Chronic Fatigue Syndrome (CFS)

• Chronic Fatigue Syndrome Overview
• Chronic Fatigue Syndrome Causes
• Chronic Fatigue Syndrome Symptoms
• When to Seek Medical Care
• Questions to Ask the Doctor
• Exams and Tests
• Chronic Fatigue Syndrome Treatment
• Self-Care at Home
• Medical Treatment
• Medications
• Other Therapy
• Next Steps
• Follow-up
• Prevention
• Outlook
• Support Groups and Counseling
• For More Information
• Web Links
• Synonyms and Keywords
• Authors and Editors
• Viewer Comments: Chronic Fatigue Syndrome - Coping With the Symptoms

Chronic Fatigue Syndrome Overview

Chronic fatigue syndrome (also called CFS) is a disorder without a known cause, although CFS may be related to a previous infection. CFS is a state of chronic fatigue that exists without other explanation for six months or more and is accompanied by cognitive difficulties (problems with short-term memory or concentration). You may have CFS if you meet the following criteria:

• if you have severe chronic fatigue for six months or longer and all other known conditions that could cause fatigue have been excluded by your health-care provider, or



• if you simultaneously have four or more of the following symptoms: significant problems with short-term memory or concentration, sore throat, tender lymph nodes, muscle pain, pain in several joints without swelling or redness, headaches that are different in pattern or severity from previous headaches, feeling tired and unrefreshed even after sleeping, and extreme tiredness lasting more than 24 hours after you exercise or exert yourself.

Chronic fatigue syndrome affects tens of thousands of people. It occurs more commonly in females than in males. This condition occurs most commonly in young to middle-aged adults. People with CFS are often unable to perform normally at work and home because of their long-term fatigue and problems with short-term memory. This can lead to depression, but depression is not a cause of CFS.

Chronic Fatigue Syndrome Causes

The cause of CFS is unknown, but the condition may be related to infection with effects on the immune system. Several viruses have been studied as possible causes of CFS, but no cause-and-effect relationship has been discovered. Some evidence indicates that the bacterium Chlamydia pneumoniae (which causes pneumonia and other illnesses) may be a cause of CFS in some cases. People with chronic fatigue syndrome related to C. pneumoniae are most likely to respond to antibiotics that kill C. pneumoniae, and their CFS symptoms may improve with antibiotic medications such as doxycycline. However, this association is still being debated. Various unrelated infections appear to lead to long-term fatigue in some people. If the fatigue is accompanied by problems with short-term memory or concentration, CFS is possible.

• One of the associated infections is the Epstein-Barr virus, or EBV. EBV causes mononucleosis, also called "mono" or the "kissing disease." Although associated in some cases, EBV does not cause CFS, and CFS is not the same thing as long-term EBV infection or long-term mononucleosis.



• Other unrelated infectious diseases that appear to lead to fatigue include pneumonia, diarrhea, and bronchitis.



• Candida albicans infections (or yeast infections) do not cause CFS.

Other conditions that cause symptoms similar to those of CFS must be ruled out. These include the following:

• adrenal insufficiency,



• malignancy,



• AIDS,



• liver disease,



• kidney disease,



• psychosomatic illness,



• Lyme disease,



• fibromyalgia,



• hepatitis C, and



• thyroid disease.

Chronic Fatigue Syndrome Symptoms

Diagnosing CFS requires ruling out other causes of chronic persistent fatigue, including a stressful lifestyle, cancer, or other illness such as adrenal or thyroid disorders, HIV, or AIDS. Since there are no laboratory tests that specifically make the diagnosis of CFS, the diagnosis is based on symptoms. People with CFS experience the following symptoms:

• Fatigue: People with CFS have long-term fatigue (lasting longer than 6 months to a year) that cannot be explained by other diseases. People with CFS may have had a previous infection. They are tired and "run down" during the infection, and the fatigue continues after the person has recovered from the illness.



• Cognitive difficulties: A typical complaint of people with CFS is that they have problems with short-term memory but not long-term memory. People with CFS may have problems finding or saying a particular word during normal speech (called dysnomia or verbal dyslexia).



• Postexertional fatigue: Postexertional fatigue may also be a problem for people with CFS. They are excessively tired after doing normal activities that were not difficult in the past.



• Fatigue after sleep: People with CFS also complain of fatigue even after long periods of rest or sleep. They do not feel refreshed after sleeping.



• Depression: People with CFS may become depressed because of difficulties performing at work or home, but depression does not cause CFS.



• Other symptoms that may be seen include headaches, muscle aches, sore throat, and even mild fever.

When to Seek Medical Care

People seek medical care when the fatigue and cognitive difficulties of chronic fatigue syndrome affect their quality of life. People who have questions about a particular treatment should contact a qualified health-care provider, local medical society, or university medical school for additional information.

Questions to Ask the Doctor

Because the cause of chronic fatigue syndrome is unknown, there is no established treatment to cure CFS. Treatment is aimed at relieving symptoms, and some proposed treatments are unproven and may be harmful. Always ask your doctor about any new treatment, including herbal supplements.

