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Rowe K. Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) in Adolescents: Practical Guidance and Management Challenges. Adolesc Health Med Ther 2023; 14:13-26. [PMID: 36632532 PMCID: PMC9827635 DOI: 10.2147/ahmt.s317314] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
This paper reviews the current understanding of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and whether any treatment strategies have been effective. ME/CFS is a condition of as yet unknown etiology that commonly follows an infective process. It includes a new onset of fatigue (of more than 3-6 month duration and not relieved by rest), post-exertional malaise, cognitive difficulties and unrefreshing sleep, and frequently orthostatic intolerance, somatic symptoms and pain. Long COVID has renewed interest in the condition and stimulated research with findings suggestive of a multisystem neuroimmune disease. There are no definitively effective treatments. Despite earlier recommendations regarding graded exercise therapy and cognitive behavior therapy, the current recommendations are managing symptoms, with lifestyle management and supportive care. This paper provides an outline of strategies that young people and their families have reported as helpful in managing a chronic illness that impacts their life socially, physically, emotionally, cognitively and educationally. As the illness frequently occurs at a time of rapid developmental changes, reducing these impacts is reported to be as important as managing the physical symptoms. Young people face a mean duration of 5 years illness (range 1-16 years) with a likely residual 20% having significant restrictions after 10 years. Their feedback has suggested that symptom management, self-management strategies, advocacy and educational liaison have been the most helpful. They value professionals who will listen and take them seriously, and after excluding alternative diagnoses, they explain the diagnosis, are supportive and assist in monitoring their progress. Remaining engaged in education was the best predictor of later functioning. This allowed for social connections, as well as potential independence and fulfilling some aspirations. The need to consider the impact of this chronic illness on all aspects of adolescent development, as part of management, is highlighted.
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Affiliation(s)
- Katherine Rowe
- Department of General Medicine, Royal Children’s Hospital, Melbourne, Victoria, Australia,Correspondence: Katherine Rowe, Department of General Medicine, Royal Children’s Hospital, Flemington Road Parkville, Melbourne, Victoria, 3052, Australia, Tel +61 412059283, Email
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Cvejic E, Li H, Hickie IB, Wakefield D, Lloyd AR, Vollmer-Conna U. Contribution of individual psychological and psychosocial factors to symptom severity and time-to-recovery after naturally-occurring acute infective illness: The Dubbo Infection Outcomes Study (DIOS). Brain Behav Immun 2019; 82:76-83. [PMID: 31376496 DOI: 10.1016/j.bbi.2019.07.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Substantial heterogeneity exists in both the severity of symptoms experienced as part of the sickness response to naturally-occurring infections, and the time taken for individuals to recover from these symptoms. Although contributing immunological and genetic factors have been previously been explored, less is known about the role of individual psychological and psychosocial factors, which may modulate the host immune response, or contribute independently, to symptom severity and duration. METHODS Longitudinally-collected data from 484 Caucasian participants (mean age: 33.5 years; 51% women) experiencing a naturally-occurring acute infective illness enrolled in the prospective Dubbo Infection Outcome Study (DIOS) were analysed. At intake and subsequent follow-up assessments, self-report questionnaires were used to ascertain individual psychological and psychosocial characteristics and symptom information. Principal component analysis was applied to symptom data to derive endophenotype severity scores representing discrete symptom domains (fatigue, mood, pain, neurocognitive difficulties) and an overall index of severity. The contribution of individual psychological (trait neuroticism, locus of control, and illness behaviours) and psychosocial factors (relative socioeconomic advantage) to endophenotype severity at baseline were examined using multivariable linear regression models; interval-censored flexible parametric proportional hazards survival models were used to explore time to recovery (defined using within-sample negative threshold values). RESULTS After controlling for time since symptom onset, greater levels of trait neuroticism consistently predicted greater symptom severity across all symptom domains (all p's < 0.015). Similarly, greater relative socioeconomic disadvantage was significantly associated with greater severity across all endophenotypes (p's < 0.025) except neurocognitive disturbance. Locus of control and illness behaviours contributed differentially across endophenotypes. Reduced likelihood of recovery was significantly predicted by greater initial symptom severity for all endophenotypes (all p's < 0.001), as well as higher levels of trait neuroticism. CONCLUSIONS Individual psychological and psychosocial factors contribute to the initial severity and to the prolonged course of symptoms after naturally-occurring infective illnesses. These factors may play an independent role, represent a bias in symptom reporting, or reflect increased stress responsivity and a heightened inflammatory response. Objective metrics for severity and recovery are required to further elucidate their roles.
