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Chronic Fatigue Syndrome     CFS

The Australian Clinical practice guidelines for CFS can be viewed *here*, it should be noted that this document is for "diagnostic and management regimens that the medical profession would regard as appropriate for sufferers of CFS" . The overview document is a side by side comparsion of the 1997 CFS Clinical Practice Guidelines and the Revised 2002 CFS Clinical Practice Guidelines(current) with both major and minor revisions highlighted.

What is CFS? It is a "catch all" term, chronic fatigue syndrome is what a patient is labeled with when they present with FATIGUE and maybe the symptoms as listed below (with or without an indentified origin) and the continued presence of FATIGUE and these symptoms can not explained by allopathic medicine(modern/western medicine). These symptoms are often cyclic or varying in presentation or intensity.

Chronic FATIGUE Syndrome is the stage after 'prolonged FATIGUE'(3-6 months). This syndrome is all about people who are very, very, very exhausted(disabling) and 'medical science' is not able to demonstrate this, or what causes this insult.

The 2007 US ICD-10 CM now only refferences one(1) CFS identity. There is no CFS entry at G93.3 only Postviral fatigue syndrome and Benign myalgic encephalomyelitis, with this caveat :- excludes1 chronic fatigue syndrome NOS (R53.82). The only entry is at R53.82 for Chronic fatigue, unspecified, Chronic fatigue syndrome NOS with excludes1 : postviral fatigue syndrome (G93.3).

Clearly there are still two Syndromes featuring the word 'fatigue' and 'syndrome', this is supported by the current UK situation where NHS treatment overseen by the "Wessely school" is excluding those CFS, PVS, ME patients where viral implications are involved or recorded. In the UK this treatment is for ME/CFS, BUT which ? The English critera ( Oxford Critera ) defines "two broad syndromes", the usual 'fatigue' CFS and also Post-infectious fatigue syndrome (PIFS) as a subtype of CFS which either follows an infection or is associated with a current infection, which may even be a broader group than CFS.

The box below is taken from the CDC's 1994 Fukuda et al research criteria, which of the two syndromes is/are the subject of this study ?

Chronic Fatigue Syndrome (CFS) is not tiredness or extreme tiredness, but a severe flu-like illness that is often precipitated by a virus, maybe glandular fever(Epstein-Barr virus) , Ross River Fever (in Australia) to mention just two of a long list. Symptoms patients may suffer include headaches, memory and concentration problems, sore throat, muscle and joint pain, irritable bowel, disturbed sleep, exhaustion after minor effort, food allergies/sensitivities and sensitivity to bright light and noise. CFS is also known as Chronic Fatigue Immune Dysfunction Syndrome (mainly in the USA) and interchanges with Myalgic Encephalomyelitis (mainly in the UK).

"CFS" or "ME", both illnesses may be severely disabling, with some patients being largely bed bound and are so for years. While many studies report higher levels of certain physical abnormalities in Chronic Fatigue Syndrome patients than in the healthy population, currently there isn't a validated diagnostic test. Diagnosis is made on the basis of symptom presentation, history and the elimination of other possible infections or causes.

The chronic fatigue syndrome is a clinically defined condition (1-4) characterized by severe disabling fatigue and a combination of symptoms that prominently features self-reported impairments in concentration and short-term memory, sleep disturbances, and musculoskeletal pain. Diagnosis of the chronic fatigue syndrome can be made only after alternative medical and psychiatric causes of chronic fatiguing illness have been excluded. No pathognomonic signs or diagnostic tests for this condition have been validated in scientific studies (5-7); moreover, no definitive treatments for it exist (8). Recent longitudinal studies suggest that some persons affected by the chronic fatigue syndrome improve with time but that most remain functionally impaired for several years (9, 10).

Ann Intern Med : Dec. 15; 1994 Vol. 121; #12: Pgs :953-959.

This "Fukuda et al.," study of 1994 is being used here as the "Carruthers et al.," of 2003 has yet to be widely accepted by all facets of the medical industry.

