Chronic fatigue syndrome and fibromyalgia. Dilemmas in diagnosis and clinical management

Abstract:

There has been a resurgence of interest in recent years in both chronic fatigue syndrome and fibromyalgia. These perplexing and common clinical conditions are a source of significant patient morbidity and frame one of the more enduring dilemmas of contemporary Western medical thought, namely the ambiguous interface between mind and body. In this article, the current definitions are reviewed, and a framework for an emerging psychobiological model of these syndromes is presented. These issues are synthesized into a pragmatic approach to clinical management.

 

Source: Demitrack MA. Chronic fatigue syndrome and fibromyalgia. Dilemmas in diagnosis and clinical management. Psychiatr Clin North Am. 1998 Sep;21(3):671-92, viii. http://www.ncbi.nlm.nih.gov/pubmed/9774804

 

Effects of exercise on cognitive and motor function in chronic fatigue syndrome and depression

Abstract:

OBJECTIVES: Patients with chronic fatigue syndrome complain of physical and mental fatigue that is worsened by exertion. It was predicted that the cognitive and motor responses to vigorous exercise in patients with chronic fatigue syndrome would differ from those in depressed and healthy controls.

METHODS: Ten patients with chronic fatigue syndrome, 10 with depressive illness, and 10 healthy controls completed cognitive and muscle strength testing before and after a treadmill exercise test. Measures of cardiovascular functioning and perceived effort, fatigue, and mood were taken during each stage of testing.

RESULTS: Depressed patients performed worst on cognitive tests at baseline. During the treadmill test, patients with chronic fatigue syndrome had higher ratings of perceived effort and fatigue than both control groups, whereas patients with depression reported lower mood. After exertion, patients with chronic fatigue syndrome showed a greater decrease than healthy controls on everyday tests of focused (p=0.02) and sustained (p=0.001) attention, as well as greater deterioration than depressed patients on the focused attention task (p=0.03). No between group differences were found in cardiovascular or symptom measures taken during the cognitive testing.

CONCLUSIONS: Patients with chronic fatigue syndrome show a specific sensitivity to the effects of exertion on effortful cognitive functioning. This occurs despite subjective and objective evidence of effort allocation in chronic fatigue syndrome, suggesting that patients have reduced working memory capacity, or a greater demand to monitor cognitive processes, or both. Further insight into the pathophysiology of the core complaints in chronic fatigue syndrome is likely to be realised by studying the effects of exercise on other aspects of everyday functioning.

 

Source: Blackwood SK, MacHale SM, Power MJ, Goodwin GM, Lawrie SM. Effects of exercise on cognitive and motor function in chronic fatigue syndrome and depression. J Neurol Neurosurg Psychiatry. 1998 Oct;65(4):541-6. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2170292/ (Full study)

 

Screening instruments for psychiatric morbidity in chronic fatigue syndrome

Abstract:

Physicians require a screening instrument to detect psychiatric disorders in patients with chronic fatigue syndrome (CFS). Different threshold scores on the Hospital Anxiety and Depression scale (HAD) and the mental health scale of the Medical Outcome Survey (MOS) were compared with two gold standards for the presence or absence of psychiatric disorder, standard diagnostic criteria (DSM-III-R) and a threshold score for the number of psychiatric symptoms at a standardized psychiatric interview (Revised Clinical Interview Schedule total cut-off score of 11/12). They were compared by use of validating coefficients and receiver operating characteristics in 136 consecutive CFS medical outpatients.

The HAD scale at cut-off of 9/10 was a valid and efficient screening instrument for anxiety and depression by comparison with both gold standards. The MOS mental health scale at its recommended cut-off score of 67/68 yielded too many false-positives to be recommended as a psychiatric screening instrument in CFS patients.

 

Source: Morriss RK, Wearden AJ. Screening instruments for psychiatric morbidity in chronic fatigue syndrome. J R Soc Med. 1998 Jul;91(7):365-8. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1296809/ (Full article)

 

Propagation and characterization of human herpesvirus-7 (HHV-7) isolates in a continuous T-lymphoblastoid cell line (SupT1)

Abstract:

After initial culture of HHV-7 in PHA-stimulated human cord blood mononuclear cells (HCBMC), six HHV-7 isolates were propagated successfully in an immature continuous T-lymphoblastoid cell line SupT1. All six isolates infected efficiently the SupT1 cells, and the infected cells became grossly enlarged and multinucleated 7-21 days post-infection. Various stages of HHV-7 morphogenesis were detected.

