Pamphlet for Physicians on M.E.

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                  Chronic Fatigue Syndrome                            
                 A Pamphlet for Physicians                            
        U.S. Department of Health and Human Services                  
                   Public Health Service                              
               National Institutes of Health                          
                 NIH Publication No. 92-484
                          May 1992
                     Table of Contents
                   Historical Perspective
                      Clinical Picture
                   Evaluation of Patients
                    Immunologic Features
                 Neuropsychologic Features
                     Etiologic Theories
                     Patient Management
Page 1
                  Chronic Fatigue Syndrome
Chronic fatigue syndrome (CFS) is an illness characterized
by debilitating fatigue and several flu-like symptoms such
as pharyngitis, adenopathy, low-grade fever, myalgia,
arthralgia, headache, difficulty concentrating, and exercise
intolerance.  These nonspecific symptoms can make the
syndrome difficult to identify.  Profound fatigue -- the
earmark of the disorder -- usually comes on suddenly and
persists or relapses throughout the course of the illness.
But unlike the short-term fatigue and malaise that often
accompanies an acute infection, by definition, CFS symptoms
linger for at least 6 months, and often for years.
Chronic fatigue is a common complaint in primary care
practice.  No evidence exists to suggest that most patients
with chronic fatigue have CFS.  Indeed, CFS is probably an
uncommon cause of chronic fatigue.
When evaluating patients with chronic fatigue of unknown
origin, physicians can use the definition of CFS in the
Appendix as a guide.  This detailed definition was developed
for research use under the leadership of the Centers for
Disease Control.  It was published in Annals of Internal
Medicine in March 1988.  Because the disease is still poorly
understood, however, the outlined criteria should be
considered provisional.
Most investigators studying CFS believe that the syndrome
has many possible causes.  For example, various infectious
agents often trigger the onset of CFS.  Preliminary research
also shows a variety of immunologic disturbances in some
patients.  No single pattern of disturbances appears
consistently, however, and in general, patients are
Page 2
not clinically immunocompromised: they do not develop
opportunistic infections.  In fact, the character,
epidemiology, and prognosis of CFS is quite distinct from
that of major immune deficiency disorders such as AIDS.
Several different latent viruses also appear to be
reactivated in some CFS patients, although reactivation has
not been shown in all patients, and it is not clear that any
of these viruses are causally related to CFS or its
symptoms.  Many patients with CFS also present with anxiety
or depression.  In summary, as with most chronic illness,
CFS has both physical and psychiatric manifestations.
Most cases of CFS are sporadic: the patient does not have a
close contact who has developed a similar illness.
Infrequently, however, close contacts, including family
members, become ill with CFS at about the same time.  During
the past 60 years, several apparent epidemics of this
illness affecting various communities or relatively large
numbers of co-workers have been reported.  Clusters of CFS
cases are unusual, however, and it is not generally thought
that people with CFS need to be isolated in any way.  The
clinical and laboratory findings of sporadic versus epidemic
cases have yet to be compared.
While the typical patient seeking medical care for CFS is a
white woman in her thirties, patients of all ages (including
the very young and very old), both sexes, many races, and
all socioeconomic groups have been affected.  CDC and
NIAID-sponsored researchers have studies under way to try to
estimate the prevalence of this disorder.
Page 3
                   Historical Perspective
Although interest in this illness has grown tremendously
since the mid-1980's CFS does not appear to be a new
disorder.  It closely resembles neurasthenia or
neurocirculatory asthenia, diagnoses commonly made in the
late 19th and early 20th centuries.  As stated earlier,
small epidemics of a very similar illness (most often called
myalgic encephalomyelitis, or ME) have been described in the
medical literature for at least 60 years.  Furthermore, case
reports describing similar illnesses date back several
centuries.  These sporadic cases of fatigue syndromes have
often been linked to bacterial, viral, or protozoal
infections (for example, brucellosis and influenza).  But
fatigue syndromes also appear outside the setting of an
infectious illness.  Several recent studies indicate that
the rheumatologic disorder called fibrositis or
fibromyalgia, first
     Febricula, Vapors
           Da Costa's (Effort) Syndrome
                       Chronic Brucellosis
               Myalgic Encephalomyelitis,
                Epidemic Neuromyasthenia
                  Total Allergy Syndrome
      Chronic Mononucleosis, Chronic EBV
                     Chronic Candidiasis
              Postviral Fatigue Syndrome
                Chronic Fatigue Syndrome
1800      1850      1900      1950
Timeline graph from 1800 to the present of other
diseases with symptoms very similar to CFS.
