Depression and somatization in the chronic fatigue syndrome

PURPOSE: To report the prevalence, clinical features, and diagnostic associations of the proposed chronic fatigue syndrome (CFS) in a cohort of patients with chronic fatigue and to assess the usefulness of a structured psychiatric interview for detecting previously unrecognized psychiatric morbidity in patients with CFS. PATIENTS AND METHODS: A consecutive sample of 200 adult patients with a chief complaint of chronic fatigue was prospectively evaluated in a referral-based clinic within a university general medicine practice. All patients received a thorough medical history, physical examination, diagnostic laboratory testing, and portions of the Diagnostic Interview Schedule, version III-A. The criteria for CFS were applied, and patients with CFS were compared with matched control subjects from the inception cohort. RESULTS: The 60 patients with CFS had similar likelihoods of current psychiatric disorders (78% versus 82%), active mood disorders (73% versus 77%), and preexisting psychiatric disorders (42% versus 43%) when compared with fatigued control subjects. Patients with CFS were more likely to have somatization disorder (p less than 0.001) and to attribute their illness to a physical cause (p less than 0.005) than fatigued controls. Patients with CFS also displayed functional symptoms, often lifelong, which are not part of the case definition of CFS. Depressive features in patients with CFS were similar to those of control subjects, but a trend toward suicidal behavior was noted. CONCLUSIONS: Patients with CFS have a high prevalence of unrecognized, current psychiatric disorders, which often predate their fatigue syndrome. Assessment of patients with CFS should include a structured psychiatric evaluation.     

Fatigue severity remains stable over time and independently associated with orthostatic symptoms in chronic fatigue syndrome: a longitudinal study

Abstract. Jones DEJ, Gray J, Frith J, Newton JL (UK NIHR Biomedical Centre in Ageing, Institute of Cellular Medicine, Institute for Ageing and Health, Newcastle University, Newcastle, UK) Fatigue severity remains stable over time and independently associated with orthostatic symptoms in chronic fatigue syndrome: a longitudinal study. J Intern Med 2011; 269 : 182–188. Objectives: To examine fatigue variability over time in chronic fatigue syndrome (CFS) and the effect of other symptoms on its predictability. Design: Longitudinal cohort study of patients with CFS (Fukuda criteria). Setting: Specialist CFS clinical service. Subjects: Phase 1: 100 patients who participated in a study of CFS symptoms in 2005 were revisited in 2009. Phase 2: 25 patients completed fatigue diaries to address intra‐ and inter‐day variability in perceived fatigue. Main outcome measures: Phase 1: subjects completed fatigue impact scale (FIS), Epworth sleepiness scale (ESS), orthostatic grading scale (OGS) and hospital anxiety and depression scale (HADS). Changes in variables represented the differences between 2005 and 2009. Phase 2: subjects rated fatigue on a scale of 0 (no fatigue) to 10 (severe fatigue) four times a day for 5 weeks. Results: Symptom assessment tools were available in both 2005 and 2009 for 74% of patients. FIS and HADS depression (HAD‐D) and anxiety (HAD‐A) scores significantly improved during follow‐up whereas ESS and OGS remained stable. FIS improved in 29/74 (39%) subjects, and by ≥10 points in 19 (26%). FIS worsened by ≥10 points in 33/74 (45%) subjects. On multivariate analysis, independent predictors of current fatigue (FIS in 2009) were FIS in 2005, HAD‐D in 2009, OGS in 2009 and change in HAD‐A. Reported fatigue was stable from week to week and from day to day. Patients reported higher fatigue in the morning (mean ± SD; 6.4 ± 2), becoming significantly lower at lunchtime (6.2 ± 2; P < 0.05) and increasing again to 7 ± 2 at bedtime. Conclusions: Current fatigue is independently associated with current autonomic symptom burden, current depression and change in anxiety during follow‐up. These findings have implications for targeted symptom management in CFS.     

