A Comprehensive Approach to Chronic Fatigue

Diane's story: "A year ago, I had the flu. Suddenly my symptoms started to worsen. I felt severe fatigue and malaise. I couldn't go to work for months, even though I hadn't missed a single day for five years before that time. I saw ten different doctors. They told me I had Epstein-Barr, and that there was nothing that could be done. I felt hopeless, especially because I was told that it was all in my head."

Diane's story is not unique. Current estimates indicate that over 200,000 Americans are suffering from chronic fatigue syndrome (CFS). Fatigue remains the number one reason why patients go to their doctor.

The Centers for Disease Control (CDC) has several major and minor criteria which must be met before a diagnosis of CFS can be made. "Major" criteria include the new onset of persistent (i.e. six months or more), debilitating fatigue that does not respond to bed rest, and the exclusion of all other possible causes.

"Minor" criteria include fever, chills, muscle aches, swollen lymph nodes, sleep disturbances, sore throats, and confusion. Viruses such as Epstein-Barr, HHV-6 and CMV, as well as another virus called a Retrovirus, are but a few of the viruses that have been implicated. Rising titers of these viruses can sometimes give clues to a patient's condition, as can a physical sign such as "Crimson crescents," which are present on the pharynx of infected individuals.

Causes of Fatigue: There are a number of conditions that can mimic the symptoms of chronic fatigue, such as anemia, hypothyroidism, candida, lyme, HIV, and clinical depression. These can be ruled out by specific tests. In addition, allergies, environmental illness, food sensitivities, intestinal dysbiosis, parasitosis, and "sick building" syndrome should all be considered, and if necessary, tested for. For example, fatigue and chest pain in a young male may indicate asthma, a cardiac condition, or sarcoidosis if shortness of breath is present. Or, excessive coldness, and/or hair loss may point to a thyroid problem.

Are You Depressed? Unfortunately, sufferers of CFS have long been stigmatized by the medical community. This disorder is frequently confused with psychiatric conditions such as clinical depression. Questions as to whether chronic fatigue syndrome is in fact a psychiatric condition persist to this day, even though studies have shown that they are two separate conditions: The Journal of Psychiatric Research concluded that major depression and seasonal effective disorder (SAD) are not the same illness as chronic fatigue syndrome. The Journal of Clinical Endocrinology and Metabolism also found clear differences between CFS and depression. Their findings pointed to a hypothalamic deficiency in chronic fatigue syndrome, a finding not present in clinical depression.

Testing Procedures: Considerable controversy exists over which tests are helpful in making the diagnosis of CFS. A recent study published in the Archives of Internal Medicine shed some new light on chronic fatigue, evaluating patients in two different areas of the country- Seattle and Boston. Certain tests, which are routinely performed in a doctor's office, were found to be elevated. (These included alkaline phosphatase, cholesterol, ANA, LDH, and IgG.) Although these findings were non-specific, they did add to the growing body of evidence that a distinct clinical disorder (CFS) exists. Other parameters, which may prove useful, include T and B cell subsets, and Natural Killer cell levels. Viral titers can at times indicate progression or regression of the acute phase of viral illness.

Richard Firshein D.O.

by Dr. Richard Firshein