Case Study: Brad
Patient Description.  Brad is a 43-year-old motivational speaker and married father of four young children who was entirely well until one year ago.

Chief Complaint.  Brad now presents with chief complaints of persistent fatigue, recurrent flu-like feelings and difficulty concentrating. He relates that whenever he “pushes” himself, he experiences terrible exhaustion, muscle pain, aching in various joints, soreness in the neck, burning eyes and, on two occasions only, indigestion and diarrhea. These symptoms may last one or two days, then subside somewhat. He is clumsy and bumps into things around the house. He notes new difficulties with memory, mental confusion, easy distractibility, word searching, difficulty making even simple decisions, trouble with even simple math and occasional disorientation or confusion, even in familiar surroundings. His complaints include generalized weakness, “restless” legs and jerking at night, night sweats, tender glands in the neck and feverish feeling but subnormal temperatures. Sleep is shallow and disrupted, and he wakes up feeling worse than when he went to bed.
 
History of Present Illness.  He awoke one morning with fever and a “terrible flu-like feeling.” He consulted his primary physician when he did not improve over several days. Initial evaluation revealed mildly elevated liver function and a slightly positive ANA, but otherwise the examination and laboratory did not reveal the cause of his illness. He has been essentially housebound for the past six months, but is able to handle most of his personal activities of daily living. However, he has had to hire a yardman and housekeeper to help out with chores. He has been physically active for up to four hours at a time “safely,” but some days he has been unable to do anything.

Medical History/Family History.  Brad’s past medical history is remarkable only for herniorrhaphy, repair of a severed nerve in the finger and cystoscopy following a GU infection. The family history is remarkable for depression in the patient’s mother and sister. There is no history of alopecia, sun sensitivity, recurrent rash, pleurisy or other serositis, recurrent mouth ulcers, Raynaud’s phenomenon, hematuria or kidney disease. There has been no swelling, heat or redness at the joints. There has been no abdominal pain, recurrent diarrhea or hematochezia of note.

Brad reports a travel history. He recalls a back-woods camping trip in Wisconsin with the family sometime prior to the onset of his symptoms. Also, in his work as a motivational speaker, Brad traveled frequently. He reports a single episode of extra-marital sex while away on business a few years ago. He reports he did not use a condom at the time.

Question:     What should be done next? (Select all that apply.)

A.     Perform physical examination.
B.     Order complete blood count (CBC), chemistry panel, erythrocyte sedimentation rate (ESR), thyroid function tests (TFTs) and urinalysis with microscopic evaluation (UA with micro).
C.     Order rheumatoid factor (RF), anti-nuclear antibody profile for double-stranded DNA (DsDNA).
D.     Obtain blood cultures and viral titers.
E.     Request gastroscopy and colonoscopy.
F.     Order HIV tests.
G.     Order Lyme Disease tests.
H.     Refer the patient for a thorough psychiatric evaluation.

Answer:     A, B, C, F and G

Perform a thorough physical examination and order and then interpret limited exclusionary laboratory studies to confirm or rule out the differential diagnoses. Key tests include CBC (to rule out elevated white count) and a chemistry panel.  If liver function tests are elevated, a hepatitis profile should be ordered as well. Rheumatoid factor and DsDNA (anti-DNA antibodies) tests are ordered to rule out or in rheumatoid arthritis and systemic lupus erythematosus, respectively. Kidney and thyroid diseases, which may cause fatigue, are ruled in or out with other tests.

There is insufficient reason to order blood cultures as Brad has no fever or hematuria. Although many cases of chronic fatigue syndrome, including Brad’s case, begin with a flu-like illness, there has been no scientific evidence that a specific virus triggers or perpetuates this disorder. Hence, viral titers are not indicated.

The absence of persistent gastrointestinal symptoms makes endoscopic evaluation of the GI tract unnecessary at this time.

Brad’s symptoms, his history of unsafe sex in the past and his travel history should lead the clinician to order testing to rule out or in HIV and Lyme disease.

Finally, although you have identified no physical cause for Brad’s complaints yet, there has been no compelling reason to assume that they are psychiatric in origin. The primary care clinician, however, should evaluate Brad with the Beck Depression Inventory™ or other screening tool to assess whether Brad is depressed. A psychiatric or psychological referral is not indicated at this time.

Case Study: Judy
Patient Description.  Judy is a 21-year-old single woman from the Midwest who relates her onset of symptoms to a flu-like illness when she was only 14 years old.

Chief Complaint.  “Whenever I try to do very much, I crash.”

History of Present Illness.  Judy’s entire family was affected with fever, sore throat, fatigue and upper respiratory congestion at the same time. Although her father remained ill for four months, every one else recovered while Judy developed overwhelming fatigue, migratory joint pain, intermittent abdominal pain, photophobia, new pressure-like headaches, dizzy spells and difficulty sleeping.

All of her symptoms were worse with even minimal exertion. Judy had difficulty keeping up with school — especially math — and she described a “brain fog” or lack of mental acuity. Judy felt dizzy on rising quickly, and she developed weakness and faintness when standing for short periods in church or even in the shower. She was unable to keep up at school, and dropped out to take homebound classes. She has been frustrated and disappointed by her inability to attend school and socialize with her friends, and gets weepy at times but denies being depressed.

Question #1:     A reasonable differential diagnosis includes which of the following? (Select all that apply.)

A.     Chronic fatigue syndrome.
B.     Collagen vascular disorder, such as sys-temic lupus.
C.     Rheumatological disorder, e.g., juvenile rheumatoid arthritis.
D.     An infectious illness.
E.     School phobia or depression.
F.     Chronic hepatitis.

Answer #1:     All of the above

The chief complaint of exertional fatigue, recurrent flu-like feelings, and neurocognitive problems is a classical triad of symptoms for chronic fatigue syndrome.

Collagen vascular disease and the arthridites are possible, but not well supported by history.

An infectious illness such as Lyme disease or chronic active hepatitis could persist, but other diseases are unlikely to persist for several years. 

Teens with school phobia may present with a number of symptoms in an effort to avoid school. Judy was doing quite well at school, however, and she had none of the other hallmarks of school phobia such as academic problems, difficulty with personal relationships, or difficulty separating from her parents.

There was no evidence of malingering or Munchausen by proxy.

Question #2:     Is CFS infectious?

Answer #2:     Although outbreaks or “epidemics” of chronic fatigue syndrome have been reported, no infectious agent has ever been identified and epidemiological studies are not consistent with an infectious agent; there is little evidence for person-to-person spread, a vector or a fixed incubation period. Nevertheless, the onset of chronic fatigue syndrome occurs after an acute viral-like illness in the majority of cases, and most cases are sporadic rather than epidemic. Toxic agents, radiation exposure and the like can also explain these “epidemics,” but no such non-infectious causes have been associated yet with chronic fatigue syndrome.

Question #3:     Should a psychological evaluation be obtained?

Answer #3:     Perhaps.