Physical examination: positive findings

• Appearance: tired and droopy/hunched over
  • unkempt (normally well groomed)
• Cognition: difficulty focusing on interview questions
  • problems groping for words
  • difficulty remembering questions during the interview
• Vital signs: temperature 36.2° C
  • BP lying 90/60, standing 80/50 and lightheaded
• ENT: non-exudative pharyngitis with bilateral red crescents, tender
  • cervical nodes & left supraclavicular node
• CVS: nail beds of both hands and feet were white
• CNS: normal reflexes, negative Romberg and a positive Tandem test

Differential diagnosis of CFS/myalgic encephalomyelitis must exclude active treatable diseases

• Addison’s disease
• Cushing’s syndrome
• hypo- or hyperthyroidism
• iron deficiency and other anemias
• iron overload
• rheumatological disorders
• infectious diseases: HIV, mononucleosis, lyme disease, hepatitis, TB
• substance abuse
• neurological disorders: MS, Parkinson’s disease, myasthenia gravis
• primary psychiatric disorders
• diabetes mellitus
• cancer
• treatable sleep disorders: apnea, upper airway resistance syndrome

Criteria

• Fatigue: new onset with persistent debilitating physical and mental fatigue that substantially reduces activity level.
• Post-exertional fatigue/malaise: loss of physical and mental stamina, associated with pain or cluster symptoms with a pathologically slow recovery period of 24 hours or more.
• Sleep: unrefreshed, interrupted, non-restorative with chaotic diurnal sleep rhythms.
• Pain: arthralgias and/or myalgias. Headaches of new type, pattern or severity.
• Neurological/cognitive manifestations: decreased concentration and short-term memory, slowed processing, overload phenomenon (inability to multitask), perceptual and sensory disturbances e.g. difficulty focusing, photophobia and hypersensitivity to noise.
• At least one symptom from two of the following categories:
  • Autonomic nervous system: orthostatic intolerance, postural hypotension, light-headedness, nausea, IBS, urinary bladder disturbances, cardiac arrhythmias, exertional dyspnea.
  • Neuroendocrine: thermostatic instability, subnormal body temperature, heat and cold intolerance, feelings of feverishness and cold extremities, marked weight change with anorexia or abnormal appetite, loss of adaptability and worsening of symptoms with stress.
  • Immune: recurrent sore throat, tender lymph nodes, flu-like symptoms, general malaise, new sensitivities to food, medications and/or chemicals.
• Persistence of the illness: for at least 6 months in adults and 3 months in children.
• All other causes of the above symptoms must be ruled out and the above criteria must be present before the diagnosis of CFS/ME is made.

Mrs. R’s diagnosis

• First, any active disease process that can cause the major CFS symptoms including fatigue, sleep disturbance, pain, and cognitive dysfunction must be excluded by history, physical examination, lab tests and necessary investigations. This means that for Mrs. R. you have to rule out primary depression, cancer, sleep apnea, arthritis, HIV, vitamin B12 deficiency, etc.
• Second, you need to check the list of criteria to see if Mrs. R. has the seven criteria that define CFS/ME.
• In the case of Mrs. R., everything else was ruled out and she had the 7 criteria so the diagnosis of chronic fatigue syndrome/myalgic encephalomyelitis was made.

Epidemiology of CFS/ME

• Statistics Canada found over 340,000 people in Canada have been diagnosed with CFS/ME.
• The 2003 Canadian Community Health Survey stated the prevalence of CFS/ME was 0.8% in men, 2.1% in women, and 3.3% in women aged 45-65.

Other investigations

There is no single definitive test for CFS/ME, however, many tests may indicate abnormalities.

• laboratory test: not available but is under development
• SPECT scan: decreased blood flow to the brain
• sleep studies: show reduced deep sleep and multiple alpha wave intrusions
• hypothalamic-pituitary-adrenal axis function is blunted; adrenal glands are small, serum cortisol is in the low range compared to depressed patients who have high cortisol levels
• standing cardiac echocardiography research shows in some severely disabled patients severe diastolic dysfunction with a functional class score of III out of IV on the American Medical Association’s scale of cardiac disability
• Holter monitor shows repetitive oscillating T-wave inversions (you must ask for this)
• neuropsychological testing documents poor concentration and short-term memory, difficulty groping for words, slowed processing and difficulty multitasking
• immune functional testing shows decreased natural killer cell activity

Prognosis

CFS/ME can be mild, moderate or severely disabling affecting adults and children. Patients with milder cases may be able to work part time or full time. The severe cases are often disabled and may need home care. Many patients do improve with supportive symptomatic care; but only after you make a diagnosis.