, reflexes
Extremities
Edema
Lab Workup
Unknown etiology
CBC with differential
Chemistry profile
TSH, with reflex freeT4
Ferritin, ESR
Consider
Urinalysis
EBV/Mono, Cocci
Pregnancy, Vitamin D
Creatine Kinase, HIV
PPD/IGRA (Interferon gamma release assay for tuberculosis)
US Olympic Blood Workup
RBC, Hgb, Hct, WBC,
Differential
Chemistry, Creatine Kinase
(CK), LDH
Ferritin, Iron, TIBC, Transferrin
Saturation
Cortisol
Lipids, Urine specific gravity
Clinical Indicators for Lab Tests
Hemoglobin/Ferritin
Pallor, tachycardia, dyspnea, symptoms of anemia
Dietary, personal or family history of anemia risk:
Heavy exercise, meat restriction/vegetarian
White blood cell count
Fever, evidence of infection
Weight loss, lymphadenopathy
Erythrocyte sedimentation rate (ESR)
Arthralgia, arthritis, concern for malignancy
Clinical Indicators for Lab Test
Electrolytes
Medications: Diuretics, steroids
Renal function
Elevated blood pressure, edema, pruritis
Medication affecting renal function
Glucose
Polydipsia, polyuria, polyphagia, family history
Thyroid Stimulating Hormone (TSH)
Dry hair/skin, change in bowel habits, menses
Lab Utility
Primary care
5% hit rate
Higher in students?
Useful in students
Positive
Iron, anemia, mono,
thyroid
Negative
Depression, stress,
sleep, nutrition,
overtraining
Psychiatric
Depression / Anxiety
Adjustment disorder,
somatization
Stress, expectations
Family/relationship
Domestic violence
Disordered eating
Anorexia, Bulimia
Substance abuse
Grief
Feeling bad on Facebook
• 200 Facebook profiles were evaluated
• 25% displayed depressive symptoms
–2.5% met criteria for Major Depressive Episode
• References to depression were more common
when a response to prior disclosure occurred
•
Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on
a social networking site, Depression and Anxiety, 2011, 0:1-9
Depression
Seen in 2-10 % of
college population
Overlap with
Adjustment disorder
Grief
Stress & Anxiety
Sleep disturbances
Responsive to:
Counseling
Medication
Self-management
Depression
loss of interest in pleasure
loss of motivation
loss of sense of control
functional impairment may not
relate with severity of depression
denial is frequent
Ask about mood,
stressors, and suicide
Depression Screening & Treatment
We’re implementing screening with PHQ-2,
followed by PHQ-9
Sharing of notes and care manager between
counseling and medical sides
Screening is a gateway to conversation about
mood, sleep, suicidal thoughts
Objective measure of mood for tracking
Tools for providers to assess, diagnose, treat and
track are available in EMR (medical record)
Infectious
Acute, subacute, chronic
Mono, CMV, HIV
Cocci (Valley Fever)
cough, fevers, rash
erythema nodosum
College lifestyle can cause:
Inadequate recovery
Impaired healing
Weakened immunity
50 Fatigued Aussie Athletes
} 50%
Mononucleosis
Epstein-Barr Virus
Upper respiratory infection
followed by fatigue/malaise
Posterior cervical nodes
Splenic rupture
Risk estimates ~ 1:500
Spontaneous, Valsalva or
traumatic
Rest from sports, strenuous
activity for 4 weeks
Mononucleosis
4-6 week incubation
no quarantine
EBV serology to confirm
simultaneous Strep common
rupture most likely in 3 weeks
as late as 7 weeks
if feeling well, light exercise at 3
weeks, progress slowly
rare prolonged fatigue syndrome
typical recovery by 6-8 weeks
Natural History of Mono
• 150 patients aged 16 and up, followed for 6 months
Symptom
Initial %
1 Mo
2 Mo
6 Mo
Sore Throat
74
16
11
11
Fatigue
77
28
21
13
Sleeping too much
45
18
14
9
Headache
50
15
15
16
Sore muscles
28
14
11
11
Rea, TD, Prospective study of the natural history of infectious
mononucleosis caused by Epstein-Barr Virus, JABFP, 2001; 14(4):
234-42. 150 patients aged 16 and up, followed for 6 months
Coccidioidomycosis (Valley Fever)
• AKA: Valley Fever, Cocci, Desert Rheumatism, San Joaquin
Valley Fever
• AZ, CA, NV, UT, NM, TX, Mexico, Guatemala, Honduras,
Equador, Paraguay, Argentina
• Caused by inhaling spore found in soil: fungal infection
• Severity: mild (60%), moderate (30%), severe (10%)
• NOT contagious, incubation period of 7-21 days
• Majority have mild symptoms, and do not seek care
Cocci
Valley Fever Center for Excellence
www.vfce.arizona.edu
520-626-6517
web search: "CDC Valley Fever"
Cocci
• Symptoms: Fatigue, night sweats, cough, chest pain, dyspnea,
hemoptysis, headache, arthralgias (diffuse/migratory)
• Signs: Fever, weight loss, erythema nodosum/multiforme,
eosinophilia, elevated ESR
• Xray: infiltrates (unilateral), hilar adenopathy, effusions
