Case history
Case history #1
A 40-year-old physician and marathon runner develops a sudden-onset flu-like illness that does not resolve over a period of several weeks. Her symptoms progress with persistent daytime fatigue, arthralgia without joint swelling or redness, sleep fragmentation, memory problems, new-onset migraine, and difficulties sustaining minor levels of physical activity. Activities that were previously well tolerated, such as walking to a grocery store, now induce body heaviness, difficulty with cognition, and sensation of instability. Tasks require far greater effort to complete, and are followed by an incapacitating reduction in working memory, total body pain, and listlessness. Her electronic medical record system at work has become incomprehensible, which has reduced her ability to see patients, and caused her manager to suspend her from work because of unproductivity. Resting between tasks, naps, and overnight sleep are unrefreshing and do not resolve symptoms. Sadness and frustration are an anticipated reaction to the abrupt chronic decline in health and stamina, and family and former peers have shown disbelief. Repeated physical exams and routine laboratory studies over the last 6 months have been within normal limits. Hypothyroidism, HIV, substance misuse, and other medical and psychiatric illnesses have been excluded.
Case history #2
After a winter working as a ski instructor, a 28-year-old lumberjack resumes his usual work in March. In April, he notes new fatigue and myalgia each evening after eating. Despite going to sleep earlier at night, he is not refreshed in the morning, and wakes feeling pain in all body regions; he is also mildly disoriented and unsure of his plans for the day. He begins to wear sunglasses to protect his eyes from the glare of the sun, and ear protection against the sound of the chainsaw, which he perceives as becoming increasingly loud. Despite his best efforts, he is unable to meet his quotas for cutting wood, and in August is reassigned to the camp kitchen. By October, he is unable to peel potatoes because of generalized myalgia and arthralgia, worsening fatigue, and the need to sit while doing chores. He is medically evacuated to a regional hospital where repeated medical examinations over the course of 6 weeks cannot identify a cause, and blood work for sexually transmitted infections including HIV, liver and endocrine function, and drug screen are normal.
Other presentations
The onset of ME/CFS may be sudden, with the complete syndrome developing within 30 days, or symptoms may start more insidiously.[10]
Among adolescents, ME/CFS is the most common cause of prolonged medical leave from school.[11] In addition to fatigue, children and adolescents with ME/CFS present with headaches, sleep disturbance, cognitive difficulties, orthostatic intolerance, and large activity reduction.[12][13] Stomach ache is more common than in adults. Younger age is associated with a more equal gender balance and sore throats but fewer cognitive symptoms. Adolescents are more likely to have headaches and comorbid depression. By comparison, adults experience greater levels of anxiety, tender lymph nodes, palpitations, dizziness, general malaise, and pain.[14] Additional features are decline in academic performance, disruption of daily routines, loss of friends, dropping out of extracurricular activities such as sports, and irritability in response to their disease.
Recall bias may interfere with the description of initial symptoms given that ME/CFS is not typically diagnosed in adults until after 6 months of symptoms (3 months for children) and negative medical evaluation.[3][4][5][6]
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