Chronic fatigue Syndrome (CFS)
Dr Gehad ElGhazali, MD, SBCI, PhD
Associate Professor of Clinical Immunology
Head, Consultant in Immunology
Department of Immunology
King Fahad Medical City
• CFS is a diagnosis of exclusion.
• ME (myalgic encephalomyelitis) is an
inapproperiate term as there is no
evidence for an encephalomyelitis.
CFS is charcterized by persistent or
relapsing, and unexplaned fatigue
resulting in severe impairment in
• i.e. The main complaint of patients with CFS
is persistent severe fatigue, but most have
many concomitant symptoms like:
• Cognitive dysfunction
*memory / concentration*
US and UK Case definition for CFS
1. Severe disabling fatigue affecting physical and
2. Minimum duration of symptoms
= 6 months.
3. Fuctional impairment= disabling
4. Mental fatigue required
5. No other symptoms required
6. No evidence for other medical illness
7. Normal screening blood tests
US and Canada (additions)
• Physical causes of fatigue excluded
• Psychiatric disorders excluded
-organic brain disease
CDC case definition for CFS
+ Fatigue is of new or defined onset
+ Fatigue is not the result of an organic
disease or of continuing exertion
+ Fatigue is not alleviated by rest
+ four of the following symptoms, concurrently
present for ≥ 6 months:
- Impaired memory or concentration
- Tender cervical or axillary lymph nodes
- Muscle pain (myalgia)
- Pain in several Joints (non-specific
arthralgia, no athritis)
- new headache
- non-refreshing sleep
- Malaise after exertion
- Sore throat
• Medical condition explaining fatigue
• Major depressive or bipolar disorders
• Schizophrenia, dementia, or delusional
• Anorexia nervosa, bullaemia nervosa
• Substance abuse
• Severe obesity
• Up to 20% of patients may turn out to have other
medical or surgical problems like:
-chronic infections: EBV, HIV, Coxsackivirus,
- Connective tissue diseases: SLE, Sjögren’s
disease, Rheumatoid arthritis, polymyositis.
-other autoimmune diseases: especially
thyroid, adrenal, pituitary disease or
diabetes. Also gastrointestinal & CNS.
-Poisoning: CO, heavy metal,
-Primary psychiatric disorders like
depression (it can be 2nd to CFS).
• The prevalence varies greatly but it varies between
0.25-0.5 % (western countries and USA).
• Women are more affected with higher rates in the
• People with lower educational attainment and
occupational status are more affected.
• Fully recovery without treatment is rare.
• Median recovery rate of 5% and mediam
improvement rate 40%.
• A better outcome was predicted by less
severe fatigue at baseline and the patient not
attributing the illness to physical causes.
• Poorer outcome is predicted by psychiatric
• Many somatic and psychosocial hypotheses on the
aetiology of CFS has been explored:
– Viral infections (e.g. EBV, CMV)
– Immune dysfunction
(low CD4/CD8, poor B lymphocyte function, increased markers for T lymphocyte
activation, abnormalities of NK cells/monocytes, minor abnormalities of IgG
– Neuroendocrine responses
– Dysfunction of the central nervous system
Well-controlled studies failed to relate CFS to any of the above causes
independently, apart from sutle changes in the hypothalmic-pituitary-
adrenal axis (short synacthen test= abnormal response).
Aetiology and pathogenesis:
Different factors are involed:
- predisposing factors
Personality characteristics & lifestyle might
influence vulnersbility to CFS.
Inactivity during childhood or after infectious
mononucleosis increase the rish of CFS.
Host genetics *twin studies*
Acute physical or psychological stress might
trigger the onset.
75% of patients reported an infection, cold or
flu-like illness, or infectious mononucleosis,
as a trigger (causal relation with the later).
• Serious life events- loss of a loved one or a
job, and other stressful situations were
defined as precipitating factors.
Several maintaining factors can impede
- Psychological processes:
This involves ideas or cognitions of
patients about complaints (avoid activities so
as not to increase symptoms), that result in fatigue
severity and functional impairment.
Inactivity or avoidance in CFS is caused
by perceptions and expectations rather
than by physical fitness.
Other psychological processes involved are
related to perception problems for sleep
disturbance and cognitive performance.
Lack of social support
Doctors:unneccessary medical diagnostics
suggesting psychological causes
Not acknowledging CFS as a diagnosis
(causing communication problems)
Long lasting disease: disengagement might
contribute to persistence of CFS
• There is no known cause and there is no know Cure.
• Two evidence-based therapies proved to be beneficial:
- Cognitive behaviour therapy (CBT)
(causal relation between behaviour and cognitive factors, and
-Graded exercise therapy (GET)
• Psychotherapy: directed at changing
condition-related cognitions and behaviours.
central components of CBT for CFS include:
explain the aetiology model
motivation for CBT
challenging and changing of
Achieving and maintenance of basic
gradual increase in physical
Planning of rehabilitation
Lifestyle management allowing optimun
adaption to the illness/ approperiate balance
of rest and activity.
Stepwise approach for management of CFS
1st Education of the patient about the disease
(Reasurrance and psychotherapy)
2nd Activity and exercise
*balanced rest and exercise*
3rd Rehabilitational program
*avoid GIT irritants, fried greasy foods, Tobaco,
caffeine* also sugar.
Vit. B12 and Omega3/fish oil might be of help.
5th Symptomatic therapy (last)
• Sleep management
• Headache control
• In conclusion