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Affiliation(s)
- Erin Cvejic
- The University of Sydney, School of Public Health, Faculty of Medicine and Health, NSW, Australia; School of Psychiatry, Faculty of Medicine, UNSW Sydney, NSW, Australia.
| | - Hui Li
- Viral Immunology Systems Program, Kirby Institute, UNSW Sydney, NSW, Australia
| | - Ian B Hickie
- The University of Sydney, Brain and Mind Centre, Faculty of Medicine and Health, NSW, Australia
| | - Denis Wakefield
- School of Medical Sciences, Faculty of Medicine, UNSW Sydney, NSW, Australia
| | - Andrew R Lloyd
- Viral Immunology Systems Program, Kirby Institute, UNSW Sydney, NSW, Australia
| | - Uté Vollmer-Conna
- School of Psychiatry, Faculty of Medicine, UNSW Sydney, NSW, Australia
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Pedersen M, Asprusten TT, Godang K, Leegaard TM, Osnes LT, Skovlund E, Tjade T, Øie MG, Wyller VBB. Predictors of chronic fatigue in adolescents six months after acute Epstein-Barr virus infection: A prospective cohort study. Brain Behav Immun 2019; 75:94-100. [PMID: 30261303 DOI: 10.1016/j.bbi.2018.09.023] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/08/2018] [Accepted: 09/24/2018] [Indexed: 10/28/2022] Open
Abstract
INTRODUCTION Acute Epstein-Barr virus (EBV) infection is a trigger of chronic fatigue and Chronic Fatigue Syndrome (CFS). This study investigated baseline predictors of chronic fatigue six months after an acute EBV infection. MATERIALS AND METHODS A total of 200 adolescents (12-20 years old) with acute EBV infection were assessed for 149 possible baseline predictors and followed prospectively. We performed linear regression to assess possible associations between baseline predictors and fatigue (Chalder Fatigue Questionnaire total score) six months after the acute EBV infection. A total of 70 healthy controls were included for cross-sectional reference. This study is part of the CEBA-project (Chronic fatigue following acute Epstein-Barr virus infection in adolescents). RESULTS In the final multiple linear regression model, fatigue six months after acute EBV infection was significantly and independently predicted by the following baseline variables (regression coefficient B[95% CI]): Sensory sensitivity (0.8[0.09-1.6]), pain severity (0.2[0.02-0.3]), functional impairment (1000 steps/day) (-0.3[-0.5 to -0.08]), negative emotions (anxiety) (0.4[0.2-0.6]), verbal memory (correct word recognition) (1.7[0.1-3.3]), plasma C-reactive protein (2.8[1.1-4.4] for CRP values >0.86) and plasma Vitamin B12 (-0.005[-0.01 to -0.001]). CONCLUSIONS Development of fatigue after acute EBV infection is to a larger extent predicted by baseline variables related to symptoms and functions than to baseline variables reflecting infectious and immune processes. TRIAL REGISTRATION ClinicalTrials, ID: NCT02335437, https://clinicaltrials.gov/ct2/show/NCT02335437.
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Affiliation(s)
- Maria Pedersen
- Institute of Clinical Medicine, University of Oslo, Norway; Dept. of Pediatrics, Akershus University Hospital, Norway
| | - Tarjei Tørre Asprusten
- Institute of Clinical Medicine, University of Oslo, Norway; Dept. of Pediatrics, Akershus University Hospital, Norway
| | - Kristin Godang
- Section of Specialized Endocrinology, Dept. of Endocrinology, Oslo University Hospital, Norway.
| | - Truls Michael Leegaard
- Institute of Clinical Medicine, University of Oslo, Norway; Dept. of Microbiology and Infection Control, Akershus University Hospital, Norway.
| | - Liv Toril Osnes
- Dept. of Immunology and Transfusion Medicine, Oslo University Hospital, Norway.
| | - Eva Skovlund
- Dept. of Public Health and Nursing, Norwegian University of Science and Technology, Trondheim, Norway; Norwegian Institute of Public Health, Norway.
| | | | - Merete Glenne Øie
- Dept. of Psychology, University of Oslo, Norway; Dept. of Research, Innlandet Hospital Trust, Norway.
| | - Vegard Bruun Bratholm Wyller
- Institute of Clinical Medicine, University of Oslo, Norway; Dept. of Pediatrics, Akershus University Hospital, Norway.