The Canadian Consensus Document for ME/CFS   Carruthers et al.   2003
Clinical Working Case Definition of ME/CFS -   - criteria headlands
  1. Fatigue
  2. Post-Exertional Malaise and/or Fatigue
  3. Sleep Dysfunction
  4. Pain
  5. Neurological/Cognitive Manifestations
  6. At Least One Symptom from Two of
    • Autonomic Manifestations
    • Neuroendocrine Manifestations
    • Immune Manifestations
  7. The illness persists for at least six months

How is Chronic Fatigue Syndrome diagnosed?

There is no currently accepted, definitive test for Chronic Fatigue Syndrome. The currently most widely accepted criteria for diagnosing CFS were published in the Annals of Internal Medicine, Vol 121, No 12, PP953 -959 on December 15, 1994. For a CFS diagnosis all other possible conditions must be excluded and the following 2 criteria must be present:

  1. Clinically evaluated, unexplained, persistent or relapsing chronic fatigue that is of new or definite onset (has not been lifelong); is not the result of ongoing exertion; is not substantially alleviated by rest; and results in substantial reduction in previous levels of occupational, educational, social, or personal activities.

  2. The concurrent occurrence of four or more of the following symptoms, all of which must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue:
    • self-reported impairment in short-term memory or concentration severe enough to cause substantial reduction in previous levels of occupational, educational, social, or personal activities,
    • sore throat,
    • tender cervical or axillary lymph nodes,
    • muscle pain,
    • multi-joint pain without joint swelling or redness,
    • headaches of a new type, pattern, or severity,
    • unrefreshing sleep, and
    • post-exertional malaise lasting more than 24 hours.

This 1994 definition(Fukuda et al.,) liberalises a more restrictive 1988 definition(Holmes et al.,).

Please note that in the above criteria for diagnosing CFS for research there is no reference to infection, viral or otherwise so perhaps this paper is dealing with Chronic fatigue, unspecified or Chronic fatigue syndrome NOS (R53.82).

What conditions should be excluded before a diagnosis of CFS is made? While you doctor should exclude the possibility of all the below conditions, particular attention should be paid to phosphate diabetes, sleep problems and coeliac's disease as these conditions are commonly missed by GPs.

  • Neuromuscular Disease:
    • Multiple Sclerosis,
    • Myasthenia Gravis,
    • Parkinson's Disease,
    • rare muscle disorders.
  • Chronic Infections:
    • Brucellosis,
    • Giardia,
    • Hepatitis A,B,C,
    • HIV,
    • Leptospirosis hardjo,
    • Lyme Disease, ( note significant numbers are misdiagnosed.)
    • Parvovirus,
    • Post-polio Syndrome,
    • Toxocara (children),
    • Toxoplasmosis.
  • Gastric Disorders:
    • Coeliac's Disease,
    • Crohn's Disease,
    • Food Allergies,
    • Irritable Bowel Syndrome.
  • Hormonal Imbalance:
    • Addison's Disease,
    • Fluid Retention Syndrome,
    • Hypothyroidism,
    • Haemochromatosis,
    • Hypocalcaemia,
    • Hyponatraemia,
    • Thyrotoxicosis,
    • Pituitary Tumour .
  • Psychiatric Disorders:
    • Anxiety,
    • Depression,
    • Post Traumatic Stress Disorder.
  • Rheumatic Disorders:
    • Fibromyalgia,
    • Sjogren's Syndrome,
    • Systemic Lupus Erythematosus.
  • Miscellaneous:
    • Alcohol abuse,
    • Anaemia,
    • Cervical Canal Stenosis,
    • Chiari Syndrome,
    • Hodgkin's Lymphoma,
    • Organophosphate pesticides,
    • Phosphate Diabetes,
    • Sarcoidosis,
    • Sick Building Syndrome,
    • Sleep Apnoea and Narcolepsy,
    • TB - Tuberculosis.

What causes CFS?

The causes of CFS/CFIDS are many for example; Endocrine dysfunction -particularly adrenal insufficiency, and/or Neurological dysfunction caused by the original virus/toxin. The list is very long.