Page 4
described in the 19th century, is very similar to CFS.  The
average age of the patient with fibrositis is a bit older,
however, and soft tissue pain is a more prominent symptom in
this illness.
In the early 1980's, several studies indicated that antibody
levels to one virus, Epstein-Barr virus (EBV), were somewhat
higher in patients with CFS than in healthy individuals.  It
is important to put this observation in context.  EBV
infection is extremely common: approximately 90 percent of
American adults have been infected, and they harbor a
lifelong infection thereafter.  In most people the virus
remains dormant.  Antibody studies indicate that EBV may be
reactivated - i.e., replicating itself - more often in
patients with CFS than in healthy individuals.  But the
difference is not striking.  Moreover, as mentioned earlier,
evidence shows that several other viruses may also be
reactivated in CFS.  Therefore, investigators believe that
there is no proof that EBV causes CFS, at least in most
                      Clinical Picture
A hallmark of CFS is the sudden onset of the illness,
typically with flu-like symptoms.  In contrast to the usual
flu-like illness, however, the symptoms of CFS do not fully
resolve; they persist chronically, or wax and wane
frequently, accompanied by debilitating fatigue and malaise.
In a few cases, CFS seems to follow from a bout of classic
acute infectious mononucleosis rather than from a
nonspecific flu-like illness.  In these cases, EBV - the
cause of most cases of acute mononucleosis - may play a role
in the pathogenesis of CFS.
Clearly some CFS symptoms - headache, myalgia, sleep
disorder, difficulty concentrating - could be secondary
symptoms of a primary affective disorder.  However, other
symptoms such as pharyngitis, fever,
Page 5
adenopathy, and arthralgias suggest a different underlying
Many patients have a history of allergies years before the
onset of CFS, and occasionally allergic symptoms worsen
after these patients become ill.  Allergies are so prevalent
in CFS patients that it is important to differentiate those
symptoms that are allergy-related and thus amenable to
The course of CFS varies greatly, with symptoms lasting
anywhere from many months to many years.  Symptoms typical
of CFS are often seen for short periods of time; but these
symptoms must persist for at least 6 months, according to
the current CDC definition, to entertain a diagnosis of CFS.
Fortunately, CFS is not a progressive disease: usually the
symptoms are most severe in the first year of illness.
Systematic studies are under way to better define the
                   Evaluation of Patients
The patient with the complaint of chronic fatigue that is
interfering with his or her life must be taken seriously.
CFS symptoms overlap with those of many well-recognized
illnesses.  For example, Lyme borreliosis, mild systemic
lupus erythmatosus (SLE), and early or mild multiple
sclerosis (MS) are among the numerous disorders that
resemble CFS.  A history of potential tick exposure, the
typical Lyme rash (erythema chronicum migrans), and
antibodies to the Lyme spirochete suggest the diagnosis of
Lyme borreliosis. In both SLE and MS, debilitating chronic
fatigue can be more prominent than rheumatologic or
neurologic symptoms.  Psychiatric illnesses that most
resemble CFS include major depressive episode, panic
disorder, generalized anxiety disorder, and somatization
disorder.  It remains unresolved whether
Page 6
prior or current depressive episodes should exclude a
diagnosis of CFS.
Although infectious agents can trigger the syndrome, the
diagnosis of CFS currently is one of exclusion.  The
Appendix lists several illnesses that must be considered and
"ruled out" when first evaluating a patient with chronic
fatigue.  This list is a useful guide but should not be
thought of as exhaustive.
The patient's medical history -- particularly his or her
potential epidemiologic exposures -- and physical
examination will help determine the need for various
laboratory tests.  A reasonable initial laboratory workup
would include a urinalysis, complete blood count and
differential count, chemistry panel, thyroid function test
(a TSH test may be sufficient), erythrocyte sedimentation
rate, anti-nuclear antibodies, and rheumatoid factor.
Significantly abnormal results on any of these tests should
prompt consideration of alternative diagnoses.  It is
prudent for physicians today to also consider the
possibility of infection with the human immunodeficiency
virus.  Subsequent workup should be guided by the clinical
picture and may necessitate a chest X-ray, an
electrocardiogram, an Ig level, a tuberculin skin test, and
serum cortisol determinations, among other tests.