• 30% of Community Acquired Pneumonia cases in Tucson
–80% had at least one course of antibiotics
• 31% received multiple courses
• Averaged 5 months and 3 clinic visits to reach correct diagnosis
(in adult population)
Cocci
• Serologies
•
Positive: suggestive, especially in light of clinical history
•
Negative: NEVER excludes the diagnosis
• Risk factors: Immunosupression, Diabetes, Pregnancy
• Treatment: reserved for serious infections, antifungals,
fluconazole, itraconazole
• Complications: Bone infection, cavitary lung lesions, systemic
• Prognosis: Good, but very slow (weeks to months)
Endocrine/Hematologic
Iron deficiency
Anemia
Hypothyroid
Diabetes
Polydipsia, Polyphagia
Polyuria, Weight loss
Vitamin D deficiency
Iron deficiency
History
Meat restriction
Insidious
Females
Increased activity
Screening
CBC, Ferritin, iron studies
Treatment
Oral iron, nutrition
Iron deficiency
ferritin < 35 ng/ml
precedes anemia
declining MCV
absorbed in proximal small bowel
give with vitamin C or OJ
plan 3-4 months of iron
recheck at 4-6 weeks
female vegans have 40% risk
Decline in iron during boot camp
• Basic Combat Training, female recruits
–7% at start were iron deficient
–18% at end
–iron status correlated with running performance
• 1 to 1.5 hours of exercise
–4-6 days/week, for 9 weeks
–16,000 steps/day vs 8,000 for civilians
• ~1 lb weight gain over 9 weeks
•
McClung, JP, Longitudinal decrements in iron status during military training in female
soldiers. Br J Nutr, 2009; 102: 605-9
Added iron in female soldiers
• 219 female Army soldiers
•8 week basic combat training
•20% had iron deficiency anemia
• 100 mg of ferrous sulfate daily vs placebo
–Iron improved Vigor scores
–on Profile of Mood States (POMS)
–Limited iron loss associated with BCT
•Did NOT eliminate it at this dose
–Improved running performance only if anemic
•
McClung, JP, Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers
during military training: effects on iron status, physical performance, and mood. Am J Clin Nutr 2009;90:12431
Iron status in young athletes
• Elite athletes from 11-25 years old
• Most females failed to meet iron RDA
•63% vs 19% for males
• Low ferritin <35 more common
•57% vs 31% for males
• Low levels associated with:
•
diet in females
•
higher expenditures in males
–Koehler, K, Iron status in elite young athletes: gender-dependent
influences of diet and exercise, Eur J Appl Physiology, 2011, DOI
10.1007/s00421-011-2002-4
Iron and the body
Iron deficiency affects:
physical endurance
immune response
temperature regulation
energy metabolism
cognitive performance
behavior disturbances
Murray-Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J
Clin Nutr, 2007; 85:778-87
Iron Supplementation Improves:
Performance (ferritin below 20)
Increased speed on 15 km bike ergometer
Increased VO2Max, and oxygen consumption
“Maximal voluntary contraction strength” in knee
extension (response to training effect)
Labs: Increase in ferritin, may see Hgb rise
Subjective (ferritin below 35)
Decreased sensation of “Fatigue”
in adult females (non-athletes)
Iron and cognition
Blinded, placebo controlled study comparing:
Normal vs Iron deficient (ID) vs Iron deficiency anemia (IDA)
(Hb >= 10.5 and < 12)
IDA < ID < Normal on baseline cognitive testing
Increased Ferritin responders
Attention and Learning scores increased significantly
Memory score increased as well (p<0.07)
Increased Hemoglobin responders
Attention and memory scores increased
Learning task speed improved
Murray-Kolb, LE, Iron treatment normalizes cognitive functioning in young women, Am J
Clin Nutr, 2007; 85:778-87
Types of iron supplements
Ferrous sulfate
Ferrous gluconate
Iron/Vit C - FerroGels Forte
ascorbic acid, folic acid,
cyanocobalamin, and ferrous
fumarate
Iron/Colace - Ferro-Sequel
Ferrous fumarate, sodium
docusate
Vegetarian/Kosher
Solgar Gentle Iron
Anemia
History
Prior diagnosis
Unable to donate blood
Trial with iron
Check response
dilutional or sports
anemia
Thalassemia trait anemia will not
respond to iron
supplements
Anemia
• fatigue with activity
• pica - compulsive ingestion of
nonnutratives
• pagophagia - ice chewing
• anemia can be relative
• additional workup when
appropriate
•
Eichner, ER. Iron Deficiency Anemia, Cur
Sp Med Rep, 2010; 9(3): 122-3
Hypothyroid
15% of women
3-4% of men
weight gain, fatigue, cold
intolerance, constipation,
weakness
thyroid stimulating hormone
(TSH), usually reflex fT4
levothyroxine replacement
Target TSH?