Dr. Martin Pall believes that excessive production of inflammatory cytokines that induce, in turn, the inducible nitric oxide synthase (iNOS). This enzyme, in turn, synthesizes excessive amounts of nitric oxide which reacts with another compound ( superoxide ) to produce the potent oxidant peroxynitrite   more....

Epstein-Barr virus (chronic Mononucleosis) and the rest of the Herpes virus family (CMV, HHV6, HHV etc) have still not been elimated from the possible cause list, as some studies sill show [Ablashi et al., the Dubbo studies]. The Dubbo studies also showed Ross River virus and Coxiella burnetii(Q Fever) can lead to a CFS state.

Many investigators have reported enteroviral in CFS also, a number of studies have suggested that parvovirus can produce CFS [Kerr 2001, 2002; Matano, 2003]. Toxoplasma gondii(Toxoplasmosis) is one of the parasitic entries in this field.

Chronic Fatigue Syndrome is a state of mutated gene expression, a sequelae following insult by infection or infections. Why is CFS now being identified so regularly in non epidemic settings?

Who gets CFS?

Chronic Fatigue Syndrome strikes people of all ages, races and socioeconomic backgrounds. Most diagnosed cases fall into the 15 to 45 age group (at onset). Women appear to be more likely to develop CFS, with some studies suggesting that up to two thirds of all PWCs(patients) are women. A 1980's media description of CFS as "yuppie flu" is completely inaccurate - it crosses all socioeconomic barriers, even the less well off.

How many people have CFS?

There are no precise figures of how many people have CFS. This is due to the fact that many people may be unsure of what they have, many doctors have hitherto not accepted that PWCs are ill and some PWCs simply 'drop out' when they cannot get any medical help. Also the ambiguity surrounding this syndrome is hindering the gathering and collation of the requiered statistics.

In May 2002, a Working Group formed under the auspices of the Royal Australasian College of Physicians published a report that estimated from the published literature that between 0.2% and 0.7% of the population has CFS. This equates to between about 38,000 and 133,000 Australians. By way of comparison, about 22,000 Australians have been infected with HIV and about 15,000 have multiple sclerosis.

Are PWCs "malingering" or psychiatric cases?

Unfortunately, the name chronic fatigue syndrome unfairly implies that what is a quite painful, severe illness may only be tiredness or something imaginary.
A committee under the US Secretary for Health is currently considering a name change.
No serious researcher in the CFS area believes that they are looking at a trivial or imagined condition. In 1989, a New Zealand researcher, Dr L Simpson, had his research published in the New Zealand Medical Journal. It showed that PWCs, as a group, had larger numbers of misshapen red blood cells. Since then there have been more than 40 studies documenting various physical abnormalities observed in PWCs as a group. A full list of studies can be obtained from the Association's office.

Unfortunately, many doctors are not familiar with these studies. Doctors may also obtain the list of studies from the Association or special doctors' kit.

What are the symptoms?

The symptoms of Chronic Fatigue Syndrome vary from person to person. The symptoms which are almost always present are exhaustion after a small amount of activity, difficulties with memory and concentration, headaches, face pallor particularly when symptoms are severe, and disrupted and disturbed sleep. Other symptoms can include sore throats, fever, raised glands, dizziness and balance problems, muscle weakness and pain, sore joints, sensitivity to noise and light, sensitivity to heat and cold, cognitive function problems (such as spatial disorientation and impairment of speech and reasoning), sensitivity to alcohol, irregular heartbeat, abdominal pain, irritable bowel, diarrhoea, dryness of the mouth and eyes, cold hands and feet, weight changes without changes in diet, anxiety and irritability, and new allergies or sensitivities to foods or chemicals.A more complete list is available here...

Can Chronic Fatigue Syndrome be treated and what is the prognosis?

The vast majority of PWCs experience some improvement in the condition and At least (and could be more if there were more accurate figures) 13% to 25% make a full recovery.
Unfortunately, it does appear that about one fifth to one quarter of PWCs face a very long-term problem with the condition. The important thing is to take all sensible measures to get better and make sure that you are not one of them!

Is there any action to find a cure to CFS?

Yes! And your help is needed!


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