Diagnosing chronic fatigue syndrome: comparison of a protocol and computerised questionnaires

BACKGROUND: In the context of outpatient care and within the framework of scientific research, guidelines and measuring instruments have been developed to help improve CFS diagnostics. The purpose of this study was to measure the agreement between the evaluations of chronically fatigued patients by physicians using a CFS protocol and by researchers using computerised questionnaires. METHODS: The sample consisted of 516 patients referred to an internal medicine outpatient clinic with complaints of chronic fatigue. Retrospectively the medical records and the computerised questionnaires were checked separately and compared to see whether the criteria for diagnosis of CFS had been met. In addition, the reasons for not diagnosing CFS were evaluated. RESULTS: Agreement between the physicians' and the researchers' evaluations was 84%. Disagreement mostly concerned severity of fatigue and functional impairment, or premorbid exclusion criteria. A physical cause for the chronic fatigue was only found in 3% of the cases. CONCLUSIONS: For physicians, questionnaire assessment may be complementary to the CFS protocol in optimising the process of diagnosing CFS.     

Chronic fatigue syndrome: a clinical and laboratory study with a well matched control group

Abstract. Objective. To investigate the relation between severity of complaints, laboratory data and psychological parameters in patients with chronic fatigue syndrome (CFS). Subjects. Eighty-eight patients with CFS and 77 healthy controls matched for age, sex and geographical area. Methods. Patients and controls visited our outpatient clinic for a detailed medical history, physical examination and psychological tests: Checklist Individual Strength (CIS), Beck Depression Inventory (BDI) and Sickness Impact Profile (SIP). Venous blood was drawn for a complete blood cell count, serum chemistry panel, C-reactive protein and serological tests on a panel of infectious agents. Results. All patients fulfilled the criteria for CFS as described by Sharpe et al. (J R Soc Med 1991; 84 : 118–21), only 18 patients (20.5%) fulfilled the CDC criteria. The outcome of serum chemistry tests and haematological tests were within the normal range. No significant differences were found in the outcome of serological tests. Compared to controls, significant differences were found in the results on the CIS, the BDI, and the SIP. These results varied with the number of complaints (CDC criteria). When the number of complaints was included as the covariate in the analysis, there were no significant differences on fatigue severity, depression, and functional impairment between patients who fulfilled the CDC criteria and patients who did not. Conclusion. It is concluded that the psychological parameters of fatigue severity, depression and functional impairment are related to the clinical severity of the illness. Because the extensive panel of laboratory tests applied in this study did not discriminate between patients and controls, it was not possible to investigate a possible relation between the outcomes of psychological and laboratory testing.     

Co-existence of chronic fatigue syndrome with fibromyalgia syndrome in the general population. A controlled study

OBJECTIVE: To determine the proportion of adults with fibromyalgia syndrome (FMS) in the general population who also meet the 1988 Centre for Disease Control (CDC) criteria for chronic fatigue syndrome (CFS). METHODS: Seventy-four FMS cases were compared with 32 non-FMS controls with widespread pain and 23 with localized pain, all recruited in a general population survey. RESULTS: Among females, 58.0% of fibromyalgia cases met the full criteria for CFS, compared to 26.1% and 12.5% of controls with widespread and localized pain, respectively (p=0.0006). Male percentages were 80.0, 22.2, and zero, respectively (p=0.003). Compared to those with FMS alone, those meeting the case definitions for both FMS and CFS reported a worse course, worse overall health, more dissatisfaction with health, more non-CFS symptoms, and greater disease impact. The number of total symptoms and non-CFS symptoms were the best predictors of co-morbid CFS. CONCLUSIONS: There is significant clinical overlap between CFS and FMS.     

Double-blind, randomized study of the effects of influenza vaccination on the specific antibody response and clinical course of patients with chronic fatigue syndrome.

OBJECTIVE: To determine whether influenza immunization is associated with early side effects, a deleterious impact on the illness course and depressed antibody response in patients with chronic fatigue syndrome (CFS). DESIGN: Prospective, randomized, double-blind, placebo controlled trial. CFS patients and healthy volunteers filled out a questionnaire on immunization side effects and had hemagglutination-inhibiting (HI) antibody titres measured pre- and three weeks after immunization. CFS patients completed symptom and function questionnaires before and during the six-week, postimmunization period. SETTING: Ambulatory care. POPULATION STUDIED: Convenience sample of 40 CFS patients fulfilling the Centers for Disease Control and Prevention criteria and 21 demographically matched healthy volunteers. INTERVENTIONS: CFS patients were randomly selected to receive commercially available whole virus influenza vaccine (n=19) or an injection of saline placebo (n=21). Healthy volunteers received vaccine only. MAIN RESULTS: As a group, immunized CFS patients had lower geometric mean HI antibody rises than healthy volunteers (P<0.001). However, there was no difference in the rates of fourfold titre rises, and immunization did achieve a probably protective titre (1:32 or greater) in most CFS patients. No difference could be detected between immunized and placebo CFS patients in immunization side effects, although CFS patients as a group reported four times as many side effects as healthy volunteers. Further, in the six weeks following immunization, placebo and immunized CFS patients did not demonstrate any differences in terms of functioning, symptom severity and sleep disturbance. CONCLUSIONS: In patients with CFS, influenza immunization is safe, not associated with any excess early reactions, and stimulates an immunizing response comparable with that of healthy volunteers.     

