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Chronic Fatigue Syndrome

Chronic fatigue syndrome (CFS) is characterized by at least 6 months of exceptional fatigue, with several associated chronic symptoms. Chronic diseases that would exclude the diagnosis of CFS include untreated hypothyroidism, sleep apnea, chronic active hepatitis, any psychotic disorder, dementia, anorexia nervosa or bulimia nervosa, recent substance abuse, and

Patients with CFS may be of any age, of either sex, and from all walks of life; the typical patient is a

The onset is often sudden, frequently after an acute "viral" syndrome. In unusual cases, CFS follows in the wake not of a nondescript "flulike" illness but of a well-defined acute infectious illness, including chronic fatigue syndrome, cronic, fatige

CFS is associated with a wide range of chronic fatigue syndrome, cronic, fatige. Some patients appear to be completely disabled by the fatigue, cognitive impairment, muscle weakness, and pain. There is growing evidence of objective biologic abnormalities in patients with CFS. Various imaging and functional studies of the central nervous system and immune system have been reported, and these include low levels of circulating immune complexes, elevated total complement (CH50), elevated IgG, atypical lymphocytosis, elevated alkaline phosphatase, low lactate dehydrogenase, elevated total cholesterol, and low levels of antinuclear antibody. No infectious agent has been convincingly shown to be a cause of CFS. Nevertheless, there is

A patient with chronic fatigue, as described, should have the following diagnostic tests: complete blood count, manual differential white blood cell count, erythrocyte sedimentation rate, chemistry panel, thyroid-stimulating hormone, antinuclear antibody, rheumatoid factor (if arthralgias), and


Nonpharmacologic Management

Management of the patient with CFS requires more than pharmacotherapy. First, the clinician must make a personal judgment as to whether patients are accurately relating their symptoms--both those that they admit to and those that they deny. CFS is an illness defined only by symptoms. Thus, an occasional patient seeking secondary gain may fabricate a "perfect story" for CFS. Somewhat more commonly, patients who have

Pharmacologic Therapy

No treatment has been proved to benefit patients with CFS in large randomized controlled trials that have been replicated by other investigators in other populations of patients. Moreover, without a better understanding of the pathogenesis of CFS, it is unlikely that definitive treatment will be

Low-Dose Tricyclic Agents

The most widely used treatment of CFS is sedating tricyclic antidepressant agents in low doses: amitriptyline (Elavil)* or doxepin (Sinequan),* 5 to 20 mg at bedtime. For unusually low doses, the liquid form of the medication may be necessary. Low-dose tricyclic agents have been proved efficacious in

Antidepressant Agents

Half or more of patients with CFS develop major depression in the months and years after the onset of their illness, although only a minority have experienced an episode of depression in the years before their illness. When patients are suffering from depression, antidepressant therapy is .

Anxiolytic Agents

Panic disorder and generalized anxiety disorder may be more common in patients with CFS, after the onset of the illness, than in the general

Nonsteroidal Anti-inflammatory Drugs

The majority of patients with CFS experience myalgias, arthralgias, headaches, and migratory paresthesias. For some, the pain is the most

Antimicrobial Therapy

Because there is no proven infectious cause of CFS, it is not surprising that antimicrobial agents are rarely used. One randomized controlled study found

Immunomodulation Therapy

Several controlled trials of intravenous immune globulin* have been tried, on the premise that some kind of immune dysregulation may explain CFS.

Antiallergy Therapy

Many patients with CFS have experienced atopic symptoms since childhood, and the atopic symptoms often

Antihypotensive Therapy

A substantial fraction of patients with CFS have modest abnormalities of the autonomic nervous system, leading to neurally mediated hypotension.