Differential diagnosis and co-existing conditions

Patients with many medical conditions may exhibit fatigue as a symptom, but do not meet the case definition of CFS or lack other characteristic features.

Other diagnoses to consider include:

• Depression - F32# (if low or sad mood is prominent)
• Chronic mixed anxiety and depression - F41.2
• Panic disorder - F41.1 (if anxiety attacks are prominent)
• Somatization disorders

Co-morbidity of CFS and mood disorder is common (ref 45). Patients may have both; and both will need management. In clinical practice the two are not mutually exclusive, although the research definitions necessarily try to avoid co-morbidity.

Assessment

The clinical history is crucial. A well-taken history might also help the patient in validating their problem, and encourage a good clinician-patient relationship. (ref 46,47). Physical examination is obligatory, usually normal, and largely serves to exclude other conditions. Assessment must also include examination of the patient's mental state and a psychosocial assessment. Investigations should include a full blood count, C-reactive (CRP) (or ESR), thyroid function tests, urea and electrolytes, blood sugar and liver function tests. If clinically indicated, screening for gluten-sensitive enteropathy or autoimmune disease might be helpful.

Alternative diagnoses should be considered in particular circumstances, for example where there us:

• significant weight loss
• a history of foreign travel
• any documented fever
• extremes of life (very young or very old)
• any physical sign
• myalgic symptoms only after exertion and not associated with any symptoms of mental fatigability (suggests possible myopathy).

References

45 Abbey S, Garfinkel P. Chronic fatigue syndrome and depression: cause, effect or covariate. Rev Infect Dis 1991, 13(suppl 1): S73-S83.

46 Prins J, Bleijenberg G, Rouweler E et al. Doctor-patient relationship in primary care of chronic fatigue syndrome: Perspectives of the doctor and the patient. J Chronic Fatigue Syndrome 2001, 7: 3-15.

47 Butler C, Rollnick S. Missing the meaning and provoking resistance: a case of myalgic encephalomyelitis. Family Pract 1996, 13: 106-109.

Last edited: 30/1/2004

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