Overlapping conditions among patients with chronic fatigue syndrome, fibromyalgia, and temporomandibular disorder

BACKGROUND: Patients with chronic fatigue syndrome (CFS), fibromyalgia (FM), and temporomandibular disorder (TMD) share many clinical illness features such as myalgia, fatigue, sleep disturbances, and impairment in ability to perform activities of daily living as a consequence of these symptoms. A growing literature suggests that a variety of comorbid illnesses also may commonly coexist in these patients, including irritable bowel syndrome, chronic tension-type headache, and interstitial cystitis. OBJECTIVE: To describe the frequency of 10 clinical conditions among patients with CFS, FM, and TMD compared with healthy controls with respect to past diagnoses, degree to which they manifested symptoms for each condition as determined by expert-based criteria, and published diagnostic criteria. METHODS: Patients diagnosed as having CFS, FM, and TMD by their physicians were recruited from hospital-based clinics. Healthy control subjects from a dermatology clinic were enrolled as a comparison group. All subjects completed a 138-item symptom checklist and underwent a brief physical examination performed by the project physicians. RESULTS: With little exception, patients reported few past diagnoses of the 10 clinical conditions beyond their referring diagnosis of CFS, FM, or TMD. In contrast, patients were more likely than controls to meet lifetime symptom and diagnostic criteria for many of the conditions, including CFS, FM, irritable bowel syndrome, multiple chemical sensitivities, and headache. Lifetime rates of irritable bowel syndrome were particularly striking in the patient groups (CFS, 92%; FM, 77%; TMD, 64%) compared with controls (18%) (P<.001). Individual symptom analysis revealed that patients with CFS, FM, and TMD share common symptoms, including generalized pain sensitivity, sleep and concentration difficulties, bowel complaints, and headache. However, several symptoms also distinguished the patient groups. CONCLUSIONS: This study provides preliminary evidence that patients with CFS, FM, and TMD share key symptoms. It also is apparent that other localized and systemic conditions may frequently co-occur with CFS, FM, and TMD. Future research that seeks to identify the temporal relationships and other pathophysiologic mechanism(s) linking CFS, FM, and TMD will likely advance our understanding and treatment of these chronic, recurrent conditions.     

Neurally mediated hypotension in fatigued Gulf War veterans: a preliminary report

BACKGROUND: Many patients with chronic fatigue syndrome (CFS) have neurally mediated hypotension when subjected to head-up tilt, suggesting autonomic nervous system dysfunction. Some Gulf War veterans have symptoms similar to CFS. Whether they also tend to have neurally mediated hypotension is unknown. METHODS: We performed 3-stage tilt-table testing on 14 Gulf War veterans with chronic fatigue, 13 unfatigued control Gulf War veterans, and 14 unfatigued control subjects who did not serve in the Gulf War. Isoproterenol was used in stages 2 and 3 of the tilt protocol. RESULTS: More fatigued Gulf War veterans than unfatigued control subjects had hypotensive responses to tilt (P < 0.036). A positive response to the drug-free stage 1 of the tilt was observed in 4 of 14 fatigued Gulf War veterans versus 1 of 27 unfatigued control subjects (P < 0.012). Heart rate and heart rate variation during stage 1 was significantly greater in the fatigued group (P < 0.05). CONCLUSION: We conclude that more fatigued Gulf War veterans have neurally mediated hypotension than unfatigued control subjects, similar to observations in CFS. Autonomic nervous system dysfunction may be present in some fatigued Gulf War veterans.     