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Katz BZ, Collin SM, Murphy G, Moss-Morris R, Wyller VB, Wensaas KA, Hautvast JLA, Bleeker-Rovers CP, Vollmer-Conna U, Buchwald D, Taylor R, Little P, Crawley E, White PD, Lloyd A. The International Collaborative on Fatigue Following Infection (COFFI). FATIGUE-BIOMEDICINE HEALTH AND BEHAVIOR 2018; 6:106-121. [PMID: 30666281 DOI: 10.1080/21641846.2018.1426086] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background The purpose of the Collaborative on Fatigue Following Infection (COFFI) is for investigators of post-infection fatigue (PIF) and other syndromes to collaborate on these enigmatic and poorly understood conditions by studying relatively homogeneous populations with known infectious triggers. Utilizing COFFI, pooled data and stored biosamples will support both epidemiological and laboratory research to better understand the etiology and risk factors for development and progression of PIF. Methods COFFI consists of prospective cohorts from the UK, Netherlands, Norway, USA, New Zealand and Australia, with some cohorts closed and some open to recruitment. The 9 cohorts closed to recruitment total over 3,000 participants, including nearly 1000 with infectious mononucleosis (IM), > 500 with Q fever, > 800 with giardiasis, > 600 with campylobacter gastroenteritis (CG), 190 with Legionnaires disease and 60 with Ross River virus. Follow-ups have been at least 6 months and up to 10 years. All studies use the Fukuda criteria for defining chronic fatigue syndrome (CFS). Results Preliminary analyses indicated that risk factors for non-recovery from PIF included lower physical fitness, female gender, severity of the acute sickness response, and autonomic dysfunction. Conclusions COFFI (https://internationalcoffi.wordpress.com/) is an international collaboration which should be able to answer questions based on pooled data that are not answerable in the individual cohorts. Possible questions may include the following: Do different infectious triggers different PIF syndromes (e.g., CFS vs. irritable bowel syndrome)?; What are longitudinal predictors of PIF and its severity?
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Affiliation(s)
- Ben Z Katz
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Division of Infectious Diseases, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, USA
| | - Simon M Collin
- Centre for Child & Adolescent Health, School of Social & Community Medicine, University of Bristol, UK
| | | | - Rona Moss-Morris
- Health Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, UK
| | | | - Knut-Arne Wensaas
- Research Unit for General Practice, Uni Research Health, Bergen, Norway
| | - Jeannine L A Hautvast
- Department of Primary and Community Care, Radboud university medical centre, Nijmegen, NL
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine, Division of Infectious Diseases, Radboud University Medical Centre, Nijmegen, NL
| | - Ute Vollmer-Conna
- School of Psychiatry, University of New South Wales, Sydney, Australia
| | - Dedra Buchwald
- Department of Psychiatry and Behavioral Sciences, University of Washington, USA
| | - Renée Taylor
- Department of Occupational Therapy, University of Illinois at Chicago, USA
| | - Paul Little
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Esther Crawley
- Primary Care and Population Sciences Division, University of Southampton, Southampton, UK
| | - Peter D White
- Wolfson Institute of Preventive Medicine, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, UK
| | - Andrew Lloyd
- Kirby Institute, University of New South Wales, Sydney, New South Wales, Australia
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Harvey JM, Broderick G, Bowie A, Barnes ZM, Katz BZ, O'Gorman MRG, Vernon SD, Fletcher MA, Klimas NG, Taylor R. Tracking post-infectious fatigue in clinic using routine Lab tests. BMC Pediatr 2016; 16:54. [PMID: 27118537 PMCID: PMC4847210 DOI: 10.1186/s12887-016-0596-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Accepted: 04/21/2016] [Indexed: 12/25/2022] Open
Abstract
Background While biomarkers for chronic fatigue syndrome (CFS) are beginning to emerge they typically require a highly specialized clinical laboratory. We hypothesized that subsets of commonly measured laboratory markers used in combination could support the diagnosis of post-infectious CFS (PI-CFS) in adolescents following infectious mononucleosis (IM) and help determine who might develop persistence of symptoms. Methods Routine clinical laboratory markers were collected prospectively in 301 mono-spot positive adolescents, 4 % of whom developed CFS (n = 13). At 6, 12, and 24 months post-diagnosis with IM, 59 standard tests were performed including metabolic profiling, liver enzyme panel, hormone profiles, complete blood count (CBC), differential white blood count (WBC), salivary cortisol, and urinalysis. Classification models separating PI-CFS from controls were constructed at each time point using stepwise subset selection. Results Lower ACTH levels at 6 months post-IM diagnosis were highly predictive of CFS (AUC p = 0.02). ACTH levels in CFS overlapped with healthy controls at 12 months, but again showed a trend towards a deficiency at 24 months. Conversely, estradiol levels depart significantly from normal at 12 months only to recover at 24 months (AUC p = 0.02). Finally, relative neutrophil count showed a significant departure from normal at 24 months in CFS (AUC p = 0.01). Expression of these markers evolved differently over time between groups. Conclusions Preliminary results suggest that serial assessment of stress and sex hormones as well as the relative proportion of innate immune cells measured using standard clinical laboratory tests may support the diagnosis of PI-CFS in adolescents with IM. Electronic supplementary material The online version of this article (doi:10.1186/s12887-016-0596-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Gordon Broderick
- Department of Medicine, University of Miami, Miami, FL, USA. .,Institute for Neuro Immune Medicine, Nova Southeastern University, University Park Plaza, 3440 South University, Fort Lauderdale, 33328, FL, USA. .,University of Alberta, Edmonton, AB, Canada.
