慢性疲劳综合征医学系.ppt

ApatientwithChronicFatigueSyndrome,KristinSteffen,MD2/22/06,Ihavenofinancialdisclosures.,Objectives,IdentifycasedefinitionforChronicFatigueSyndrome(CFS)RecognizesimilaritiesbetweenCFSandfibromyalgiaDescribeclinicalpresentation,prognosisofCFSReviewrecommendationsfordiagnosisIdentify2treatmentsIdentifyusefulreferencesInformationalpresentationonly(Iamnotsolicitingreferrals!),CaseofAF,AFisa35yoFdiagnosedwithCFSin1992withabruptonsetofsymptomsfollowingURIExtensivenegativeworkupforalternativecause(14physicians,everyrecommendedtestplusmorethantwiceasmanymore)Extensivetrialsofexperimentaltreatments(32+)OnSSItotaldisability,appealingemployerdecisiontorevokeemployer-baseddisabilitybenefitStable:neitherimprovingnorworsening,currentlytakingnospecificpharmacologictherapy,1994CDCCaseDefinitionforCFS,I.Clinicallyevaluated,unexplained,persistent,orrelapsingfatiguethatisofnewordefiniteonset;itisnottheresultofongoingexertion;isnotalleviatedbyrest;andresultsinsubstantialreductioninpreviouslevelsofoccupational,educational,social,orpersonalactivitiesAND,1994CasedefinitionofCFS,cont,II.Fourormoreofthefollowingsymptomsthatpersistorrecurduringsixormoremonthsofillnessthatdonotpredatefatigue:Self-reportedimpairmentinshorttermmemoryorconcentrationSorethroatTendercervicaloraxillarynodesMusclepain,1994CasedefinitionofCFS,cont,II.Fourormoreofthefollowingsymptomsthatpersistorrecurduringsixormoremonthsofillnessthatdonotpredatefatigue:MultijointpainwithoutrednessorswellingMusclepainHeadachesofanewpatternorseverityUnrefreshingsleepPost-exertionalmalaiselasting24hours,ConditionsthatexcludeCFSDx,AnyactivemedicalconditionthatmayexplainthepresenceofchronicfatigueAnypreviouslydiagnosedmedicalconditionwhoseresolutionhasnotbeendocumentedbeyondreasonabledoubtAnypastorcurrentdiagnosisofspecifiedpsychiatricdisordersAlcoholorothersubstanceabuseSevereobesity(BMI45),ConditionsthatdonotexcludeCFSDx,AnyconditiondefinedprimarilybysymptomsthatcannotbeconfirmedbydiagnosticlaboratorytestsAnyconditionunderspecifictreatmenttoalleviateallsymptomsrelatedtothatconditionandforwhichadequacyoftreatmenthasbeendocumentedAnycondition,suchasLymediseaseorsyphilis,thatwastreatedwithdefinitivetherapybeforethedevelopmentofchronicsymptomaticsequelae.,ConditionsthatdonotexcludeCFSDx,AnyisolatedorunexplainedPEfindingorlaborimagingtestabnormalitythatisinsufficienttostronglysuggesttheexistenceofanexclusionarycondition,IdiopathicChronicFatigue,Clinicallyevaluated,unexplainedchronicfatigueofgreaterthan6monthsdurationthatdoesnotmeetcriteriaforCFSdiagnosis,SimilaritiesbetweenCFSandFibromyalgia,CommoninwomenMyalgiasandfatiguein90%Symptomsincommon:cognitiveandmood,headache,nonrestorativesleepNoknowncauseClinicaldiagnosis(nospecificdiagnostictests,excepttriggerpointsinfibromyalgia)Chronicsymptoms,nohighlyeffectivetreatment,FibromyalgiaDiagnosticCriteria,Widespreadbodypain(leftandright,aboveandbelowthewaist)andaxialskeletalpain(neck,chestwall,midorlowback)Presencein11of18tenderpointsitesondigitalpalpationwith“anapproximateforceof4kg”,CauseofCFS,UNKNOWNPossibleprecipitantsthathavebeenstudiedbuthavenotbeenfoundtobecausative:InfectionImmunedysfunctionEndocrine-metabolicdysfunctionNeurally-mediatedhypotension,ClinicalPresentationwithCFS,VariableSuddenonsetoffatigueafterURIAfterURI,continuedoverwhelmingfatigueplusaddlsx(e.g.alteredsleep,cognition)SymptomsexacerbatedbyexcessivephysicalactivityNopriorhxofbackache/chronicheadache,ClinicalPresentation,cont.,TypicallyinformerlyhighfunctioningindividualsOnceincitingillnessresolved,physicalexamisNORMALFeelfeverish,butnormaltempAchyjoints,butnofindingsonexamMusclefatigue,butnormalbiopsiesFrequentsorelymphnodesDisabledbysymptoms,butoutwardlyhealthyappearing,ClinicalPresentation,cont.,Patientsmaybeaccusedofmalingeringbyfamily,colleagues*Cognitivedysfunction:nospecificpatternofcerebralabnormalitiesuniquelycharacterizeCFSpatients;mostprominentfeaturesmaybeslowedprocessingspeed,impairedworkingmemory,poorlearning(cant“rulein”CFSbyneuropsychtesting,cant“ruleout”cognitivedysfunctionsymptomasnotlegitimate),Prognosis,Somerecovercompletely,somerecoverandareabletoworkbuthaveflares,someneverrecoverOfthosewhorecover,mostrecoverwithin5yearsAsillnessprogressesreportsofmusclepainandforgetfulnessincrease,depressiondecreasesPoorerprognosiswhenpatientbelievestheillnessisduetoa(given)physicalcause,Diagnosis,Clinical,basedontypicalpresentation,casedefinitionNodiagnosticexamortestfindingsexistPurposeofevaluationistoidentifyandtreatanyunderlyingcontributingfactors,Diagnosis,Recommendedevaluation:HistoryandphysicalexamCBCwithdiff,ESR,chemistries(electrolytes,kidneytests,livertests,glucose,totalprotein,iron),TSHFurthertestsIFclinicallyindicatedtoexcludealternativediagnosessuspectedonthebasisofinitialtestingSpecialimmunologictesting,brainimaging,etc.arenotrecommendedNospecificcognitivetestingrecommended,TreatmentofCFS,Onlytwotherapieshavebeenshownbeneficialinclinicaltrials:CognitivebehavioraltherapyGradedexerciseNoknown“Cure”Goal:symptommanagementandreintegrationintosocialandoccupationalnetworks,IneffectiveMeasures,ImmuneserumglobulinAcyclovirGalantamineCorticosteroidsAmantadineDoxycyclineMagnesiumColonicenemas,EveningprimroseoilVitaminB12AmpligenEssentialFattyacidsLiverextractDialyzableleukocyteextractInterferonExclusiondietsRemovalofdentalfillingsEtc,Sy