OVERVIEW
Chronic fatigue syndrome (CFS) is a disorder marked by extreme fatigue for which no underlying cause can be found. It is also known as systemic exertion intolerance disease (SEID) or myalgic encephalomyelitis (ME). It is often referred to by the abbreviation ME/CFS.

CFS/ME can affect persons of all ages including children. However, it is more frequent in women, and usually develops around the 40s to 50s.

Myalgic Encephalomyelitis (ME) is a multi-system disease that affects proper functioning of the neurological, endocrine immune systems and normal metabolic activities.

It often follows an infection leaving nearly 75% of those affected unable to work and about 25% bedridden and house bound. It is estimated that 15-30 million people suffer from ME/CFS

POSSIBLE CAUSES & RISK FACTORS
The cause of CFS/ME remains unclear and no single cause has been identified yet despite ongoing research
The condition may be triggered by various factors including minor viral illness such as flu or extreme stress.

RISK FACTORS FOR CFS
• Stress
• Female sex
• Weak immunity
• Hormonal imbalance – often associated with abnormal blood levels of hormones secreted by hypothalamus, pituitary glands or adrenal glands
• Viral illness
• Possibly genetic predisposition
• Environmental factors
• Allergies

VIRAL INFECTIONS ASSOCIATED WITH CFS/ME
Though CFS can occasionally follow a viral infection, no single type of infection has been shown to directly cause CFS. Some viral infections that have been linked to CFS/ME include
• Epstein-Barr virus (EBV)
• Rubella
• Human herpesvirus 6
• Ross River virus (RRV)

Bacterial infections including Coxiella burnetii and Mycoplasma pneumoniae, have also been looked at for possible association to CFS.

SYMPTOMS OF CFS/ME
Symptoms of CFS varies depending on the person and the severity of the condition
• The most common symptom is extreme fatigue that impacts daily life and routine activities.
• To diagnose CFS, symptoms of extreme tiredness affecting performance of routine activities must be present for at least six months
• Tiredness not be relieved by rest
• Extreme fatigue following physical or mental activity that lasts for days to weeks. This is termed as post-exertional malaise (PEM)
• Sleep difficulties
• Insomnia
• Feeling tired and listless even after overnight sleep
• Loss of concentration and inability to focus
• Memory issues
• Orthostatic hypotension (feeling dizzy on standing from sitting posture or getting up from lying posture)
• Muscle and joint pains
• Recurrent headaches
• Frequent sore throat
• Swollen lymph glands in neck and armpits

Occasionally, CFS occurs in cycles, with intervening symptom free periods. Rarely, symptoms may sometimes resolve completely, and the patient goes into remission. However, the symptoms may recur at a later date, referred to as relapse. This pattern of remission and relapse makes diagnosis and treatment even more challenging

COMPLICATIONS OF CFS
• Depression
• Social isolation
• Limitations in lifestyle and difficulties in relationships
• Frequent absence from work

DIAGNOSIS OF CFS/ME
CFS is not easy to diagnose as it mimics several other conditions and it is usually a diagnosis of exclusion following thorough, physical examination and tests to rule out other causes for the symptoms. There is no test to diagnose CFS. Since many patients look well, the diagnosis is often overlooked.

Other conditions that must be borne in mind and ruled out include
• Infectious mononucleosis
• Multiple sclerosis
• Major depression
• Fibromyalgia
• Lyme disease
• SLE
• Hypothyroidism
• Sleep disorders – obstructive sleep apnea, insomnia
• Heart or lung disease (exercise tolerance test can help to assess heart and lung status)
• Extreme obesity
• Drug related – side effect of antihistamines, alcohol

TREATMENT OF CFS/ME
There is no cure for CFS/ME. Treatment aims to provide symptomatic relief

MEDICATIONS
Treatment varies according to the person and severity of the condition. Medications may be given for relief of pain, nausea and sleep issues
Antidepressants may help control symptoms since many patients with CFS are depressed. Seeing a mental health care provider may be beneficial

MANAGING ACTIVITIES
Activity management or pacing to balance rest and activities may help to reduce symptoms of post-
exertional malaise (PEM). Pacing or graded exercise therapy (GET)muse be tailored to suit each patient
and activities must be planned according to each person’s limits and maintained as such under the supervision of a physical therapist. Keeping a diary can help patients be aware of their personal limits
Importantly, although vigorous aerobic exercise is useful for most chronic conditions, people with CFS cannot cope with such exercise routines

COGNITIVE BEHAVIORAL THERAPY
Counselling helps patients figure out options and work around the limitations caused by CFS/ME. Once the person gains control of their life and routine and gains self-esteem and a positive outlook, the symptoms may improve dramatically.

HOME REMEDIES & LIFESTYLE CHANGES
• Develop a fixed sleep routine. Go to bed around the same time daily
• Avoid activities at night that can disrupt sleep
• Limit intake of coffee, tea, alcohol and tobacco
• Avoid daytime napping if it affects night sleep
• Dietary modifications to avoid triggering of CFS
• Oral supplements including magnesium, vitamin B12, coenzyme Q, and vitamin C (although evidence is limited)
• Joining a support group can help in getting information and guidance to cope better with the condition

ALTERNATIVE MEDICINE
Acupuncture, yoga, massage, reflexology and tai chi may help control pain associated with CFS. Discuss with your doctor before starting any alternative or complementary therapies

PROGNOSIS
Unfortunately, in many patients, symptoms are chronic and last for years. Symptoms are usually severe in the first one or two years but tend to improve over time in most cases