| | | | | | - Ben Z Katz
- Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | | | | | - Mary Ann Fletcher
- Institute for Neuro Immune Medicine, Nova Southeastern University, University Park Plaza, 3440 South University, Fort Lauderdale, 33328, FL, USA
| | - Nancy G Klimas
- Institute for Neuro Immune Medicine, Nova Southeastern University, University Park Plaza, 3440 South University, Fort Lauderdale, 33328, FL, USA
| | - Renee Taylor
- University of Illinois at Chicago, Chicago, IL, USA
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Twisk FNM. Accurate diagnosis of myalgic encephalomyelitis and chronic fatigue syndrome based upon objective test methods for characteristic symptoms. World J Methodol 2015; 5:68-87. [PMID: 26140274 PMCID: PMC4482824 DOI: 10.5662/wjm.v5.i2.68] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2014] [Revised: 02/10/2015] [Accepted: 05/27/2015] [Indexed: 02/06/2023] Open
Abstract
Although myalgic encephalomyelitis (ME) and chronic fatigue syndrome (CFS) are considered to be synonymous, the definitional criteria for ME and CFS define two distinct, partially overlapping, clinical entities. ME, whether defined by the original criteria or by the recently proposed criteria, is not equivalent to CFS, let alone a severe variant of incapacitating chronic fatigue. Distinctive features of ME are: muscle weakness and easy muscle fatigability, cognitive impairment, circulatory deficits, a marked variability of the symptoms in presence and severity, but above all, post-exertional “malaise”: a (delayed) prolonged aggravation of symptoms after a minor exertion. In contrast, CFS is primarily defined by (unexplained) chronic fatigue, which should be accompanied by four out of a list of 8 symptoms, e.g., headaches. Due to the subjective nature of several symptoms of ME and CFS, researchers and clinicians have questioned the physiological origin of these symptoms and qualified ME and CFS as functional somatic syndromes. However, various characteristic symptoms, e.g., post-exertional “malaise” and muscle weakness, can be assessed objectively using well-accepted methods, e.g., cardiopulmonary exercise tests and cognitive tests. The objective measures acquired by these methods should be used to accurately diagnose patients, to evaluate the severity and impact of the illness objectively and to assess the positive and negative effects of proposed therapies impartially.
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Rimes KA, Papadopoulos AS, Cleare AJ, Chalder T. Cortisol output in adolescents with chronic fatigue syndrome: pilot study on the comparison with healthy adolescents and change after cognitive behavioural guided self-help treatment. J Psychosom Res 2014; 77:409-14. [PMID: 25260861 DOI: 10.1016/j.jpsychores.2014.08.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2014] [Revised: 08/23/2014] [Accepted: 08/31/2014] [Indexed: 12/16/2022]
Abstract
OBJECTIVE This study examined cortisol in adolescents with chronic fatigue syndrome (CFS) compared to healthy adolescents and changes in cortisol after cognitive behavioural guided self-help treatment. Exploratory analyses investigated the association between cortisol output and psychological variables. METHODS Salivary cortisol was measured upon awakening, at 15, 30, 45 and 60 min afterwards and at 12 noon, 4:00 p.m. and 8:00 p.m., in adolescents with CFS and healthy controls (HC). Groups were matched for age, gender, menarche status, menstrual cycle and awakening time. Twenty-four adolescents with CFS provided saliva samples six months after treatment. The main outcome measure was total salivary output over the day, calculated by area under the curve (AUC). The salivary awakening response was also assessed. RESULTS Cortisol output over the day was significantly lower in the CFS group (n=46) than in healthy controls (n=33). Within the CFS group, lower daily cortisol output was associated with higher self-reported perfectionist striving and prosocial behaviour. There were no significant group differences in the awakening response (n=47 CFS versus n=34 HC). After treatment, adolescents with CFS (n=21) showed a significant increase in daily cortisol output, up to normal levels. CONCLUSION The reduced daily cortisol output in adolescents with CFS is in line with adult findings. Associations between reduced cortisol output and two psychological variables-perfectionism and prosocial behaviour-are consistent with cognitive behavioural models of chronic fatigue syndrome. The mild hypocortisolism is reversible; cortisol output had returned to healthy adolescent levels by six months after cognitive behavioural guided self-help treatment.
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Affiliation(s)
| | | | | | - Trudie Chalder
- King's College London, Institute of Psychiatry, London, UK
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