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Chronic Fatigue Syndrome

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Chronic Fatigue Syndrome, Chronic Fatigue Immune Deficiency Syndrome, Myalgic Encephalomyelitis, Systemic Exertional Intolerance Disease

  • See Also
  1. Fatigue (includes Fatigue Red Flags)
  2. Fatigue Diagnostic Testing
  3. Fatigue Causes
  4. Medication Causes of Fatigue
  • Epidemiology
  1. Prevalence may be as high 0.8% to 2.2% in U.S. (or as low as 37 in 100,000)
    1. Fatigue is common complaint (20% of all patients)
    2. Higher Incidence may be in age 20-50 year old women
    3. Case reports include children as young as age 5 years
  2. Outbreaks have been known to occur for centuries
    1. Los Angeles County Hospital (1934)
    2. Akureyri, Iceland (1948)
    3. Royal Free Hospital, London (1955)
    4. Punta Gorda, Florida (1945)
    5. Incline Village, Nevada (1985)
  3. Gender
    1. More common in women (3-4 fold)
  4. Age
    1. Bimodal peaks in teen years and 30-40 years old
    2. Age range extends into older adults (70 to 80 years old)
  • Causes
  1. Idiopathic, likely multifactorial
  2. Genetic predisposition in some patients
  3. Childhood Trauma increases chronic Fatigue risk 6 fold
    1. Heim (2009) Arch Gen Psychiatry 66(1):72-80 [PubMed]
  4. Various viruses have been implicated (with possible chronic immune activation)
    1. COVID-19
    2. Epstein Barr Virus (Mononucleosis)
      1. EBV titers no higher than in healthy controls
      2. Linde (1992) J Infect Dis 165:994-1000 [PubMed]
    3. Mycoplasma pneumoniae
    4. Coxsackie virus
    5. Human Herpes Virus 6
    6. Cytomegalovirus
    7. Measles
    8. HTLV-II
  • Precautions
  1. Chronic Fatigue Syndrome is a clinical, organic condition and is debilitating
  2. Chronic Fatigue Syndrome is not a psychological condition or condition of Malingering or Somatization
  • Pathophysiology
  1. Energy Metabolism abnormalities in neurologic and Immune Systems
    1. Impaired ATP generation and utilization
  2. Inflammatory response
    1. T-Cell Activation
    2. Cytokine release
      1. Related to alpha-intrusion sleep disorder
  • Symptoms
  1. See Fatigue
  • Diagnosis
  1. See Chronic Fatigue Diagnosis
  • Differential Diagnosis
  1. See Fatigue Causes
  2. See Fatigue Red Flags
  • Labs (based on other likely possible Fatigue Causes)
  1. See Fatigue Diagnostic Testing
  • Course
  1. Most patients partially recover within 2 years
  2. All Chronic Fatigue patients are prone to relapse
  3. Level of Disability varies
    1. Up to 25% of patients are able to work
    2. Homebound or bedbound in 10 to 25%
  • Management
  1. Understanding physician with regularly scheduled visits
    1. Listen
    2. Counsel
    3. Empathy
    4. Validation
  2. General Measures
    1. Minimize symptoms and maximize function
    2. Consider support group
    3. Avoid Alcohol and substance use
  3. Specific treatment approaches
    1. See Orthostatic Hypotension
    2. See Major Depression Management
    3. See Insomnia
    4. Brain fog
      1. Cognitive pacing
      2. Employ memory aids
    5. Postexertional Malaise
      1. Follow "Stop, Rest, Pace" to avoid postexertional malaise
      2. Assistive Device (e.g. shower chair, walker)
      3. Handicapped parking card
      4. Symptom journal
      5. Work and school accommodations
    6. Pain
      1. See Chronic Pain Management
      2. NSAIDS
      3. Selective Serotonin Reuptake Inhibitors (SSRI)
      4. Duloxetine (Cymbalta)
      5. Tricyclic Antidepressants
        1. Amitriptyline 10 to 25 mg orally at bedtime and increase as tolerated
  4. Previously recommended measures that have fallen out of favor
    1. Cognitive behavior therapy
      1. Identify unhealthy coping mechanisms
    2. Graded Aerobic Exercise
      1. Originally recommended, but later found to be harmful, worsening postexertional malaise
      2. Larun (2019) Cochrane Database Syst Rev 10(10):CD003200 8. +PMID: 31577366 [PubMed]
    3. Avoid empiric therapies which are not yet supported by good evidence
      1. Nicotinamide-adenine dinucleotide (NADH)
      2. Hydrocortisone 5-10 mg PO qd
  • Resources
  1. CDC: Chronic Fatigue Syndrome
    1. https://www.cdc.gov/me-cfs/
  • References
  1. Gantz in Noble (2001) Primary Care Medicine, p. 1325
  2. Craig (2002) Am Fam Physician 65(6):1083-95 [PubMed]
  3. Fulcher (1997) BMJ, 314:1647-52 [PubMed]
  4. Latimer (2023) Am Fam Physician 108(1): 58-69 [PubMed]
  5. Morrison (2001) Obstet Gynecol Clin North Am 28:225-40 [PubMed]
  6. Yancey (2012) Am Fam Physician 86(8): 741-6 [PubMed]