The effect of granisetron, a 5-HT3 receptor antagonist, in the treatment of chronic fatigue syndrome patients--a pilot study

OBJECTIVE: To explore the effect of granisetron, a 5-HT3 antagonist, on fatigue and functional impairment in patients with chronic fatigue syndrome (CFS). METHODS: Five female patients were eligible to receive oral granisetron for one month (1 mg a day for the first two weeks and 2 mg a day for the second two weeks). The patients had to be between 18 and 65 years of age and suffering from CFS according to the CDC criteria. The effect was assessed by pre- and post-testing, using validated instruments designed to assess the different dimensions of CFS. Treatment response was also evaluated by visual analogue scales (VAS) for fatigue. Analysis was based on intention to treat. RESULTS: Treatment with granisetron resulted in significant improvement in fatigue severity and functional impairment. Activity level showed no significant increase. CONCLUSION: The promising results of this study have encouraged us to perform a placebo-controlled, double-blind study to evaluate the efficacy of 5-HT3 receptor antagonists in the treatment of CFS.     

Autoimmunity in chronic fatigue syndrome in children

We have reported that about half of children with chronic non-specific complaints were positive for antinuclear antibodies (ANA) and that the commonest complaint was fatigue in ANA-positive patients. Therefore, we have proposed a novel disease entity of autoimmune fatigue syndrome (AIFS). In order to investigate the relationship between AIFS and chronic fatigue syndrome (CFS) in children, all CFS patients seen in our clinic were immunologically assessed. Immunological examinations including ANA, autoantibody analysis by Western immunoblotting, lymphocyte subsets and NK activities were performed on 14 CFS patients. Clinical courses of these patients were reviewed retrospectively. None of the patients had fulfilled the CDC criteria for CFS at their first visit. They fulfilled the criteria in a relatively short time, with a 6 months to 6 years smoldering period. All patients had been diagnosed as school refusal by physicians or school teachers. Thirteen patients were positive for ANA and the other one was positive for rheumatoid factor. Twelve patients were positive for antibodies to the 62 kDa protein (anti-Sa) which had been detected in about 40% of AIFS patients. NK activity was not as low as reported in adult patients with CFS. Most of the children with CFS were positive for ANA, suggesting an autoimmune mechanism may play an important role in the pathogenesis of childhood CFS. AIFS patients should be carefully followed because of the possibility of later development of CFS.     

Double-blind,randomized study of the effects of influenza vaccination on the specific antibody response and clinical course of patients with chronic fatigue syndrome

OBJECTIVE:

To determine whether influenza immunization is associated with early side effects, a deleterious impact on the illness course and depressed antibody response in patients with chronic fatigue syndrome (CFS).

DESIGN:

Prospective, randomized, double-blind, placebo controlled trial. CFS patients and healthy volunteers filled out a questionnaire on immunization side effects and had hemagglutination-inhibiting (HI) antibody titres measured pre- and three weeks after immunization. CFS patients completed symptom and function questionnaires before and during the six-week, postimmunization period.

SETTING:

Ambulatory care.

POPULATION STUDIED:

Convenience sample of 40 CFS patients fulfilling the Centers for Disease Control and Prevention criteria and 21 demographically matched healthy volunteers.

INTERVENTIONS:

CFS patients were randomly selected to receive commercially available whole virus influenza vaccine (n=19) or an injection of saline placebo (n=21). Healthy volunteers received vaccine only.

MAIN RESULTS:

As a group, immunized CFS patients had lower geometric mean HI antibody rises than healthy volunteers (P<0.001). However, there was no difference in the rates of fourfold titre rises, and immunization did achieve a probably protective titre (1:32 or greater) in most CFS patients. No difference could be detected between immunized and placebo CFS patients in immunization side effects, although CFS patients as a group reported four times as many side effects as healthy volunteers. Further, in the six weeks following immunization, placebo and immunized CFS patients did not demonstrate any differences in terms of functioning, symptom severity and sleep disturbance.

CONCLUSIONS:

In patients with CFS, influenza immunization is safe, not associated with any excess early reactions, and stimulates an immunizing response comparable with that of healthy volunteers.Key Words: Chronic fatigue syndrome, Humoral immunization response, Influenza immunization     

