MKSAP: 32-year-old woman with chronic fatigue syndrome

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 32-year-old woman is evaluated following a diagnosis of chronic fatigue syndrome. She has a several-year history of chronic disabling fatigue, unrefreshing sleep, muscle and joint pain, and headache.

A comprehensive evaluation has not identified any other medical condition, and a screen for depression is normal. Her only medications are multiple vitamins and dietary supplements. Physical examination is normal.

Which of the following is the most appropriate management for this patient’s symptoms?

A: Acyclovir
B: Evening primrose oil
C: Graded exercise program
D: Growth hormone
E: Sertraline

MKSAP Answer and Critique

The correct answer is C: Graded exercise program.

The most appropriate management for this patient is to begin a graded exercise program. Chronic fatigue syndrome (CFS) is defined as medically unexplained fatigue that persists for 6 months or more and is accompanied by at least 4 of the following symptoms: subjective memory impairment, sore throat, tender lymph nodes, muscle or joint pain, headache, unrefreshing sleep, and postexertional malaise lasting longer than 24 hours. Management of CFS is challenging and is geared toward managing symptoms and maintaining function, rather than seeking cure. A comprehensive, individually tailored approach is required, typically based on nonpharmacologic therapy, such as lifestyle modification and sleep hygiene. Specific treatment options that have been demonstrated to improve symptoms include graded exercise programs and cognitive-behavioral therapy (CBT). CBT in this setting is targeted in part at breaking the cycle of effort avoidance, decline in physical conditioning, and increase in fatigue and can work well in combination with graded exercise in this regard. CBT reduces fatigue and improves functional status.

Although Epstein-Barr virus and a host of other infectious agents have been considered in the pathogenesis of CFS, none have been borne out by careful study; therefore, antiviral therapy, including acyclovir, has no role in the treatment of CFS. A variety of other medications have been tried, including corticosteroids, mineralocorticoids, growth hormone, and melatonin, but with no clear evidence of benefit, and are not indicated for this patient.

Current evidence is not sufficiently robust to recommend dietary supplements, herbal preparations (evening primrose oil), homeopathy, or even pharmacotherapy. Patients with concomitant depression should be treated with antidepressants. Although no specific class of antidepressant is recommended in this setting, tricyclic antidepressants are often utilized in patients with CFS and depression owing to their adjunct effectiveness in treating muscle pain.

Key Point

  • Effective treatment options for chronic fatigue syndrome include graded exercise programs and cognitive-behavioral therapy.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to KevinMD.com on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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  • DoubtfulGuest

    Did you check her for muscle weakness? Did you check her for *fatiguable* muscle weakness? What’s the patient’s exercise history? What kind of headaches? Are they migraines? Any family history of migraines? Any hearing loss or eye problems? What all was ruled out by the “comprehensive evaluation”? What are the “multiple vitamins and dietary supplements” for? Does she think any of them help? Are the muscle and joint pain associated with exertion or any other factors that she can identify?

    What evidence do you have for “effort avoidance” in this patient? If she responds poorly to CBT and graded exercise, what are you going to do next?

  • DoubtfulGuest

    I know, right? Something about this looked “off” to me, so I searched for other MKSAP on this blog and skimmed about ten of those on the list. The history for this one is kinda on the short side compared with the others. I’m picturing this fictional doctor going: “Well, *I* would like to stay in bed all day, but I can’t. Get thee onto a treadmill, start with five minutes. And we’ll send you to a therapist to help you with your laziness.”

    What’s really fun is when they use “chronic fatigue syndrome” interchangeably with “fibromyalgia” e.g. in letters to the referring physician. Do they think we won’t notice the wastebasket “diagnosis”? I turned out to have a mitochondrial myopathy, and that might not apply to this case…but they’re not *asking* her anything to help rule it out, either. I’ll be the first to say that exercise is important, but too much or the wrong kind is dangerous. Try again, guys. :/

  • DoubtfulGuest

    “…and I think what we’ve got here is — well, it’s called AFPS. That stands for Annoying Female Patient Syndrome. And the reason we know that you have this is, well, you’re female. I personally find you kind of annoying, and I don’t feel like asking you many questions — that’s what really tipped me off. On top of that, you’re 32 years old, I don’t like that, either. I think that’s about all the information we need. Now, there is no cure for AFPS, but thankfully, we have some treatments to help you maintain function, make you less exasperating to me…”

  • Aziza Jansen

    The PACE Trial has shown emphatically that GET and CBT do not treat M.E. and CFS. Therefore it is reasonable to speculate that the 15% that responded to these treatments were misdiagnosed. Those participants may have had illnesses that included deconditioning and fear-avoidance ameliorable with the therapies. http://www.plosone.org/annotation/listThread.action;jsessionid=0149466DAA8BD87887B125E366733575?root=52493

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