Chronic Fatigue Syndrome Clinical Presentation

Patients with chronic fatigue syndrome (CFS) present with prolonged fatigue of an indeterminate cause. If the source of the fatigue can be explained, the patient probably does not have CFS.

Patients with CFS often report a history of an antecedent infection that precipitated the prolonged state of fatigue and followed the initial illness. The patient may have a history of Epstein-Barr virus (EBV) infectious mononucleosis, cytomegalovirus (CMV) infectious mononucleosis, pneumonia, diarrhea, or upper respiratory tract infection.

Patients with acute disease caused by these infections experience fatigue during the acute illness, but the fatigue resolves as the patient recovers. In patients with CFS, the fatigue continues for 6 months or more after they have recovered from the acute infectious event.

From a personality standpoint, patients with CFS are usually cardiac type A intensive people. They are not malingerers, and they do not seek secondary gain. As a group, they typically want a fully functioning life to be restored to them, and they become frustrated by their inability to perform their work and home tasks because of their prolonged fatigue and cognitive dysfunction.

Patients with CFS may be depressed because of their inability to perform normal duties at home and at work, but they are not depressive individuals per se. Depressive individuals typically report longstanding depression (of several years’ duration), and they typically lack the cognitive dysfunction characteristic of individuals with CFS.

Patients with CFS typically report problems with short-term memory but not with long-term memory. They may also report verbal dyslexia that is manifested as the inability to find or say a particular word during normal speech. This typically disturbs patients with CFS and may interfere with their occupation.

Patients with CFS also typically report postexertional fatigue, feeling excessively tired after doing relatively normal tasks that they did for years before their CFS without any particular problem. Patients also report fatigue even after prolonged periods of rest or sleep. Patients with CFS do not recharge or arise refreshed after sleeping and rarely have sore throats or fevers.

The diagnosis of CFS depends on eliminating other causes of chronic persistent fatigue. Many patients have lifestyles that would make anyone feel fatigue on a long-term basis. This may be related to job, family, or home stress. Patients with malignancy should be excluded because fatigue often accompanies neoplastic disease.

Many patients who experience fatigue but not CFS have a supratentorial component to the illness, and psychosomatic illness often manifests as otherwise unexplained fatigue.

If the above conditions can be excluded, then the diagnosis of CFS may be considered.

CFS should be diagnosed only after other causes of fatigue are excluded and the fatigue has lasted for at least 6 months. An absence of cognitive difficulties should exclude a diagnosis of CFS. Signs of adrenal or thyroid disorders should also exclude a diagnosis of CFS, in that the fatigue is explained by endocrinologic factors. Similarly, HIV infection and AIDS may also cause chronic fatigue.

The physical examination often reveals no abnormalities, but left axillary node involvement or crimson crescents are the most consistent findings during a physical examination.

Patients with CFS have small, moveable, painless lymph nodes that most commonly involve the neck, axillary region, or inguinal region. A single lymph node that is very large, tender, or immobile suggests a diagnosis other than CFS. Similarly, generalized adenopathy suggests a diagnosis other than CFS.

In the oropharynx, purple or crimson discoloration of both anterior tonsillar pillars in the absence of pharyngitis is a frequent marker in patients with CFS. The cause of crimson crescents is not known, but they are common in patients with CFS. However, crimson crescents are not specific for CFS.

Trigger points, which suggest fibromyalgia, are absent in patients with CFS. CFS and fibromyalgia rarely coexist in the same patient.

According to the Centers for Disease Control and Prevention (CDC) case definition, no specific physical findings serve to confirm the diagnosis of CFS. CFS is defined by symptoms and not signs. However, adolescents, particularly girls, may have signs and symptoms of postural tachycardia syndrome, including upright and sometimes supine tachycardia, pallor, hypotension, and other vasomotor findings.