Autoimmunity in chronic fatigue syndrome in children

Abstract

We have reported that about half of children with chronic non-specific complaints were positive for antinuclear antibodies (ANA) and that the commonest complaint was fatigue in ANA-positive patients. Therefore, we have proposed a novel disease entity of autoimmune fatigue syndrome (AIFS). In order to investigate the relationship between AIFS and chronic fatigue syndrome (CFS) in children, all CFS patients seen in our clinic were immunologically assessed. Immunological examinations including ANA, autoantibody analysis by Western immunoblotting, lymphocyte subsets and NK activities were performed on 14 CFS patients. Clinical courses of these patients were reviewed retrospectively. None of the patients had fulfilled the CDC criteria for CFS at their first visit. They fulfilled the criteria in a relatively short time, with a 6 months to 6 years smoldering period. All patients had been diagnosed as school refusal by physicians or school teachers. Thirteen patients were positive for ANA and the other one was positive for rheumatoid factor. Twelve patients were positive for antibodies to the 62 kDa protein (anti-Sa) which had been detected in about 40% of AIFS patients. NK activity was not as low as reported in adult patients with CFS. Most of the children with CFS were positive for ANA, suggesting an autoimmune mechanism may play an important role in the pathogenesis of childhood CFS. AIFS patients should be carefully followed because of the possibility of later development of CFS.     

Human herpesvirus 6 and chronic fatigue syndrome

The cause of chronic fatigue syndrome (CFS) is still enigmatic. Using indirect immunofluorescence testing for measuring antibody against human herpesvirus 6 (HHV-6), this study investigated the association of CFS with infection by HHV-6. Seventeen patients (group A) fulfilling the Centers for Disease Control (CDC) definition for CFS were compared with eight patients (group B) with chronic fatigue but not meeting the CDC criteria. No significant difference was found between the two groups for 30 parameters including sex, age, exposure to children and serology for Epstein-Barr virus, cytomegalovirus, herpes simplex virus, and toxoplasma. Univariate analysis showed that patients in group A complained more frequently of a sore throat, headache and of recurrent type of fatigue. These three parameters are discriminant in identifying patients who will meet the CDC case definition of CFS. The titre of antibody against HHV-6 in group A (1:99) was significantly higher than in group B (1:15) (P=0.007). Elevated HHV-6 titres suggests that this virus could be a cofactor in the pathogenesis of CFS.     

Psychiatric Illness in patients with chronic fatigue and those with rheumatoid arthritis

Objectives:To identify psychiatric differences between patients with chronic fatigue and those with rheumatoid arthritis and to investigate whether patients meeting Centers for Disease Control (CDC) criteria for chronic fatigue syndrome (CFS) can be differentiated from patients with chronic fatigue on measures of disability and psychosocial distress. Design:Cross-sectional study comparing 98 patients with chronic fatigue with 31 patients with rheumatoid arthritis on structured psychiatric interviews and patient questionnaires. Nineteen patients meeting CDC criteria for CFS were compared with 79 patients with chronic fatigue not meeting CDC criteria on questionnaires measuring disability and psychosocial distress. Setting:Consecutive patients with chronic fatigue were selected from a chronic fatigue clinic at the University of Washington, and 31 consecutive patients with rheumatoid arthritis were sampled from a private rheumatology practice. Main results:Patients with chronic fatigue had a significantly higher prevalence of lifetime major depression and somatization disorder than did patients with rheumatoid arthritis. Patients with chronic fatigue also had a significantly higher prevalence of current and lifetime psychiatric diagnoses. Only 19 of 98 patients with chronic fatigue met CDC criteria for CFS. Patients meeting CDC criteria for CFS could not be differentiated from the larger group of patients with chronic fatigue on any study variable. Conclusions:Patients with chronic fatigue have a significantly higher burden of psychiatric illness than do patients with rheumatoid arthritis. The psychiatric illness preceded the development of chronic fatigue in over half the patients. Centers for Disease Control criteria for CFS did not select a subset of chronic fatigue patients who could be differentiated on disability or psychosocial parameters from patients with chronic fatigue who did not meet CDC criteria. Supported by a grant from NARSAD.     

Abnormal impedance cardiography predicts symptom severity in chronic fatigue syndrome

BACKGROUND: Findings indicative of a problem with circulation have been reported in patients with chronic fatigue syndrome (CFS). We examined this possibility by measuring the patient's cardiac output and assessing its relation to presenting symptoms. METHODS: Impedance cardiography and symptom data were collected from 38 patients with CFS grouped into cases with severe (n = 18) and less severe (n = 20) illness and compared with those from 27 matched, sedentary control subjects. RESULTS: The patients with severe CFS had significantly lower stroke volume and cardiac output than the controls and less ill patients. Postexertional fatigue and flu-like symptoms of infection differentiated the patients with severe CFS from those with less severe CFS (88.5% concordance) and were predictive (R2 = 0.46, P < 0.0002) of lower cardiac output. In contrast, neuropsychiatric symptoms showed no specific association with cardiac output. CONCLUSIONS: These results provide a preliminary indication of reduced circulation in patients with severe CFS. Further research is needed to confirm this finding and to define its clinical implications and pathogenetic mechanisms.     

