chronic fatigue syndrome _cfs_2

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					 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
daily functioning.
• i.e. The main complaint of patients with CFS
  is persistent severe fatigue, but most have
  many concomitant symptoms like:

     • Pain
     • Cognitive dysfunction

     *memory / concentration*
     US and UK Case definition for CFS

1. Severe disabling fatigue affecting physical and
   mental functioning.
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
     -bipolar disorders
     -eating disorders
     -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
         Exclusion criteria

• Medical condition explaining fatigue
• Major depressive or bipolar disorders
• Schizophrenia, dementia, or delusional
• Anorexia nervosa, bullaemia nervosa
• Substance abuse
• Severe obesity
          Differential diagnosis
• Up to 20% of patients may turn out to have other
  medical or surgical problems like:
     -chronic infections: EBV, HIV, Coxsackivirus,
       Toxoplasma, Brucella,..
     - Connective tissue diseases: SLE, Sjögren’s
       disease, Rheumatoid arthritis, polymyositis.
     -other autoimmune diseases: especially
       thyroid, adrenal, pituitary disease or
        diabetes. Also gastrointestinal & CNS.
-sleep apnoea
-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
           -precipitating factors
           -perpetuating factors
          »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*
              Precipitating factors

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.
                Perpetuating 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.

   -Social processes:
      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
          fatigue-related cognition
          Achieving and maintenance of basic
          physical activity.
        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
Personal experience:

1st Education of the patient about the disease
      (Reasurrance and psychotherapy)
2nd Activity and exercise
      *balanced rest and exercise*
3rd Rehabilitational program
4th Nutrition
    *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

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