                    Immunologic Features
Many different immunologic findings have been described in
patients with CFS, but no single immunologic disturbance has
yet been identified as typical of the syndrome.  Those
disturbances observed include depressed natural killer (NK)
cell activity, elevated viral antibody titers, and
circulating immune complexes.  These findings indicate
general differences between patient populations
Page 7
and control groups, but none is specific for CFS or abnormal
in all CFS patients.  Immunologic changes like these are
often associated with infections and other stressful
                 Neuropsychologic Features
As mentioned earlier, many patients with CFS also meet
diagnostic criteria for depression or anxiety disorders at
presentation.  It remains unclear whether a higher than
normal frequency of psychiatric disorders in this patient
group also exists in the years prior to the onset of CFS.
On the other hand, psychiatric evaluations fail to identify
any psychiatric disorders in some patients.  Because subtle
psychiatric problems can be difficult to recognize, a
consult with a psychiatrist or psychologist may benefit the
evaluation of some patients.
Many people with CFS have neurologic symptoms, including
paresthesias, disequilibrium, and visual blurring.  A few
patients who are otherwise identical to the larger group
have had more dramatic acute and transient neurologic
events, such as primary seizures, periods of severe visual
impairment, and periods of paresis.  These few patients show
no evidence of any well-recognized neurologic disorder such
as MS.  Patients with these more dramatic symptoms warrant a
more intensive neurologic workup.
One study found that people with CFS have a subtle
deficiency of the steroid hormone cortisol.  Because
cortisol is a potent suppressor of immune responses, this
finding provides an alternative explanation for some of the
immune findings in the syndrome.
Preliminary research indicates that some patients with CFS
demonstrate punctate areas of high signal in the
sub-cortical white matter on magnetic resonance imaging
scans of the brain.  Studies are under way to
Page 8
determine if these abnormalities are found more frequently
in people with CFS than in healthy individuals.  For many
patients, the cognitive impairment they experience is one of
the most disconcerting symptoms.  It is usually
characterized as an inability to concentrate, unusual
absent-mindedness, and difficulty with word finding.  CFS
patients do not exhibit gross dementia.  Neuropsychological
testing is being conducted to better define the presence,
nature, and severity of cognitive impairment in patients
with CFS.
                     Etiologic Theories
Several theories have been postulated as to the etiology of
CFS.  Most investigators currently believe that no single
etiologic agent will prove to be the cause of all cases.
Many investigators believe that the illness involves a
constant antigenic challenge to the immune system and, as a
consequence, a constant immunologic response to that
challenge.  One popular theory, which has experimental
support, suggests that elevated levels of cytokines (e.g.,
interleukin-1, interleukin-2, various interferons) are
generated by an immune system that is doing battle against
antigens that it perceives to be foreign.  The flu-like
symptoms associated with many common infections are known to
be caused by cytokines.  Moreover, when these cytokines are
administered for therapeutic purposes, such as the use of
interleukin-2 or interferon in cancer therapy, many flu-like
symptoms occur.
Preliminary evidence suggests that several latent viruses
may be actively replicating more often in CFS patients than
in healthy control subjects.  Antibody levels are higher in
patients (indirect evidence of active infection); viral
antigen is found more commonly; or there is direct evidence
that the
Page 9
virus is replicating in cells that it commonly infects, such
as lymphocytes.  Thus far, those viruses that show some
evidence of more frequent active infection are several
members of the herpesvirus family -- EBV, cytomegalovirus,
herpes simplex viruses 1 and 2, and human herpesvirus 6 --
and of the enterovirus family -- coxsackievirus and
If subsequent studies confirm that several viruses are
active more often in people with CFS than in healthy
individuals, it will then need to be determined if this
activity is a primary or secondary event.  Because the viral
agents thus far identified typically infect people in
childhood, and since most patients with CFS are young
adults, most investigators believe reactivation of these
viruses is probably secondary to some immunologic
disturbance.  If viral activation is indeed a secondary
event, it will need to be determined if it is merely an
epiphenomenon, having nothing to do with the reason the
patient feels sick, or whether the viral activation - even
if secondary -- contributes to the symptoms.
