1. Chronic Fatigue Syndrome
By Dr Hassan Raji Jallab

2. Introduction
Severe fatigue is a common complaint among patients. Often, the fatigue is transient or can be attributed to a definable organic illness. Some patients present with persistent and disabling fatigue, but show no abnormalities on physical examination or screening laboratory tests. In these cases, the diagnosis of chronic fatigue syndrome (CFS) should be considered.

3. Definition
Also called CFS/ME(Myalgic Encephalomyelitis) CFS is a disabling illness characterized by persistent fatigue , which exists without other explanation, for a long time, and is accompanied by cognitive difficulties.
CFS includes both an encephalitic component ( cognitive difficulties ) and a skeletal muscle component( chronic fatigue )
Patient without cognitive dysfunction should not be considered to have CFS.

4. Epidemiology
Chronic fatigue syndrome affects both genders, all racial, ethnic, and socioeconomic populations, and can begin as early as five years of age.
Up to 5%
Female >> Male
Caucasians > other groups
Majority in their 30s .

5. How does CFS begin?
Can begin after a minor illness such as cold, or an intestinal bug
During a period of high stress
Gradually, with no clear illness or other event starting it
The main symptoms of CFS/ME are persistent profound weakness, extreme tiredness after any form of exertion, sleep disturbance, pain disturbance and neurological and cognitive problems

6. Symptoms Fatigue 100% Difficulty concentration 90% Headache 90%
Sore throat 90%
Tender lymph nodes 80%
Muscle ache 80%
Joint aches 75%
Feverishness 75%
Difficulties sleeping 70%
Psychiatric problems 65%
Allergies 55%
Abdominal cramps 40%
Weight loss 20%

7. Diagnosis
The Centers for Disease Control and Prevention's criteria for diagnosis of chronic fatigue syndrome require the patient to present with severe fatigue lasting at least six consecutive months, have no definable organic disease, and experience associated physical symptoms.

8. Major criteria :
New onset of persistent or relapsing fatigue not previously present, sufficient to reduce daily activity by 50% or more.
Exclusion of other conditions which may produce similar symptoms.

9. Diagnosis Minor criteria : Mild fever (37.5-38.6) Sore throat
Painful cervical or axillary lymph nodes
Unexplained generalized muscle weakness.
Muscle discomfort or myalgias
Prolonged (>24hr) generalized fatigue after previously tolerated exercise

10. Diagnosis 7) Generalized headaches
8) Migratory arthralgia without jont swelling or redness
9) Neuropsychiatric complaints e.g., photophobia , forgetfulness, irritability, confusion, inability to concentrate, difficulty in thinking, depression.
10) Sleep disturbances
11) Onset of main symptom complex in hours of a few days

11. Physical criteria ;
Low grade fever
Non-exudative pharyngitis
Palpable or tender ant or post cervical or axillary nodes
>> 2 major + 6 minor + 2 physical
>> 8/11 minor

12. CDC criteria Postexertional malaise
Four or more of the following symptoms are present for six months or more:
Impaired memory or concentration
Postexertional malaise
(extreme, prolonged exhaustion and exacerbation of symptoms following physical or mental exertion)
Unrefreshing sleep
Muscle pain
Multijoint pain without swelling or redness adults
Headaches of a new type or severity
Sore throat that’s frequent or recurring
Tender cervical or axillary lymph nodes

13. DDx
Infectious
Chronic Epstein-Barr virus ,Influenza,Tuberculosis,Lyme disease
Neuroendocrine
Hypothyroidism / Hyperthyroidism
Addison's disease, Cushing's disease ,Diabetes
Psychiatric
Neuropsychologic
Obstructive sleep syndromes (sleep apnea, narcolepsy) ,Multiple sclerosis, Parkinsonism
Hematologic
Anemia, Lymphoma ,Occult malignancy
Rheumatologic
Fibromyalgia,Sjögren's syndrome ,Polymyalgia rheumatica ,Giant cell arteritis ,Polymyositis ,Dermatomyositis

14. Etiology Unknown cause Some hypotheses: INFECTIOUS
Many patients with CFS attribute the onset of their illness to an acute influenza-like infection, and It is now believed that CFS is not specific to one pathogenic agent but could be a state of chronic immune activation, possibly of polyclonal activity of B-lymphocytes, initiated by a virus.
IMMUNOLOGIC
Many of the symptoms seen in patients with CFS, such as disabling lethargy, myalgias, and cognitive impairment, are similar to the effects observed with high dosage treatments of cytokines including interleukin-2 and alpha interferon.Given that CFS may be an illness of immune dysregulation.
AUTONOMIC NERVOUS SYSTEM

15. Psychiatric : Although there is some overlap in symptoms presented by patients with CFS and those with depression, patients with CFS also show symptoms that are not typical of clinical depression, such as sore throat, lymphadenopathy, and postexertional malaise. Patients with CFS lack feelings of anhedonia, guilt, and decreased motivation classically seen in patients with depression
“Studies have shown that two thirds of patients with CFS have signs of major depressive illness and one half of all patients with CFS have experienced at least one episode of major depression. “
ALLERGEN

16. Treatment
Given the ambiguity surrounding CFS, the current suggested management includes exercise, optimal diet, appropriate sleep hygiene, low-dose tricyclic antidepressants and/or a selected serotonin reuptake inhibitor, combined with cognitive-behavior therapy.

17. Treatment Counseling : about the illness and its prognosis.
Heavy meals, alcohol and caffeine at night can make sleep even more difficult with increased fatigue.
NSAIDs alleviate headache, diffuse pain, and fever.
Allergic rhinitis and sinusitis are common; antihistamines or decongestants ma be helpful.
Reports of subtle hypocortisolism in patients with CFS has spurred interest in treatment with mineralocorticoids and corticosteroids. In a randomized control study , researchers successfully demonstrated a response to low-dose hydrocortisone (five to 10 mg daily). Fatigue was improved and disability was reduced without significant short-term adverse events.

18. Sleep hygiene
Sleep hygiene means habits that help you to have a good night’s sleep.
you can dramatically improve your sleep quality by making a few minor adjustments to lifestyle and attitude.

19. Sleep hygiene Obey your body clock :
Get up at the same time every day. Soon, this strict routine will help to set your body clock, and you’ll find yourself getting sleepy at about the same time every night.
Don’t ignore tiredness. Go to bed when your body tells you it’s ready.
Don’t go to bed if you don’t feel tired. You will only reinforce bad habits such as lying awake.
Get enough sunshine. Exposure to light during waking hours helps to set your body clock.

20. Improve your sleeping environment:
Use a mattress that is neither too hard nor too soft.
Make sure the room is at the right temperature
Ensure the room is dark enough
Only use your bed for sleeping.

21. Avoid :
Cigarettes
Alcohol
Sleeping pills

22. Coping with the mid-afternoon energy slump!!
Most people feel drowsy after lunch
This mid afternoon drop in energy levels is linked to the brain’s circadian rhythm
Prevention may be impossible, but there are ways to reduce the severity of the slump, including:
don’t over eat or skip a meal
Be careful with caffeine
Eat a combination of protein and carbohydrates for lunch,carbohydrate provide glucose for energy.
Walking for 10 minutes improves blood flow to brain.