Factors influencing the diagnosis of chronic fatigue syndrome

BACKGROUND: Most of what is believed about chronic fatigue syndrome (CFS) is based on clinic-based studies. These studies may not reflect CFS cases in the population. METHODS: We used data from a population-based study of CFS to identify factors associated with receiving a CFS diagnosis. Wichita, Kan, residents were screened by random-digit dialing. Eligible individuals completed a telephone interview. Respondents meeting CFS criteria were invited for a clinical evaluation to confirm CFS. We analyzed all persons with confirmed CFS. The main outcomes of this study, prevalence and incidence of CFS, are published elsewhere. Herein, we present an exploratory analysis with previous CFS diagnosis as the outcome, predicted by demographic and symptom characteristics. RESULTS: We confirmed CFS in 90 subjects; 14 (16%) had been previously diagnosed as having CFS. Persons in the middle- vs the higher-income group were more likely to have been diagnosed as having CFS (9 [29%] of 31 subjects vs 3 [8%] of 39 subjects; P = .03), as were those with sudden vs gradual fatigue onset (7 [41%] of 17 subjects vs 4 [6%] of 64 subjects; P < .01), those reporting tender lymph nodes (7 [33%] of 21 subjects vs 7 [10%] of 69 subjects; P = .02), and those reporting a sore throat (6 [35%] of 17 subjects vs 8 [11%] of 73 subjects; P = .02). Only 17 (21%) of 81 subjects had sudden fatigue onset, and tender lymph nodes (reported in 21 [23%] of 90 subjects) and a sore throat (reported in 17 [19%] of 90 subjects) were the least common symptoms. CONCLUSION: Most cases of CFS in the population are unrecognized by the medical community; persons diagnosed as having CFS may be different from persons with CFS in the general population.     

Diagnosis of left-ventricular non-compaction in patients with left-ventricular systolic dysfunction: time for a reappraisal of diagnostic criteria?

AIMS: Left-ventricular non-compaction (LVNC) is characterized by excessive and prominent left-ventricular (LV) trabeculations and may be associated with systolic dysfunction in advanced disease. We sought to determine the proportion of patients fulfilling LVNC criteria in an adult population referred to a heart failure clinic using current diagnostic criteria. METHODS AND RESULTS: One hundred and ninety-nine patients [age 63.5 +/- 15.9 years, 124 (62.3%) males] with LV systolic impairment were studied. All underwent clinical examination, electrocardiography, and 2-D echocardiography. The number of patients fulfilling diagnostic criteria for LVNC was retrospectively determined using three published definitions. Results were compared with 60 prospectively evaluated normal controls (age 35.7 +/- 13.5 years; 31 males, 30 blacks). Forty-seven patients (23.6%) fulfilled one or more echocardiographic definitions for LVNC. Patients fulfilling LVNC criteria were younger (P = 0.002), had larger LV end-diastolic dimension (P < 0.001), and smaller left atrial size (P = 0.01). LVNC was more common in black individuals (35.5 vs. 16.2%, P = 0.003). Five controls (four blacks) fulfilled one or more LVNC criteria. CONCLUSIONS: This study demonstrates an unexpectedly high percentage of patients with heart failure fulfilling current echocardiographic criteria for LVNC. This might be explained by a hitherto underestimated cause of heart failure, but the comparison with controls suggests that current diagnostic criteria are too sensitive, particularly in black individuals.     

Cognitive performance is of clinical importance, but is unrelated to pain severity in women with chronic fatigue syndrome

In various chronic pain populations, decreased cognitive performance is known to be related to pain severity. Yet, this relationship has not been investigated in patients with chronic fatigue syndrome (CFS). This study investigated the relationship between cognitive performance and (1) pain severity, (2) level of fatigue, and (3) self-reported symptoms and health status in women with CFS. Examining the latter relationships is important for clinical practice, since people with CFS are often suspected to exaggerate their symptoms. A sample of 29 female CFS patients and 17 healthy controls aged 18 to 45 years filled out three questionnaires (Medical Outcomes Study 36-Item Short-Form Health Survey, Checklist Individual Strength (CIS), and CFS Symptom List) and performed three performance-based cognitive tests (psychomotor vigilance task, Stroop task, and operation span task), respectively. In both groups, pain severity was not associated with cognitive performance. In CFS patients, the level of fatigue measured with the CFS Symptom List, but not with the CIS, was significantly correlated with sustained attention. Self-reported mental health was negatively correlated with all investigated cognitive domains in the CFS group. These results provide evidence for the clinical importance of objectively measured cognitive problems in female CFS patients. Furthermore, a state-like measure (CFS Symptom List) appears to be superior over a trait-like measure (CIS) in representing cognitive fatigue in people with CFS. Finally, the lack of a significant relationship between cognitive performance and self-reported pain severity suggests that pain in CFS might be unique.     