Vitamin D - Basics
Both a hormone and vitamin
Calcium absorption, utilization and release
Affects parathyroid levels
Receptors for gene signaling
Diet sources and direct conversion in skin with
light (UV) exposure
Symptoms: Nonspecific musculoskeletal
complaints, fatigue, weakness, fractures/rickets
Risk factors: Malabsorption, low dietary intake,
limited sun exposure, darker skin coloration
Vitamin D - Diagnosis
Measure:
25 hydroxy-vitamin D 25-OH-D
Deficiency (insufficiency) is common (ages > 11):
> 30% deficient (less than 20 ng/ml 25-OH-D)
> 70% insufficient (less than 32 ng/ml 25 OH-D)
Target levels are controversial
30-50 ng/ml
Sun absorption/exposure varies greatly
Treat for 2-3 months, discuss ongoing dose
Vitamin D
RDA 600 iu/day D3
Max routine daily intake 4000 iu/day D3
Daily 800-4000 iu D3 (cholecalciferol)
Weekly 50,000 iu D3
or D2 (ergocalciferol)
Ensure 1000 mg of calcium/day
Other research findings:
500,000 iu once a year D3 was NOT
effective
toxicity at 60,000 iu D3 DAILY
1500/day=10,500/week=45000/month
Vitamin D
Some evidence for mood benefits
IOM summary: Good bone health evidence
Cardiopulmonary
Myocarditis
Recent infection with
new chest pain and
fatigue
Asthma
Diminished exercise
capacity
Allergic
Exercise-induced
Functional
Nutrition
Disordered eating
Inadequate caloric
intake
Inadequate recovery
Sleep, sleep, sleep
Pregnancy
Female athlete triad
disordered eating
amenorrhea/oligomenorrhea
osteopenia
Functional
suspect nutrition:
change in activity intensity
weight loss
intense exercise
sleep/rest are essential
deficient sleep is common
Female athletic performance
• Strong relationship between caloric restriction
and vegetarian diet
• Causal relationship between energy balance and
menstrual dysfunction
• Energy deficit associated with poor athletic
performance
•
VanHeest, JL, Female Athletes: Factors Impacting Successful Performance, Cur Sp
Med Reports, 2007; 6:190-194
Insomnia
1/3 of adults report
problems in last 12
months
Triggers: Stress, illness,
scheduling, mood
disorders, drugs
Risk factor for depression,
drug abuse, suicide
Self-management,
counseling (CBT),
medications rarely
Insomnia
Educational challenge in this population:
Many have tried OTC sleep aids
Few understand basic sleep hygiene/physiology
Misunderstand the role of medication and
effectiveness of behavioral changes
FamilyDoctor.org: Insomnia: How to Get a Good Night's Sleep
Allergies
Food allergies
Blood and skin testing
Elimination diets
Chronic seasonal
Celiac Disease
Autoimmune response to gluten exposure
Strong genetic component, HLA-related
Prevalence 1%
Typical: Diarrhea, malabsorption, weight loss,
nutrient deficiencies
Atypical: anemia, osteoporosis, neurologic
symptoms
Histologic: tissue changes in small bowel, villous
atrophy, crypt hyperplasia, progressive
Celiac Disease
• Screening: Tissue transglutaminase antibodies
• Confirm: Endomysial antibodies (EMA)
•Ab levels proportional to gluten load
–Histological changes in intestine
• Gluten-Free Diet (GFD) is treatment
• Cross-contamination of food is common
–US threshold is 20 ppm
–Levels as low as 100 ppm can worsen disease
•
Celiac Prevalence and Mortality
• Comparison of 50 year-old serum samples to
matched modern samples
–Matched with two groups, similar aged males now
and males with same birthdates
• Four-fold increase in prevalence (now 1%)
• Four-fold increase in mortality
•
Rubio-Tapia, A, Increased Prevalence and Mortality in Undiagnosed Celiac Disease,
Gastroenterology, 2009; 137:88-93
Iatrogenic
Medications
hypnotics
muscle relaxants
antidepressants !!!