Cell-free supernatants from HHV-7-infected SupT1 cells were infectious to HCBMC as well as to SupT1 cells. The HHV-7-infected SupT1 and HCBMC cell lysates contained more infectious virus than the centrifuged cell culture fluid supernates from the same culture. The HHV-7 isolates H7-2, H7-3, JHC, and JB, concentrated 500 times, had average infectivity titers of 10(3.0) TCID50/ml while strains H7-4 and KHR titered approximately 1-2 logs higher. When all six HHV-7 isolates were propagated in SupT1 and culture fluid supernatants were examined 14-21 days post-infection by negative stain electron microscopy they contained an average of 1.9 x 10(9) virus particles/liter.

IFA and ELISA, using HHV-7/SupT1 cell lysate as an antigen, seem to correlate well in detecting high and low HHV-7 antibody in sera from chronic fatigue patients and healthy donors as controls. HHV-7 from SupT1 cell culture was free of HHV-6 and other human herpesviruses as tested by PCR, and the HHV-7 PCR signal was still strong when the viral preparation was diluted to 4.82 x 10(2) genome copies.

Since HCBMC are expensive to obtain and available in only small amounts, it is difficult to obtain large quantities of HHV-7 antigen. On the other hand, the SupT1 cell is an excellent source to produce consistently sufficient quantities of HHV-7 for purification studies, development of immunodiagnostics, in vivo infectivity studies, evaluation of antiviral drugs, and molecular biological studies.

 

Source: Ablashi DV, Handy M, Bernbaum J, Chatlynne LG, Lapps W, Kramarsky B, Berneman ZN, Komaroff AL, Whitman JE. Propagation and characterization of human herpesvirus-7 (HHV-7) isolates in a continuous T-lymphoblastoid cell line (SupT1). J Virol Methods. 1998 Aug;73(2):123-40. http://www.ncbi.nlm.nih.gov/pubmed/9766884

 

Low-dose hydrocortisone for treatment of chronic fatigue syndrome: a randomized controlled trial

Abstract:

CONTEXT: Chronic fatigue syndrome (CFS) is associated with a dysregulated hypothalamic-pituitary adrenal axis and hypocortisolemia.

OBJECTIVE: To evaluate the efficacy and safety of low-dose oral hydrocortisone as a treatment for CFS.

DESIGN: A randomized, placebo-controlled, double-blind therapeutic trial, conducted between 1992 and 1996.

SETTING: A single-center study in a tertiary care research institution.

PATIENTS: A total of 56 women and 14 men aged 18 to 55 years who met the 1988 Centers for Disease Control and Prevention case criteria for CFS and who withheld concomitant treatment with other medications.

INTERVENTION: Oral hydrocortisone, 13 mg/m2 of body surface area every morning and 3 mg/m2 every afternoon, or placebo, for approximately 12 weeks.

MAIN OUTCOME MEASURES: A global Wellness scale and other self-rating instruments were completed repeatedly before and during treatment. Resting and cosyntropin-stimulated cortisol levels were obtained before and at the end of treatment. Patients recorded adverse effects on a checklist.

RESULTS: The number of patients showing improvement on the Wellness scale was 19 (54.3%) of 35 placebo recipients vs 20 (66.7%) of 30 hydrocortisone recipients (P =.31). Hydrocortisone recipients had a greater improvement in mean Wellness score (6.3 vs 1.7 points; P=.06), a greater percentage (53% vs 29%; P=.04) recording an improvement of 5 or more points in Wellness score, and a higher average improvement in Wellness score on more days than did placebo recipients (P<.001). Statistical evidence of improvement was not seen with other self-rating scales. Although adverse symptoms reported by patients taking hydrocortisone were mild, suppression of adrenal glucocorticoid responsiveness was documented in 12 patients who received it vs none in the placebo group (P<.001).

CONCLUSIONS: Although hydrocortisone treatment was associated with some improvement in symptoms of CFS, the degree of adrenal suppression precludes its practical use for CFS.