Acetyl L-carnitine (ALC) treatment in elderly patients with fatigue

Fatigue is one of the conditions most frequently complained by the elderly. There are few effective treatment options for patients with chronic fatigue syndrome. To determine the efficacy, tolerability and impact on the fatigue, as well as on cognitive and functional status of elderly subjects with acetyl L-carnitine (ALC), 96 aged subjects (>70 years, range 71-88) were investigated (50 females and 46 males; mean age 76.2+/-7.6 and 78.4+/-6.4 years, respectively). They met four or more of the Holmes major criteria or at least six of Fukuda minor criteria. Fatigue was measured with the Wessely and Powell [Wessely, S., Powell, R., 1989. Fatigue syndromes: a comparison of chronic postviral fatigue with neuromuscular and affective disorders. J. Neurol. Neurosurg. Psychiatry 52, 940-948] scores, with the fatigue severity scale. At the end of the treatment, we observed a decrease of physical fatigue: 6.2 (p<0.001), of mental fatigue: 2.8 (p<0.001), of severity fatigue: 21.0 (p<0.001) and improvements in functional status: 16.1 (p<0.001) and cognitive functions: 2.7 (p<0.001). By the end of the treatment, significant differences between the two groups were found for the following parameters: muscle pain -27% versus -3% (p<0.05); prolonged fatigue after exercise: 51% versus -4% (p<0.0001); sleep disorders: 28% versus 4% (p<0.05); physical fatigue: 7 versus -0.5 (p<0.0001); mental fatigue: -3.3 versus 0.6 (p<0.0001); fatigue severity scale: -22.5 versus 1.2 (p<0.0001); functional status 17.1 versus 0.6 (p<0.0001); mini mental state examination (MMSE) improvements: 3.4 versus 0.5 (p<0.0001). Our data show that administering ALC may reduce both physical and mental fatigue in elderly and improves both the cognitive status and physical functions.     

Chronic fatigue syndrome and arthralgia following parvovirus B19 infection

OBJECTIVE: To determine the incidence of arthralgia and fatigue complicating B19 infection, along with associated B19 markers and autoantibodies. METHODS: We studied patients with acute B19 infection (n = 51), patients followed from the time of acute B19 infection (mean 22.5 mo) (n = 39), and healthy controls (n = 50). Clinical details were collected using a questionnaire and blood was tested for B19 markers and autoantibodies. RESULTS: Acute B19 arthralgia occurred in 31 patients and was associated with female sex (p = 0.007) and age > 20 years (p = 0.02). Acute B19 fatigue occurred in 8 patients and was not significantly associated with any marker. At followup, symptoms consisted of arthralgia (n = 5), arthralgia and fatigue (n = 6), fatigue (n = 7), lymphadenopathy (n = 1), and purpura due to thrombocytopenia (n = 2). Chronic B19 arthralgia was associated with persistent B19 viremia (p = 0.029). Comparison of the B19 followup group with the controls revealed a significantly increased prevalence of arthralgia (p = 0.0002), fatigue (p < 0.0001), and all other markers. Chronic B19 arthralgia was associated with both acute B19 arthralgia (p = 0.0168) and positive ANA at acute infection (p = 0.0043). Chronic B19 fatigue was associated with acute B19 fatigue (p = 0.011). Five patients fulfilled the Centers for Disease Control criteria for a diagnosis of chronic fatigue syndrome (CFS) and one of these was negative for serum anti-B19 IgG at followup by both Western blot and immunofluorescence. However, there was no characteristic pattern of B19 markers/autoantibodies in patients with B19 associated chronic fatigue. CONCLUSION: CFS may follow acute parvovirus B19 infection; however, attribution of a case of CFS to B19 infection may be extremely difficult in the absence of serological confirmation of acute infection at fatigue onset.