antihistamines
beta blockers
antibiotics
Paradoxical fatigue
with imposed rest
especially in active individuals
Exercise improves (relieves) fatigue
Acute: Over 6 weeks,
increased vigor and
decreased fatigue in
college students
Chronic: 10 to 20 weeks,
increased energy in
fatigued subjects
Dishman, RK, Effects of cycling exercise on vigor, fatigue, and
EEG activity among young adults who report persistent
fatigue. Psychophysiology, 2010; 47(6): 1066-74
O'Connor, PJ, Chronic physical activity and feelings of energy
and fatigue, Med Sci Sports Exerc, 2005; 37(2):299-305
Case 1
25 year old male graduate student with about 4 weeks of fatigue
with exercise, mild shortness of breath and cough
Asthma treatment was not helpful
Infection workup negative (not Cocci)
More detailed history reveals history of air travel
and some mild leg pain preceding fatigue
DX: Pulmonary embolism
Case 2
22 year old female student with about 2 months of fatigue with
exercise, and non-specific leg pain
Physical exam reveals very fair skin, little to no
evidence of solar damage (after 4 years in
Tucson, 360 days of sunshine per year)
Basic lab workup is negative, except vitamin D
DX: Vitamin D deficiency
Symptoms resolve with vitamin D replacement
Case 3
24 year old male graduate student with about 8 weeks of
generalized fatigue, worse with exercise, as well as some
motivation and concentration problems that he attributes to grad
school
History reveals: Recreational runner, 30-60
minutes daily, vegetarian
DX: Iron deficiency anemia
Treated with iron: energy and exercise symptoms
improve, but not mood symptoms
DX: Depression & IDA, responds to iron & SSRI
Case 4
19 year old female student-athlete with about 2 weeks of fatigue
with exercise, diminished performance
History: distance runner, prior history of iron
deficiency anemia, treated for 3 months,
improved, stopped iron.
Now a year later similar symptoms, labs confirm
low iron and hemoglobin
DX: Iron deficiency anemia - improved with iron,
after her counts normalize start daily
maintenance iron supplement while
training/exercising
Case 5
22 year old male student-athlete with about 8 weeks of fatigue with
exercise, shortness of breath with exercise, some generalized
daytime fatigue
History: Not helpful, extensive asthma workup was
negative
Labs: Elevated TSH
DX: Hypothyroid - Responds well to levothyroxine
replacement
Summary
Careful history
Timing, habits, mood, nutrition, illness
Screening labs when needed
Iron, thyroid, infection, vitamin D
Remember
Stress, mood, sleep, workload
Young adults are at risk
References
UptoDate
Catassi, C, Celiac Disease, Cur Opin Gastroenterology, 2008; 24:687-91
Eichner, ER. Iron Deficiency Anemia, Cur Sp Med Rep, 2010; 9(3): 122-3
Fallon, K, Clinical utility of blood tests in elite athletes with short term fatigue ,BJSM, 2006;40:541–544
Fallon, K, Utility of Hematological and Iron-Related Screening in Elite Athletes, CJSM, 2004;14:145–152
Killip, S, Iron Deficiency Anemia, AFP, 2007;75:671-8
Koehler, K, Iron status in elite young athletes: gender-dependent influences of diet and exercise, Eur J Appl Physiology, 2011, DOI
10.1007/s00421-011-2002-4
Kurowski, K, Food Allergies: Detection and Management, AFP, 2008; 77(12):1678-86
Kurpa, K, Diagnosing MIld Enteropathy Celiac Disease: A Randomized, Controlled Clinical Study, Gastroenterology, 2009; 136: 816-23
McClung, JP, Longitudinal decrements in iron status during military training in female soldiers. Br J Nutr, 2009; 102: 605-9
McClung, JP, Randomized, double-blind, placebo-controlled trial of iron supplementation in female soldiers during military training: effects on iron
status, physical performance, and mood. Am J Clin Nutr 2009;90:124-31
Moreno, MA, Feeling bad on facebook: Depression disclosures by college students on a social networking site, Depression and Anxiety, 2011,
0:1-9
Murray-Kolb, LE, Iron treatment normalises cognitive functioning in young women, Am J Clin Nutr, 2007; 85:778-87
O'Conor, P, Chronic Physical Activity and Feelings of Energy and Fatigue, Med Sci Sports Exer, 2005;37:299-305
Rea, TD, Prospective study of the natural history of infectious mononucleosis caused by Epstein-Barr Virus, JABFP, 2001; 14(4): 234-42.
