CDC Grand Rounds

Chronic Fatigue Syndrome — Advancing Research and Clinical Education

Elizabeth R. Unger, PhD, MD; Jin-Mann Sally Lin, PhD; Dana J. Brimmer, PhD; Charles W. Lapp, MD; Anthony L. Komaroff, MD; Avindra Nath, MD; Susan Laird, MSN; John Iskander, MD

Disclosures

Morbidity and Mortality Weekly Report. 2016;65(5051):1434-1438.

Abstract and Introduction

Introduction

Chronic fatigue syndrome (CFS) is a complex and serious illness that is often misunderstood. Experts have noted that the terminology "chronic fatigue syndrome" can trivialize this illness and stigmatize persons who experience its symptoms.^[1] The name was coined by a group of clinicians convened by CDC in the late 1980s to develop a research case definition for the illness, which, at the time, was called chronic Epstein-Barr virus syndrome. The name CFS was suggested because of the characteristic persistent fatigue experienced by all those affected and the evidence that acute or reactivated Epstein-Barr virus infection was not associated with many cases.^[2] However, the fatigue in this illness is striking and quite distinct from the common fatigue everyone experiences. A variety of other names have been used, including myalgic encephalomyelitis (ME), ME/CFS, chronic fatigue immune dysfunction, and most recently, systemic exertion intolerance disease.^[3] The lack of agreement about nomenclature need not be an impediment for advancing critically needed research and education. The term ME/CFS will be used in this article.

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Abstract and Introduction
ME/CFS Is a Significant Public Health Problem
Clinical Approach to ME/CFS
Cause or Causes of ME/CFS
Treatment of ME/CFS
Addressing ME/CFS
References

Box 1. Myalgic encephalomyelitis/chronic fatigue syndrome case history
The patient, aged 37 years, was an internet technologist for a community bank. She had been physically active in sports and working out, and had been maintaining her own household when she experienced a flu-like illness in 2011. She was bedbound at first and slow to recover. Within days she noted an unusual fatigue after minimal activity, then insomnia, achiness in the joints, and generalized muscle pain and weakness. She soon found it difficult to recall recent conversations and events. Reading concentration was limited, and she had trouble comprehending what she had read or even television shows. She would search for words, lose her train of thought, and friends would sometimes have to finish sentences for her. Previously her sleep had always been good, but now she was restless at night and would awaken unrefreshed even after many hours of bed rest. She felt stiff, sore, and foggy for 1–2 hours after awakening. She noted dizziness or lightheadedness on getting up quickly, and on a couple of occasions "saw stars," but did not experience tunnel vision or fainting. The patient was unable to keep up the house, and she had to rely on friends and family to help her with cleaning, laundry, and shopping. She would attempt to keep up at home and at work, but exertion would inevitably make symptoms worse, and if she exerted too much she would end up sick and chairbound for 1–2 days afterward. Evaluation by her primary care physician revealed low blood pressure, but there was no immediate orthostatic blood pressure drop and otherwise the examination was unremarkable. Blood work was unremarkable. Having no explanation for her symptoms despite the profound reduction in her physical abilities, the patient became anxious about her future and both frustrated and discouraged.

Box 2. Institute of Medicine criteria for diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome
Patient has each of the following three symptoms at least half of the time, to at least a moderately severe degree: A substantial reduction or impairment in the ability to engage in preillness levels of occupational, educational, social, or personal activities that persists for >6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest. Postexertional malaise* Unrefreshing sleep* Plus at least one of the two following manifestations (chronic, severe): Cognitive impairment* Orthostatic intolerance
Source: Institute of Medicine. Beyond myalgic encephalomyelitis/chronic fatigue syndrome: redefining an illness. Washington, D.C.: The National Academies Press; 2015. https://www.nationalacademies.org/hmd/reports/2015/me-cfs.aspx *Frequency and severity of symptoms should be assessed. The diagnosis of myalgic encephalomyelitis/chronic fatigue syndrome should be questioned if patients do not have these symptoms at least half of the time with moderate, substantial, or severe intensity.