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.

Clinical Approach to ME/CFS

There is no "typical" case, but a patient history can be useful in educating physicians about ME/CFS (Box 1). This composite case history illustrates the key features of ME/CFS: significant reduction in ability to perform usual activities accompanied by profound fatigue; significant worsening of symptoms after minimal physical or mental exertion (termed postexertional malaise); unrefreshing sleep; cognitive difficulties; and orthostatic intolerance (such as dizziness and lightheadedness upon standing up). In addition, this patient experienced widespread muscle pain, joint pain, and unpredictable waxing and waning of symptoms. Persons with ME/CFS might be misunderstood because they appear healthy and often have no abnormalities on routine laboratory testing. Clinicians need to be alert to this difficulty and take the time to elicit a good history of the illness, which is critical in the differential diagnosis and can provide evidence of ME/CFS.

Clinical evaluation includes a thorough medical history, psychosocial history, complete physical examination, mental health assessment, and basic laboratory tests to screen for conditions that could cause symptoms similar to ME/CFS and that should be treated before attributing the illness to ME/CFS. The screening laboratory tests can include complete blood count with differential white blood cell count, sodium, potassium, glucose, blood urea nitrogen, creatinine, lactate dehydrogenase, aspartate transaminase, alanine transaminase, alkaline phosphatase, total protein, albumin, calcium, phosphorus, magnesium, thyroid stimulating hormone, free thyroxine, sedimentation rate, C-reactive protein, antinuclear antibodies, rheumatoid factor, and urinalysis.^[11] Patients might also have comorbid conditions such as fibromyalgia, irritable bowel and bladder, Sjögren's syndrome, chemical sensitivities, and allergies.^[11] Additional tests might be clinically indicated.

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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.

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Chronic Fatigue Syndrome — Advancing Research and Clinical Education

Clinical Approach to ME/CFS

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Authors and Disclosures

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