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Chronic Fatigue Syndrome

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Chronic Fatigue Syndrome (CFS) is a condition that causes significant and persistent tiredness (fatigue) usually for ≥6 months, which does not improve with rest. It presents with other non-specific symptoms unrelated to other known medical conditions. It is also known by names like Myalgic Encephalitis (ME) or Systemic Exertion Intolerance Disease (SEID). 

The exact cause and cure are not known. 

Epidemiology

Chronic fatigue syndrome can affect anyone, including children. It is 4 times more common in women than in men, and develops most often in mid-20s to mid-40s. 

One World Health Organization (WHO) multinational study has shown the prevalence of disabling fatigue to be 1.69%. A community study among women in India revealed chronic fatigue was observed in 1 in 10 women. Another study conducted in Hong Kong among Chinese people showed the prevalence of CFS/ME to be 10.7%. 

Causes and risk factors

Till now, the exact cause of CFS has not been found. Some people may inherit a genetic predisposition for the disorder, while other risk factors associated with development of CFS include:

  • Infections
    • Viral: e.g Epstein-Barr virus, Human Herpesvirus-6, Rubella
    • Bacterial: e.g. Mycoplasma pneumoniae, Coxiella burnetii
  • Weak immune system
  • Hormonal imbalances
    • Abnormal levels of hormones e.g. Cortisol secreted by the hypothalamus, pituitary glands, or adrenal glands (HPA axis). 
    • The HPA axis regulates a lot of body processes such as the immune response, digestion, energy usage, and mood. 
  • Physical or emotional trauma e.g. injury, surgery, death of a loved one, divorce etc.

Symptoms

Symptoms of CFS vary between individuals and the intensity waxes and wanes. The core symptoms include:

  1. Debilitating fatigue for ≥6 months that is not relieved by rest, and limits ability to carry out activities which were previously usual;
  2. Extreme tiredness after physical and mental exertion i.e. Post-Exertional Malaise (PEM) which can cause patients to be bed-bound for > 24 hours after the trigger activity;
  3. Sleep disturbances – insomnia, waking frequently, and waking unrefreshed;

AND

  1. Poor memory, poor concentration – difficulty with planning or organising thoughts; OR
  2. Dizziness, especially when changing from lying or seated to standing position.

Other symptoms may include:

  • Muscle and joint pains
  • Headaches
  • Recurrent sore throat 
  • Painful swollen lymph nodes in the neck or armpits
  • Palpitations
  • Digestive issues/irritable bowel – diarrhoea or constipation

Diagnosis

Currently, there is no single test that can accurately diagnose chronic fatigue syndrome. A review of the medical history of the patient with thorough physical and mental status examination by the doctor are necessary; aforementioned core symptoms if present, aids in diagnosis of CFS. Some tests are also ordered to exclude other medical conditions which present with similar symptoms. These include:

  • Viral infections such as mononucleosis
  • Multiple sclerosis
  • Lupus
  • Hypothyroidism
  • Anemia. 
  • Depression and anxiety 
  • Obesity
  • Side effects of some drugs like antihistamines used for treating allergies, alcohol. 

It is important to seek a doctor’s help for accurate diagnosis and appropriate treatment. 

Treatment

Presently there is no specific cure for chronic fatigue syndrome (CFS). Treatment is targeted at relieving the most troublesome symptoms to maintain quality of life and function. This may be achieved with:   

Lifestyle changes

  • Establish a sleep routine 
    • Have regular and reasonable sleep and wake times e.g. ideally bedtime at 10–11 pm and wake after 7-8 hours of sleep. 
    • Avoid napping during daytime.
  • Limit caffeinated beverages and cigarette-smoking
    • Caffeine and nicotine are stimulants which can affect sleep.
  • Adopt relaxation techniques to promote a sense of well-being
    • Meditation, deep breathing exercises or yoga can be helpful to reduce pain, sleep problems, and stress or anxiety.
  • Pacing or activity management helps balance rest and activity to avoid PEM flare-ups
    • Patients need to be mindful of their limits for mental and physical activity, then plan activity and rest to stay within these limits. 
    • Keeping activity and symptom diaries may help patients find their personal limits

Cognitive Behavioural Therapy

  • Modulation of beliefs and behaviour
  • Counselling to help sufferers cope with the frustration of the condition and the limitations that it sets on their lifestyle and ambitions.

Medications

Medications can alleviate some of the symptoms in CFS:

  • Painkillers can be used to manage muscle or joint pains and headaches 
    • Paracetamol, Non-steroidal Anti-inflammatory drugs (NSAIDs) like ibuprofen, naproxen
    • Neuropathic drugs such as pregabalin, duloxetine, amitriptyline, or gabapentin. 
  • Antidepressants can aid with sleep, relief from pain and improve mood. 

Long term outlook 

CFS has certain implications e.g. limitation of physical activity may cause social isolation, depression and anxiety; the need to reduce intense workload or absenteeism from school/work may have a bearing on academic achievements or career trajectory. It may thus be helpful to join a support group, especially when making decisions and going through major transitions.

As CFS progresses differently in everyone, it is important for patients to work with their healthcare providers closely to create an individualised treatment plan that meets their needs.

Majority of CFS sufferers with mild to moderate symptoms will improve and lead near-normal lives with appropriate lifestyle changes and treatment plans, although occasional relapses may be expected.

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