Chronic Fatigue Syndrome

What is chronic fatigue syndrome?

Chronic Fatigue Syndrome (CFS) is a condition characterized by chronic and disabling fatigue, as well as various additional manifestations, including neurological and cognitive changes, motor impairment, pain, sleep disturbance, and altered immune and autonomic responses.

There are currently eight published case definitions with clinical criteria. All include persistent fatigue not attributable to a known underlying medical condition, as well as additional clinical signs and symptoms. The United States’ Centers for Disease Control and Prevention criteria for CFS include:

  • severe fatigue lasting longer than six months, as well as presence of at least four of the following physical symptoms:
    • postexertional malaise
    • unrefreshing sleep
    • impaired memory or concentration
    • muscle pain
    • polyarthralgia
    • sore throat
    • tender lymph nodes
    • or new headaches.

Diagnosis of CFS is clinical and can be made only when other diseases are excluded.

What is the etiology of chronic fatigue syndrome?

Many different potential aetiologies for CFS including neurological, endocrine, psychological, immunological, genetic, and infectious have been investigated, but the diverse nature of the symptoms can not yet be fully explained.

Epstein Barr virus, Human Herpesvirus, Espumavirus, Retrovirus, Borna virus, Coxsackie B virus, Citomegalovirus,and hepatitis C virus (HCV) have been associated to CFS, but a causal relationship has not been established yet.

What other medical conditions could present with symptoms of chronic fatigue syndrome?

A variety of medical conditions could present with chronic fatigue:

Medical, Metabolic and Mental conditions:

  • Anxiety
  • Depression
  • Dysthymia
  • Hypothyroidism
  • Hypopituitarism
  • Adrenal insufficiency
  • Cushing’s syndrome
  • Diabetes mellitus
  • Hyperparathyroidism
  • Pregnancy
  • Reactive hypoglycemia
  • Malignancy
  • Chronic renal failure
  • COPD
  • Cardiovascular disease
  • Anemia
  • Electrolyte imbalance
  • Liver disease
  • Poor sleep
  • Fibromyalgia
  • Sleep apnea
  • Snoring
  • Insomnia
  • Abusive relationhsip
  • Unhealthy work-place environment



  • Subacute bacterial endocarditis
  • Lyme disease
  • Fungal disease
  • Infectious mono
  • HIV
  • Chronic Hepatitis B or C
  • Systemic Lupus Erythematosus
  • Myasthenia gravis
  • Multiple sclerosis
  • Thyroiditis
  • Rheumatoid arthritis


  • Alcohol depenence
  • Heavy cigarette smoking
  • Opioid abuse
  • Occupational exposure the chemical


  • Cardiac calve disease
  • Vascular insufficiency

How is chronic fatigue syndrome diagnosed?

Diagnosis of chronic fatigue syndrome (CFS) is complicated and often requires multiple in-depth assessments followed by laboratory and diagnostic work ups.

Blood work ups:

  1. CBC
  2. TSH, T4
  3. Fasting glucose
  4. Electrolytes
  5. HAV, HBV, HCV, HIV serology
  6. Liver function tests
  7. Hormon studies such as testosterone levels
  8. Infectious diseases serology as indicated by history
  9. CRP
  10. ESR
  11. Serum calcium
  12. BUN, Creatinin
  13. Serum ferritin
  14. Vitamin B12 and folate if indicated by CBC

How is chronic fatigue syndrome treated?

Treatment of patients with CFS depends on the diagnosis and underlying medical condition which could include any or some of the following approaches:

  • Lifestyle modification
  • Increased physical activity
  • Improvement of sleep habits
  • Smoking cessation
  • Stop drinking alcohol or using illicit drugs
  • Treatment of depression and/or anxiety
  • Workplace modification
  • Counseling
  • Cognitive behavioral therapy
  • Graduated exercise
  • Relaxation techniques for the management of pain, sleep problems and comorbid stress or
  • Treatment of underlying medical conditions such as thyroid diseases, COPD/Asthma, heart diseases, liver diseases, anemia, …
  • Dietary and nutritional consult

Are complementary and alternative medicine and supplements effective in treatment of CFS?

There is insufficient evidence that complementary therapies are effective treatments for CFS, however, some people with CFS choose to use some of these therapies and find them helpful.

There is insufficient evidence for the use of supplements such as:

  • vitamin B12
  • vitamin C
  • co-enzyme Q10
  • magnesium
  • NADH (nicotinamide adenine dinucleotide)
  • multivitamins and minerals

However, some people with CFS have reported finding these helpful as a part of a self-management strategy for their symptoms.


The following drugs should not be used for the treatment of CFS:

  • monoamine oxidase inhibitors (MAOi)
  • glucocorticoids (such as hydrocortisone)
  • mineralocorticoids (such as fludrocortisone)
  • stimulants such as dexamphetamine, methylphenidate, …
  • thyroxine
  • antiviral agents.


  • Darbishire L, Ridsdale L, Seed PT. Distinguishing patients with chronic fatigue from those with chronic fatigue syndrome: a diagnostic study in UK primary care. Br J Gen Pract. 2003;53(491):441-445.
  • Reynolds KJ, Vernon SD, Bouchery E, Reeves WC. The economic impact of chronic fatigue syndrome. Cost Eff Resour Alloc. 2004;2(1):4.
  • Friedberg F, Bateman L, Bested AC, et al. ME/CFS: A Primer for Clinical Practitioners. Chicago: International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis; 2014.
error: Content is protected !!