A patient with Chronic Fatigue
Syndrome
Kristin Steffen, MD
2/22/06
I have no financial disclosures.
Objectives
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Identify case definition for Chronic Fatigue
Syndrome (CFS)
Recognize similarities between CFS and
fibromyalgia
Describe clinical presentation, prognosis of CFS
Review recommendations for diagnosis
Identify 2 treatments
Identify useful references
Informational presentation only (I am not
soliciting referrals!!)
Case of AF
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AF is a 35 yo F diagnosed with CFS in 1992 with
abrupt onset of symptoms following URI
Extensive negative work up for alternative cause
(>14 physicians, every recommended test plus
more than twice as many more)
Extensive trials of experimental treatments (32+)
On SSI total disability, appealing employer
decision to revoke employer-based disability
benefit
Stable: neither improving nor worsening, currently
taking no specific pharmacologic therapy
1994 CDC Case Definition for
CFS
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I. Clinically evaluated, unexplained,
persistent, or relapsing fatigue that is of new
or definite onset; it is not the result of
ongoing exertion; is not alleviated by rest;
and results in substantial reduction in
previous levels of occupational,
educational, social, or personal activities
AND
1994 Case definition of CFS,
cont
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II. Four or more of the following symptoms that
persist or recur during six or more months of
illness that do not predate fatigue:
 Self-reported impairment in short term memory
or concentration
 Sore throat
 Tender cervical or axillary nodes
 Muscle pain
1994 Case definition of CFS,
cont
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II. Four or more of the following symptoms that
persist or recur during six or more months of
illness that do not predate fatigue:
 Multijoint pain without redness or swelling
 Muscle pain
 Headaches of a new pattern or severity
 Unrefreshing sleep
 Post-exertional malaise lasting >24 hours
Conditions that exclude CFS Dx
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Any active medical condition that may explain the
presence of chronic fatigue…
Any previously diagnosed medical condition
whose resolution has not been documented beyond
reasonable doubt…
Any past or current diagnosis of specified
psychiatric disorders…
Alcohol or other substance abuse
Severe obesity (BMI>45)
Conditions that do not exclude
CFS Dx
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Any condition defined primarily by symptoms that
cannot be confirmed by diagnostic laboratory
tests…
Any condition under specific treatment to alleviate
all symptoms related to that condition and for
which adequacy of treatment has been
documented…
Any condition, such as Lyme disease or syphilis,
that was treated with definitive therapy before the
development of chronic symptomatic sequelae.
Conditions that do not exclude
CFS Dx
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Any isolated or unexplained PE finding or
lab or imaging test abnormality that is
insufficient to strongly suggest the existence
of an exclusionary condition…
Idiopathic Chronic Fatigue
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Clinically evaluated, unexplained chronic
fatigue of greater than 6 months duration
that does not meet criteria for CFS
diagnosis
Similarities between CFS and
Fibromyalgia
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Common in women
Myalgias and fatigue in >90%
Symptoms in common: cognitive and mood,
headache, nonrestorative sleep
No known cause
Clinical diagnosis (no specific diagnostic tests,
except trigger points in fibromyalgia)
Chronic symptoms, no highly effective treatment
Fibromyalgia Diagnostic Criteria
Widespread body pain (left and right, above
and below the waist) and axial skeletal pain
(neck, chest wall, mid or low back)
 Presence in 11 of 18 tender point sites on
digital palpation with “an approximate force
of 4 kg”
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Cause of CFS
UNKNOWN
 Possible precipitants that have been studied
but have not been found to be causative:
 Infection
 Immune dysfunction
 Endocrine-metabolic dysfunction
 Neurally-mediated hypotension
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Clinical Presentation with CFS
Variable
 Sudden onset of fatigue after URI
 After URI, continued overwhelming fatigue
plus add’l sx (e.g. altered sleep, cognition)
 Symptoms exacerbated by excessive
physical activity
 No prior hx of backache/chronic headache
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Clinical Presentation, cont.
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Typically in formerly high functioning individuals
Once inciting illness resolved, physical exam is
NORMAL
Feel feverish, but normal temp
Achy joints, but no findings on exam
Muscle fatigue, but normal biopsies
Frequent sore lymph nodes
Disabled by symptoms, but outwardly healthy
appearing
Clinical Presentation, cont.
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Patients may be accused of malingering by family,
colleagues
*Cognitive dysfunction: no specific pattern of
cerebral abnormalities uniquely characterize CFS
patients; most prominent features may be slowed
processing speed, impaired working memory, poor
learning
 (can’t “rule in” CFS by neuropsych testing,
can’t “rule out” cognitive dysfunction symptom
as not legitimate)
Prognosis
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Some recover completely, some recover and are
able to work but have flares, some never recover
Of those who recover, most recover within 5 years
As illness progresses reports of muscle pain and
forgetfulness increase, depression decreases
Poorer prognosis when patient believes the illness
is due to a (given) physical cause
Diagnosis
Clinical, based on typical presentation, case
definition
 No diagnostic exam or test findings exist
 Purpose of evaluation is to identify and treat
any underlying contributing factors
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Diagnosis
Recommended evaluation:
 History and physical exam
 CBC with diff, ESR, chemistries (electrolytes,
kidney tests, liver tests, glucose, total protein,
iron), TSH
 Further tests IF clinically indicated to exclude
alternative diagnoses suspected on the basis of
initial testing
 Special immunologic testing, brain imaging,
etc. are not recommended
 No specific cognitive testing recommended
Treatment of CFS
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Only two therapies have been shown beneficial in
clinical trials:
 Cognitive behavioral therapy
 Graded exercise
No known “Cure”
Goal: symptom management and reintegration
into social and occupational networks
Ineffective Measures
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Immune serum globulin
Acyclovir
Galantamine
Corticosteroids
Amantadine
Doxycycline
Magnesium
Colonic enemas
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Evening primrose oil
Vitamin B12
Ampligen
Essential Fatty acids
Liver extract
Dialyzable leukocyte
extract
Interferon
Exclusion diets
Removal of dental fillings
Etc
Symptom Management
Cognitive Behavioral Therapy and
education about CFS
 Graded exercise program
 Pharmacologic therapy for pain,
nonrestorative sleep, fatigue
 NSAIDs, tricyclics, SSRIs, anxiolytics,
?stimulants
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Myths
No evidence that CFS patients lose their
fingerprints
 No evidence for nutritional deficiency in
CFS
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