 

Source: McKenzie R, O’Fallon A, Dale J, Demitrack M, Sharma G, Deloria M, Garcia-Borreguero D, Blackwelder W, Straus SE. Low-dose hydrocortisone for treatment of chronic fatigue syndrome: a randomized controlled trial. JAMA. 1998 Sep 23-30;280(12):1061-6. http://www.ncbi.nlm.nih.gov/pubmed/9757853

 

Chronic fatigue syndrome comes out of the closet

An Alberta court ruling and new guidelines for physicians issued by the Quebec medical college are giving chronic fatigue syndrome a legitimacy it never before enjoyed. What will this mean for physicians?

Chronic fatigue syndrome (CFS) is gaining unprecedented legitimacy in Canada because of a recent Alberta count ruling, new guidelines from the Quebec medical college and recent research suggesting that the syndrome may have a biological basis. There is little doubt these developments will affect physicians across Canada.

Although viewed as a modern phenomenon, CFS was first reported by Hippocrates and has been known this century under various names: myalgic encephalomyelitis, Iceland disease, Epstein-Barr virus and yuppie flu. It has been labelled as CFS since 1988, and is currently estimated to affect 20 000 to 30 000 Canadian adults. According to the Centers for Disease Control and Prevention, CFS involves chronic fatigue for at least 6 months and a minimum of 4 other symptoms (p. 519). Scientists and doctors have been debating its existence and symptoms for years, but the debate may be winding down because of an Alberta court case (p. 533).

In March an Alberta woman finally won her case against Crown Life when the court ruled that she qualified for long-term disability benefits because of CFS. The well-publicized case emphasized the difficulty physicians have in diagnosing the illness, and the Alberta College of Physicians and Surgeons hopes to respond with CFS guidelines within a year. Dr. Brian Ward, the assistant registrar in charge of standards, says the college’s interest “began long before the case.” He says it has received frequent complaints from patients with CFS who can’t find physicians willing to treat them or follow their conditions. “They’ve asked us to increase the level of awareness among physicians and to provide education,” says Ward.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229658/pdf/cmaj_159_5_537.pdf

Comment in:

What causes chronic fatigue? [CMAJ. 1999]

What causes chronic fatigue? [CMAJ. 1999]

 

Source: Sibbald B. Chronic fatigue syndrome comes out of the closet. CMAJ. 1998 Sep 8;159(5):537-41. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229658/

 

Chronic fatigue syndrome gets court’s nod of approval as legitimate disorder

Lawyer Karen Capen looks at the implications of a recent Alberta court case involving chronic fatigue syndrome. She thinks Canada’s physicians should pay close attention to this precedent-setting case.

 

Few medical diagnoses are more hotly debated than chronic fatigue syndrome (CFS). Now, an Alberta court has added to the controversy. In Baillie v. Crown Life, a judge ruled that a women with CFS qualifies for long-term disability benefits.1 Crown Life was ordered to pay benefits to plaintiff Sharon Baillie, a former senior computer systems analyst with the insurance company.

Part of the case dealt with the insurance policy and the time requirements for filing a claim. For physicians, however, the ruling’s importance centres on how difficult it is to diagnose the condition.

This legal recognition of CFS, which the Alberta court handed down in March, should alert doctors of the need to understand the range of symptoms that fall within the condition’s diagnostic profile. The symptoms assigned to CFS generally include at least 6 months of extreme fatigue that reduces a person’s activity by 50% or more. This is accompanied by at least 4 other problems such as aching muscles and joints, headache, sleep disturbances, memory and concentration problems, and sore throat. Although the cause has yet to be determined conclusively, it is thought to involve a virus and/or a weakened immune system.

In recognizing CFS, the Alberta court recognized that a number of medical bodies have done the same thing, including the World Health Organization and the Centers for Disease Control and Prevention in Atlanta.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229657/pdf/cmaj_159_5_533.pdf

Comment in:

What causes chronic fatigue? [CMAJ. 1999]

What causes chronic fatigue? [CMAJ. 1999]

 

Source: Capen K. Chronic fatigue syndrome get court’s nod of approval as legitimate disorder. CMAJ. 1998 Sep 8;159(5):533-4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229657/pdf/cmaj_159_5_533.pdf

 

Chronic fatigue syndrome or just plain tired?