                     Patient Management
CFS is debilitating in all patients, disabling in some, but
apparently not progressive or fatal.  The debility and
disability stem from a combination of symptoms such as
fatigue, arthralgias, or cognitive impairment, and in some
patients from associated depression.  The patients need both
symptomatic treatment and emotional support.  It should be
noted, however, that some patients get better all by
It is vitally important for the physician to be the
patient's advocate.  In the absence of any proven
treatments, empiric therapies should be tried.  At the same
time, patients need to be kept from using exotic, untested
remedies that may hurt them.  Physicians also need to be on
the lookout for other medical
Page 10
problems, and to avoid the danger of interpreting every new
sign or symptom as a manifestation of CFS.
For many patients, it is important to slow the pace of their
lives and to avoid situations that are physically or
psychologically stressful.  Counseling for both the patient
and his or her family benefits their adjustment to this
chronic illness.  It is important for them to realize that
no definitive diagnostic or therapeutic approaches exist.
Neither has a specific nutritional program proved
beneficial, though a balanced diet and rest enhance
well-being.  Some patients benefit from a graduated program
of exercise.  At a minimum, patients should be encouraged to
maintain physical conditioning -- in some cases through a
sustained program of physical therapy -- at whatever level
of activity they can manage.  Abrupt resumption of vigorous
exercise should be avoided, however, because this can
exacerbate symptoms.
Symptomatic treatment can be quite helpful.  Non-steroidal
anti-inflammatory drugs may benefit the myalgias,
arthralgias, headaches, or fever associated with the
illness.  Nonsedating antihistamines may help relieve any
prominent allergic symptoms.
Very few randomized, controlled clinical drug trials for CFS
have been conducted.  One such trial found the antiviral
drug acyclovir to be no better than a placebo treatment.  In
fact, more than 40 percent of patients on placebo reported
Several empiric therapies have been tried for CFS.  Some
investigators have administered intramuscular or intravenous
gammaglobulin, particularly to those patients who, unlike
most patients with CFS, have low levels of immunoglobulins.
There are conflicting claims regarding the efficacy of this
form of therapy -- one trial found some benefit, the other
Page 11
Several empiric therapies have been tried for CFS.  Because
well-designed clinical trials have demonstrated the benefit
of low doses of tricyclic antidepressant drugs in
fibromyalgia (an illness similar to CFS), tricyclics are
widely prescribed for CFS patients.  Anecdotal experience
with tricyclics has generally been positive.  Some
investigators believe that the tricyclics act by improving
the quality of sleep.  Other types of antidepressants have
also been tried with some success.  CFS patients often
report that antidepressants exacerbate their fatigue,
however, especially when given in therapeutic doses.  It may
be necessary to escalate doses very slowly and urge patience
in detecting benefit, or to try the more activating
antidepressants such as desipramine, fluoxetine, and MAO
In brief, no strict recipe for treating CFS exists, and
sometimes several different treatment approaches may have to
be tried before the patient reports benefit.  Both the
physician and the patient need to be open to reasonable
treatment alternatives and appreciate the difficulty in
assessing their benefit in CFS.
A great deal of controversy and speculation surrounds CFS:
Is it a single disorder or a heterogeneous mix of problems?
What is its relationship to infections, the immune system,
and mood disturbances?  How can it best be treated?  These
and many more issues fuel the continuing broad debate, often
leaving patients and their physicians frustrated.  For now,
physicians don't have all the answers.  But in treating
people with CFS, they can draw on practices that have always
made medicine a valued art: exclude alternative problems,
ameliorate symptoms, and offer guidance with compassion.
Page 12
               Research Case Criteria for the
                 Chronic Fatigue Syndrome*
A case of chronic fatigue syndrome must fulfill major
criteria 1 and 2 and the following minor criteria: 6 or more
of the 11 symptom criteria and 2 or more of the 3 physical
criteria; or 8 or more of the 11 symptom criteria.
Major Criteria
1.     New onset of persistent or relapsing, debilitating
fatigue or easy fatigability in a person who has no previous
history of similar symptoms, that does not resolve with
bedrest, and that is severe enough to reduce or impair
average daily activity below 50% of the patient's premorbid
activity level for a period of at least 6 months.
2.     Other clinical conditions that may produce similar
symptoms must be excluded by thorough evaluation, based on
history, physical examination, and appropriate laboratory
findings.  These conditions include malignancy; autoimmune
disease; localized infection (such as occult abscess);
chronic or subacute bacterial disease (such as endocarditis,
Lyme disease, or tuberculosis), fungal disease (such as
histoplasmosis, blastomycosis, or coccidioidomycosis), and
parasitic disease (such as toxoplasmosis, amebiasis,
giardiasis, or helminthic infestation); disease related to
human immunodeficiency virus (HIV) infection; chronic
psychiatric disease, either newly diagnosed by history (such
as endogenous depression; hysterical personality disorder;
anxiety neurosis; schizophrenia; or chronic use of major
tranquilizers, lithium, or antidepressive medications);
chronic inflammatory disease (such
*From Holmes GP, et al.  Chronic fatigue syndrome: a working
case definition.  Ann. Intern. Med. 1988;108:387-9.