Exams and Tests

There is no single test to diagnose chronic fatigue syndrome. The disease is a diagnosis of exclusion, which means that all other conditions and illnesses that cause the symptoms are ruled out. CFS may be diagnosed based on the following:

• Certain signs and symptoms must be present. (People without cognitive dysfunction do not have CFS.)



• Some nonspecific laboratory tests, such as blood tests and tests of the immune system, suggest the diagnosis.

Laboratory tests are used to rule out other fatigue-causing diseases. Also, some laboratory abnormalities are seen in CFS and support the diagnosis.

Your doctor may perform the following tests:

• Tests to exclude other causes of fatigue: Thyroid, adrenal, and liver function tests are useful to rule out disorders that may cause fatigue. In people with CFS, the results of these tests should be normal.



• Blood tests: The most consistent laboratory abnormality in people with chronic fatigue syndrome is an extremely low erythrocyte sedimentation rate (ESR, the measurement of settling red blood cells in anticoagulated [non-clotting] blood). If the ESR is elevated or even in the high-normal range, another diagnosis is likely. If any other abnormalities are found on blood tests, your doctor may rule out CFS and begin testing for another condition.



• Antibody tests: Your doctor may order antibody tests to determine whether you have had a prior infection, such as Lyme disease, Chlamydia pneumoniae pneumonia, or Epstein-Barr virus.
  

Your doctor may perform the following imaging studies:

• CT scans or an MRI of the brain is useful to rule out other disorders of the central nervous system (CNS). Results of CT scans and MRI are normal in people with CFS.



• Single-photon emission computed tomography and/or positron emission tomography scans show decreased blood flow in areas of the brain (the frontoparietal/temporal region). This decreased blood flow explains the cognitive difficulties (short-term memory problems) in chronic fatigue syndrome.

Chronic Fatigue Syndrome Treatment

There are many described therapies for chronic fatigue syndrome. Because the cause of chronic fatigue syndrome is unknown, treatment programs are directed at relief of symptoms rather than cure. The goal is to regain some level of preexisting function and well-being. With this in mind, many people with CFS do not quickly return to a satisfactory level of function. People who expect a prompt recovery and do not experience it may have worsening CFS symptoms because they work too hard, become frustrated, and become less responsive to rehabilitation programs.

Always talk to your doctor about any treatment decisions for CFS. You and your doctor together will develop a treatment program individually tailored to your needs. The treatment program should be based on your overall medical condition and current symptoms and should be modified over time as your symptoms change. This requires regular follow-up visits to your doctor to monitor changes in your condition. Currently, most doctors use a combination of the therapies discussed below.

Self-Care at Home

Physical activity performed at a comfortable pace is important for everyone to maintain good health, including people with chronic fatigue syndrome. People with CFS need to learn how much activity is helpful and when to stop, so they do not increase their level of fatigue.

In general, people with CFS should pace themselves carefully and avoid excessive physical or emotional stress. Remember, the goal is to avoid increasing fatigue or pain. Maintain a regular and manageable daily routine to avoid a relapse or increase of symptoms. Exercise should be supervised by a knowledgeable health-care provider or physical therapist.

Total rest should also be avoided as it may make your fatigue worse. You should maintain physical activity at a comfortable pace. If you increase your level of physical activity, do so gradually.

Decreased consumption of alcohol and caffeine at night may help you sleep.

Try to minimize social isolation.

Medical Treatment

Medical therapy is designed to relieve the specific symptoms of chronic fatigue syndrome. People with CFS are often sensitive to many medications, especially those that affect the central nervous system. Usually, your doctor will begin with low doses of medication and gradually increase the dose depending on side effects and your response to the medication. Because drug therapy is directed at symptom relief, medications should only be used in CFS if all other causes of the symptom have been ruled out. Remember that all medications can cause side effects. Talk to your doctor before beginning any new medication and if any side effect develops.

Medications

• Nonsteroidal anti-inflammatory drugs: People use these medications, also called NSAIDs, for pain relief. Some are available without a prescription, including naproxen (Aleve) and ibuprofen (Advil, Bayer Select, Motrin, Nuprin). Prescription drugs include tramadol hydrochloride (Ultram), celecoxib (Celebrex), and other naproxen-containing medications (Anaprox, Naprosyn).



• Low-dose tricyclic antidepressants: These medications may improve sleep and relieve mild generalized pain. Examples include doxepin (Adapin, Sinequan), amitriptyline (Elavil, Etrafon, Limbitrol, Triavil), desipramine (Norpramin), and nortriptyline (Pamelor).



• Other antidepressants: Newer antidepressants have been used to treat depression in people with chronic fatigue syndrome. These antidepressants include fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), venlafaxine (Effexor), trazodone (Desyrel), and bupropion (Wellbutrin).



• Anxiolytic agents: These medications are used to treat anxiety in people with CFS. Examples include alprazolam (Xanax) and lorazepam (Ativan).



• Stimulants: Stimulants may be used to treat lethargy or daytime sleepiness. Studies using modafinil (Provigil) have been completed, but the results have not been published, and currently this drug is only indicated for narcolepsy (brief attacks of deep sleep) and excess daytime sleepiness in patients identified in proper sleep studies.