Reid, VL, Clinical investigation of athletes with persistent fatigue and/or recurrent infections, BJSM, 2004;38:42-45
Reynolds, Gretchen, Crash and Burnout, NY Times, 3/2/2008
Ricci, JA, J Occup Environ Med 2007;49:1
Rodenberg, R, Iron as an Ergogenic Aid: Ironclad Evidence?, CSMR, 2007;6:258-264
Rosenthal, T, Fatigue: An Overview, AFP, 2008;78:1173-1179
Rubio-Tapia, A, Increased Prevalence and Mortality in Undiagnosed Celiac Disease, Gastroenterology, 2009; 137:88-93
VanHeest, JL, Female Athletes: Factors Impacting Successful Performance, Cur Sp Med Reports, 2007; 6:190-194
Verdon, V, Iron supplementation for unexplained fatigue in non-anaemic women: double blind randomised placebo controlled trial, BMJ,
2003;326:1124
Zotter, H, Abnormally high serum ferritin levels among professional road cyclists, BJSM, 2004;38:704-708
Photos: AbnelPhoto.com, Adam Piggott, *Sean, fffriendly, John Althouse Cohen, MarcoIE, Mariano Kamp, OskarN, Raphael Goetter, SirMervs,
Sister72, Slaff, Thomas Hawk, future15pic, chotda, UA athletics, sgym@662, vramak, Barry Yankowitz, Maurese Polizio, Tezza#, Martin
Gommel[Flickr.com]
•
Medicine & Science in Sports & Exercise. 34(3):411-417, March 2002. GLEESON, MAREE; PYNE, DAVID B.; P. AUSTIN,
JASON; LYNN FRANCIS, J.; CLANCY, ROBERT L.; MCDONALD, WARREN A.; FRICKER, PETER A. GLEESON, M., D. B.
PYNE, J. P. AUSTIN, J. L. FRANCIS, R. L. CLANCY, W. A. MCDONALD, and P. A. FRICKER. Epstein-Barr virus reactivation
and
•
upper-respiratory illness in elite swimmers. Med. Sci. Sports Exerc.,Vol. 34, No. 3, pp. 411-417, 2002.
•
Purpose: The aim of this study was to investigate the relationships
•
between latent viral shedding of Epstein-Barr virus (EBV) in saliva,
•
upper-respiratory illness, and mucosal immune suppression in a cohort
•
of highly trained swimmers undertaking intensive training.
•
Methods: Saliva was collected before selected training sessions from
•
14 elite male swimmers during a 30-d period of intensive training.
•
Prior infection with EBV was determined by EBV antibody serology.
•
Salivary IgA concentrations were measured by enzyme linked
•
immunosorbent assay (ELISA), and EBV viral shedding (EBV-DNA) was
•
detected by polymerase chain reaction (PCR). Symptoms of
•
upper-respiratory illness were recorded daily.
•
Results: Eleven swimmers (79%) were seropositive for prior EBV
•
infection. Seven EBV seropositive swimmers (64%) had EBV-DNA detected
•
during the study period. Upper-respiratory symptoms (URS) were
•
reported in six of seven swimmers in whom EBV-DNA was detected and in
•
three of four swimmers with no EBV-DNA detection. No URS were reported
•
in the EBV seronegative swimmers. There was a statistically
•
significant relationship between EBV serology status and URS (P =
•
0.027). EBV-DNA was detected in saliva before the appearance of URS.
•
Salivary IgA levels were significantly lower immediately before the
Multifactorial Nature of Fatigue
Functional
Neuropsych
Nutrition, Overtraining
Pregnancy, Asthma
Allergies, Celiac
Sleep, Stress
Depression, Grief
Adjustment Disorder
Concussion
Domestic violence
Substance abuse
FATIGUE
Metabolic
Infectious
Diabetes, Thyroid
Anemia, Iron
Vitamin D
Mono, Cocci, HIV,
Sinusitis
Chronic Infection
Hematologic Screening
Australian Institute of Sport
CBC, ferritin, iron, transferrin
120 males, and 174 females over 2 years
Males
8 % had abnormal results
4 % had low ferritin
Females
51 % had abnormal results
16 % had low ferritin
One had hemachromatosis (persistent ↑ iron)