Page 13
as sarcoidosis, Wegener's granulomatosis, or chronic
hepatitis); neuromuscular disease (such as multiple
sclerosis or myasthenia gravis); endocrine disease (such as
hypothyroidism, Addison disease, Cushing syndrome, or
diabetes mellitus); drug dependency or abuse (such as
alcohol, controlled prescription drugs, or illicit drugs);
side effects of chronic medication or other toxic agent
(such as chemical solvent, pesticide, or heavy metal); or
other known or defined chronic pulmonary, cardiac,
gastrointestinal, hepatic, renal, or hematologic disease.
Specific laboratory tests or clinical measurements are not
required to satisfy the definition of the chronic fatigue
syndrome, but the recommended evaluation includes serial
weight measurements (weight change of more than 10% in the
absence of dieting suggests other diagnoses); serial morning
and afternoon temperature measurements; complete blood count
and differential; serum electrolytes; glucose; creatinine,
blood urea nitrogen; calcium, phosphorous; total bilirubin,
alkaline phosphatase, serum aspartate aminotransferase;
creatine phosphokinase or aldolase; urinalysis;
posteroanterior and lateral chest roentgenograms; detailed
personal and family psychiatric history; erythrocyte
sedimentation rate; antinuclear antibody;
thyroid-stimulating hormone level; HIV antibody measurement;
and intermediate-strength purified protein derivative (PPD)
skin test with controls.
If any of the results from these tests are abnormal, the
physician should search for other conditions that may cause
such a result.  If no such conditions are detected by a
reasonable evaluation, this criterion is satisfied.
Page 14
Minor criteria
Symptom criteria
To fulfill a symptom criterion, a symptom must have begun at
or after the time of onset of increased fatigability, and
must have persisted or recurred over a period of at least 6
months (individual symptoms may or may not have occurred
simultaneously).  Symptoms include:
1.  Mild fever -- oral temperature between 37.6 degrees C
and 38.6 degrees C, if measured by the patient -- or chills.
(Note: oral temperatures of greater than 38.6 degrees C are
less compatible with chronic fatigue syndrome and should
prompt studies for other causes of illness.)
2.  Sore throat.
3.  Painful lymph nodes in the anterior or posterior
cervical and axillary distribution.
4.  Unexplained generalized muscle weakness.
5.  Muscle discomfort or myalgia.
6.  Prolonged (24 hours or greater) generalized fatigue
after levels of exercise that would have been easily
tolerated in the patient's premorbid state.
7.  Generalized headaches (of a type, severity, or pattern
that is different from headaches the patient may have had in
the premorbid state).
8.  Migratory arthralgia without joint swelling or redness.
9.  Neuropsychologic complaints (one or more of the
following: photophobia, transient visual scotomata,
forgetfulness, excessive irritability, confusion, difficulty
thinking, inability to concentrate, depression).
10. Sleep disturbance (hypersomnia or insomnia).
11. Description of the main symptom complex as initially
developing over a few hours to a few days (this is not a
true symptom, but may be considered as equivalent to the
above symptoms in meeting the requirements of the case
Page 15
Physical Criteria
Physical criteria must be documented by a physician on at
least two occasions, at least 1 month apart.
1.  Low-grade fever - oral temperature between 37.6 degrees
C and 38.6 degrees C, or rectal temperature between 37.8
degrees C and 38.8 degrees C.  (See note under Symptom
Criterion 1.)
2.  Nonexudative pharyngitis.
3.  Palpable or tender anterior or posterior cervical
axillary lymph nodes.  (Note: lymph nodes greater than 2 cm
in diameter suggest other causes. Further evaluation is
To receive a CFS information packet, contact:
Office of Communications
National Institute of Allergy and
  Infectious Diseases
Building 31, Room 7A32
9000 Rockville Pike
Bethesda, MD 20892
(301) 496-5717
National Institute of Allergy
and Infectious Diseases
NIH Publication No. 92-484
May 1992

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