The complaint of unremitting fatigue has been around for centuries. Over the years, people with fatigue have been said to suffer from myalgic encephalomyelitis, Icelandic disease, neurasthenia, nervous exhaustion, febricula and Yuppie flu.1,2 Interest in the illness known today as chronic fatigue syndrome (CFS) grew when a cluster of patients in Nevada were found to have a chronic mononucleosis-like syndrome associated with persistently high titres of antibodies to Epstein–Barr virus (EBV) in the late 1980s.2 Today, the role of EBV and other potential viral and immunologic triggers of CFS remains unclear, and even in the wake of a recent flurry of research, the pathophysiology of CFS is poorly understood and no single diagnostic test can confirm its presence.

While CFS support groups lobby for disability coverage for individuals with CFS and insurance companies fight the claims, neither the public nor the medical community unanimously agrees on the existence of CFS as a real clinical entity. Some believe it is merely a presentation of depression or other psychosomatic illness; others argue that individuals claiming to have CFS have seized upon a convenient diagnosis to explain the effects of overwork or “normal” fatigue.

You can read the rest of this article here: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229654/pdf/cmaj_159_5_519.pdf

Comment in:

What causes chronic fatigue? [CMAJ. 1999]

What causes chronic fatigue? [CMAJ. 1999]

 

Source: Caplan C. Chronic fatigue syndrome or just plain tired? CMAJ. 1998 Sep 8;159(5):519-20. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1229654/

 

Structure and Determinants of Illness Representations in Chronic Disease: A Comparison of Addison’s Disease and Chronic Fatigue Syndrome

Abstract:

Although the clinical relevance of illness representations has been demonstrated in several studies, research on the structure and determinants of illness representations is rare. This article examines the illness representations of chronically ill patients, using a structured interview technique and taking chronic fatigue syndrome (CFS) and Addison’s disease (AD) as examples.

Considerable differences were found between the group of CFS patients (n = 98) and the group of AD patients (n = 63) with regard to their ideas about the identity, time line, control/cure , and consequences of their illness. Despite these differences, the pattern of correlations among these four dimensions of illness representation was found to be similar for the two groups. Moreover, the strength of the correlations points to the coherent nature of illness representations. The relations between the illness representations, personal variables, and disease- related variables were also explored.

Regression analyses showed the dimensions of illness representation to be explained rather well by personal and disease-related variables. Disease-related variables were the most important predictors for the dimensions of identity and consequences; personal variables showed strong associations with time line and control/cure.

 

Source: Heijmans M, De Ridder D. Structure and Determinants of Illness Representations in Chronic Disease: A Comparison of Addison’s Disease and Chronic Fatigue Syndrome. J Health Psychol. 1998 Oct;3(4):523-37. Doi: 10.1177/135910539800300406. http://www.ncbi.nlm.nih.gov/pubmed/22021411

 

Risk factors for ischemic heart disease in patients with chronic fatigue syndrome

Abstract:

Risk factors of coronary artery disease (CAD) between a group of patients suffering of chronic fatigue syndrome (CFS) and a control group of healthy persons (whose exercise activity was not health-limited) were compared.

Thirty three patients (27 women, 6 men, average age 39.9 +/- 11.7 years) and the same number of controls matched in age (39.8 +/- 10.3 years), gender and body weight. The Minnesota Questionnaire (by Taylor) and the Compendium of Physical Activities (by Ainsworth) were used to estimate total energetic expenditure in exercise activity as well as in job.

The risk factors of CAD in the patients with CFS were not higher than in the control group. Aerobic physical fitness, basic anthropometric data, blood pressure, spectrum of blood lipoproteins, blood uric acid and smoking habits were not different between the compared groups.

Patients suffering from CFS had lower total energetic expenditure in exercise activity. Nevertheless, this significant difference in sports activity was not large enough to cause any difference in risk factors of CAD between the CFS patients and the control group.

 

Source: Vilikus Z, Marecková H, Janatková I, Krystůfková O, Barácková M, Boudová L, Brandejský P, Fucíková T. Risk factors for ischemic heart disease in patients with chronic fatigue syndrome. Sb Lek. 1998;99(1):53-61. [Article in Czech] http://www.ncbi.nlm.nih.gov/pubmed/9748798