A TIRED TEENAGER
History
Charlotte is 14 years old. She is referred to the paediatric outpatient department by her GP. Over the last 6 months she has been complaining of feeling tired all the time, she has a sore throat, headaches, pains in her arms, legs and abdomen, and feels weak. She has not been to school for the last 6 weeks because she can’t manage the walk to the bus stop and now she needs her mother’s assistance to walk around her house. The referral letter says that they have attended the GP’s surgery five times over this period, and the mother is very anxious about what is causing this. The GP did some blood tests and says that a full blood count, renal and liver function tests were normal. Further history reveals that this all started with a sore throat and fever for a few days. From then on, she started to get headaches, worse in the evening, and became weak and lethargic. She seemed to get worse each week, until she was hardly doing anything herself, staying in bed or watching television. Despite sleeping a lot, she doesn’t feel refreshed after sleeping. Her mother has to help her to shower and dress, as she feels so weak. She aches all over and finds it very hard to concentrate on anything. Her periods have become irregular. Charlotte was getting top grades at school before all this and wants to be a doctor. She enjoys school and denies any bullying. She lives with her mother and stepfather. She has always been very reliant on her mother. Her sister was successfully treated for acute lymphoblastic leukaemia 3 years ago. Charlotte has never been in hospital before and usually does swimming team training five times per week. Her mother is very worried that this could be something sinister and she has looked on the internet and thinks it could be a brain tumour or thyroid problem. She is upset that the GP hasn’t taken it seriously and only did blood tests because she made a fuss.
Examination
Charlotte is rather quiet, but will participate in conversation when prompted. Her weight is 45 kg (25th centile) and her height is 164 cm (75th centile). Otherwise, physical examination is unremarkable.
Questions
• What is the most likely diagnosis?
• Would you request any more investigations?
• What is the prognosis?
Medicine
The most likely diagnosis is chronic fatigue syndrome (CFS). This condition is also known as myalgic encephalopathy (ME), but the term CFS is now preferred. The cause of this condition is unknown. The diagnosis requires persistent fatigue disrupting daily life for 6 months, associated with typical symptoms and no underlying cause found by routine investigation. Typical symptoms include malaise, headache, nausea, sore throat, painful lymph nodes, myalgia, abdominal pain, poor sleep and poor concentration. Teenagers are more often affected than younger children. This girl’s personality, social and emotional background are probably predisposing factors. It is necessary to exclude organic pathology early on, and to demonstrate that the symptoms are being taken seriously. At the same time it is important to indicate from the start that CFS could be the cause of all these symptoms. Thorough physical examination should include lying and standing heart rates and blood pressure, neurological assessment and examination for lymphadenopathy, hepatosplenomegaly, tonsil abnormalities and sinusitis. Investigations should rule out active infection, inflammation, endocrine problems and malignancy. When headache is prominent, it may be necessary to perform an MRI scan of the brain to exclude a space-occupying lesion.
Recommended investigations in patients suspected to have CFS
May indicate:
Full blood count and blood film Anaemia/leukaemia
Erythrocyte sedimentation rate and Inflammatory/infectious cause
C-reactive protein Urea, creatinine Renal disease
Glucose and electrolytes Endocrine disease, e.g. Addison’s
Creatine kinase Myositis
Liver function Hepatitis
Thyroid function Hypothyroidism
Urine dipstick Diabetes mellitus, renal disease
Epstein–Barr Virus (EBV) serology Current EBV infection
Prognosis is quite variable and although two-thirds of patients make a full recovery, this may take 3–4 years. A multidisciplinary approach is often required. Management begins with assessment of baseline function using an activity diary. Supportive treatment can be aimed at alleviating symptoms, improving nutrition and sleep patterns and preventing over-exertion. A graded programme of return to activity is often instituted once a stable baseline has been achieved. Support from physiotherapy, occupational therapy and child and adolescent mental health services may also be needed. Occasionally inpatient management is required for investigation, evaluation and planning of treatment. In this case, Charlotte was admitted to the paediatric ward for about 4 weeks, initially for investigation, and then for some intensive assessment by physiotherapists, occupational therapists and child and adolescent mental health services. It was difficult to make Charlotte and her mother accept the diagnosis of CFS. She was discharged after her baseline activity level had been established and a programme of rehabilitation had been planned. She had regular follow-up to support her in achieving her goals. After 18 months she has returned to about 60 per cent of her previous activity levels, and continues to make slow progress. She has dropped back 1 year at school, but now manages to attend most of her lessons.
KEY POINTS
• Chronic fatigue syndrome can be a debilitating condition requiring a multidisciplinary approach.
• Chronic fatigue and associated features should have been present for at least 6 months.
• Other medical causes of the same symptoms should be excluded.
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