• Antimicrobials: A specific infection as a cause for chronic fatigue syndrome has not been identified, and antibiotic, antiviral, and antifungal drugs should not be prescribed for treatment of CFS in general. However, in people with elevated C. pneumoniae levels, particularly increased IgM titers, antibiotic therapy with doxycycline (Doryx, Doxy) may be effective.



• Anti-allergy therapy: Some people with CFS have allergies that periodically flare up. Nonsedating antihistamines may be helpful and include desloratadine (Clarinex), fexofenadine (Allegra), and cetirizine (Zyrtec). However, allergy therapy does not treat CFS itself.

Other Therapy

Other therapies tried by people with chronic fatigue syndrome include massage therapy, acupuncture, chiropractic therapy, cranial-sacral techniques, self-hypnosis, and therapeutic touch. People with CFS may feel better with such techniques, but these therapies should be combined with an individualized exercise program that includes stretching.

Many people report successful treatment of CFS symptoms with experimental therapies, herbal supplements, and dietary modifications. Various dietary and herbal products have been promoted in the market to improve symptoms of CFS. Many of these have not been tested in controlled trials. Preparations that have been claimed to have benefit to CFS patients include astragalus, borage seed oil, bromelain, comfrey, echinacea, garlic, Ginkgo biloba, ginseng, primrose oil, guercetin, St. John's wort, and Shiitake mushroom extract. Dietary supplements and herbal preparations can have potentially serious side effects, and some can interfere or interact with prescription medications. Do not begin any experimental treatments without consulting your doctor or health-care provider.

Next Steps

Follow-up

Regular follow-up is necessary for your doctor to monitor your treatment program. Because the treatment program should be based on your overall medical condition and current symptoms, it should be modified over time. Visit your health-care provider regularly.

Prevention

Chronic fatigue syndrome symptoms are worsened by stress, too much exercise, or lack of sleep. Avoid these triggers.

Outlook

The percentage of people who completely recover from chronic fatigue syndrome is not known. Most people with CFS have improvement in their symptoms over time with proper treatment strategies and regular care. People with CFS may have cyclical symptoms in which they have periods of illness followed by periods or relative wellness. Most patients recover within five years of the beginning of the illness.

Support Groups and Counseling

Many support groups are available for people with chronic fatigue syndrome, but not everyone with CFS will find a support group useful. Groups can add more stress for some people rather than relieving it. When considering joining a support group, think about the following:

• A useful group involves both newcomers and people who have had CFS for a longer time.



• You should feel comfortable with the people in the group.



• Group leaders should make shy members feel welcome and prevent others from dominating discussions. Discussions should provide you with useful information.



• Established groups are often more useful because the history of the group may indicate that it is stable and meets the needs of its members.



• Groups that promise immediate cures and solutions are probably unrealistic.



• Some group discussions are merely complaint sessions and do not offer helpful information or constructive discussions.



• Avoid any group that encourages you to stop the multimodality therapy prescribed by your doctor.



• Groups should not require you to reveal personal or sensitive information.



• Groups should not charge high fees or require you to buy products.

For More Information

National Center for Infectious Diseases
Centers for Disease Control and Prevention
Mailstop A15
Atlanta, GA 30333

National Institute of Allergy and Infectious Diseases
National Institutes of Health
Bethesda, MD 20892

Web Links

National Institutes of Health, National Institute of Allergy and Infectious Diseases (NIAID), Chronic Fatigue Syndrome

National Center for Infectious Diseases, Chronic Fatigue Syndrome

CFIDS Association of America

American Association for Chronic Fatigue Syndrome

Synonyms and Keywords

encephalomyalgia, CFS, chronic fatigue immune dysfunction syndrome, CFIDS, myalgic encephalitis, postural orthostatic tachycardia syndrome, POTS, chronic tiredness, muscle pain, fibromyalgia, weakness, stress, chronic fatigue syndrome

Authors and Editors

Author: William C. Shiel Jr., MD, FACP, FACR

Editor: Melissa Conrad Stöppler, MD, Chief Medical Editor, eMedicineHealth.com

Previous contributing authors and editors:

Author: Wesley W Emmons, MD, FACP, Assistant Professor, Department of Medicine, Thomas Jefferson University; Consulting Staff, Infectious Diseases Section, Department of Internal Medicine, Christiana Care, Newark, DE.

Coauthor(s): Jessica B Johnson, Medical Writer, eMedicine.com, Inc; Dhiren M Haria, MD, Clinical Research Assistant, Department of Medicine, Division of Nephrology, Kings County Hospital, SUNY Downstate Medical Center.

Editors: Joseph Richard Masci, MD, Chief of Infectious Diseases, Director, Department of Internal Medicine, Division of Infectious Diseases, Elmhurst Hospital Center, Professor of Medicine, Mount Sinai School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Michael Stuart Bronze, MD, Chairman, Professor, Department of Medicine, University of Oklahoma Health Science Center.

Last Editorial Review: 2/10/2009