Chronic Fatigue Syndrome
Pediatric Chronic Fatigue Syndrome (CFS)
Chronic Fatigue Syndrome (CFS), also known as Myalgic Encephalomyelitis (ME), is a complex and debilitating disorder characterized by persistent, unexplained fatigue that is not alleviated by rest and is accompanied by a constellation of other symptoms.
Key Points
- Affects both children and adolescents, with a peak incidence in the teenage years
- Significant impact on physical, mental, and social functioning
- Lack of clear understanding of the underlying pathophysiology
- Requires a multidisciplinary approach for effective management
Causes and Risk Factors
Multifactorial Etiology
- Viral infections (e.g., Epstein-Barr virus, enterovirus, parvovirus B19)
- Immune system dysregulation and inflammation
- Genetic predisposition and familial clustering
- Hormonal imbalances (e.g., hypothalamic-pituitary-adrenal axis dysfunction)
- Psychological and environmental factors (e.g., stress, trauma, sleep disturbances)
Risk Factors
- Female sex (2-4 times more common in females)
- Age (peak incidence in adolescents and young adults)
- Sedentary lifestyle and deconditioning
- Comorbid mental health conditions (e.g., depression, anxiety)
- History of viral infections or other triggering events
The exact cause of CFS remains unclear, and it is likely a combination of genetic, immunological, and environmental factors that contribute to the development of the condition.
Clinical Presentation
Cardinal Symptoms
- Persistent, unexplained fatigue that is not alleviated by rest
- Post-exertional malaise (worsening of symptoms after physical or mental exertion)
- Unrefreshing sleep or sleep disturbances
- Impaired cognitive function ("brain fog," difficulty concentrating, memory problems)
Additional Symptoms
- Muscle and joint pain
- Headaches
- Sore throat
- Tender lymph nodes
- Orthostatic intolerance (dizziness, lightheadedness upon standing)
- Gastrointestinal disturbances (e.g., nausea, abdominal pain, irritable bowel syndrome)
- Temperature dysregulation (chills, sweats)
The symptoms of CFS can fluctuate in severity and may worsen with physical or mental exertion, leading to significant functional impairment.
Diagnosis
Diagnostic Criteria
- Persistent, unexplained fatigue lasting at least 6 months
- Significant reduction in daily activities compared to pre-illness level
- Presence of at least four of the following symptoms:
- Post-exertional malaise
- Unrefreshing sleep
- Cognitive impairment
- Orthostatic intolerance
- Muscle/joint pain
- Exclusion of other medical and psychiatric conditions that could explain the symptoms
Diagnostic Workup
- Detailed medical history and physical examination
- Laboratory tests to rule out other conditions (e.g., complete blood count, metabolic panel, thyroid function, autoimmune markers)
- Psychological evaluation to assess for comorbid mental health conditions
- Autonomic function tests (e.g., tilt-table test) to assess for orthostatic intolerance
- Ruling out alternative diagnoses through appropriate imaging or specialized testing
The diagnosis of CFS is primarily based on clinical criteria, as there is no single diagnostic test to confirm the condition.
Management
Multidisciplinary Approach
- Symptom management and treatment of associated conditions
- Medications (e.g., pain relievers, sleep aids, antidepressants)
- Lifestyle modifications (e.g., pacing, sleep hygiene, dietary changes)
- Rehabilitative interventions
- Graded exercise therapy (gradually increasing physical activity)
- Cognitive-behavioral therapy (to address thoughts, emotions, and behaviors)
- Supportive care and education
- Counseling and mental health support
- School accommodations and vocational rehabilitation
- Patient and family education on disease management
The treatment plan should be tailored to the individual patient's symptoms, preferences, and level of functioning.
Prognosis
Natural Course
- CFS is a chronic, fluctuating condition with periods of remission and relapse
- Most patients experience a gradual improvement in symptoms over time, but complete recovery is uncommon
- Some patients may remain severely disabled, with significant impact on quality of life
Factors Affecting Prognosis
- Early diagnosis and appropriate management
- Severity of initial symptoms and level of functional impairment
- Comorbid mental health conditions and their management
- Adherence to treatment recommendations and lifestyle modifications
- Availability of social support and access to specialized care
With a multidisciplinary approach and appropriate management, most pediatric patients with CFS can achieve some improvement in symptoms and quality of life, though a complete return to pre-illness functioning is uncommon.
