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 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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