Chronic fatigue syndrome (CFS) involves fatigue that is sufficiently intense and persistent to reduce normal daily activities by at least 50% for a minimum of six months. Women account for 70% of cases of CFS, with the typical patient being a Caucasian woman in her mid-20s to late 40s. The prevalence is 4 to 10 formally diagnosed cases per 100,000 U.S. adults (18 years or older). Women are affected almost twice as often as men.

Although not conclusive, CFS may be precipitated by infectious agents (for example, Borrelia burgdorferi), herpesviruses, Candida albicans, and parasitic agents. This may very well be a multifactorial pathologic entity with lifestyle and constitutional/psychological makeup a factor.

• Stressed immune system caused by recent acute illness, chronic health problems, emotional factors (anxiety, depression), or poor nutrition
• Possibly environmental pollutants and contaminants

• Sudden onset of severe fatigue, developing over a few hours to a few days and often after an acute viral illness
• Low-grade fever (less than 100.4°F) and chills
• Sore throat
• Lymphadenopathy
• Myalgias and arthralgias
• Headaches
• Sleep disturbances
• Decreased ability to concentrate or remember
• Allergies
• General muscle weakness

Rule out conditions producing fatigue.

• Fibromyalgia
• Psychiatric: extreme anxiety, depression
• Endocrine or metabolic: hypothyroidism, diabetes, pituitary insufficiency, hypoparathyroidism, hypercalcemia, Addison's disease, chronic renal failure
• Pharmacologic: use of sleeping pills, antihypertensives, or tranquilizers
• Infectious: subacute bacterial endocarditis, hepatitis, AIDS, syphilis, Lyme disease, intestinal parasites, tuberculosis, cytomegalovirus, toxoplasmosis, fungal disease
• Musculoskeletal disorders, neoplastic or hematologic conditions
• Cardiopulmonary: chronic congestive heart failure, chronic obstructive pulmonary disease
• Immunologic: systemic lupus erythematosus, hypogammaglobulinemia
• Toxic disorders: lead or mercury poisoning
• Inadequate sleep or sleep apnea

The patient may appear exhausted and obviously ill, eyes with dark circles, ecchymosis in the throat, swollen tonsils, and enlarged lymph nodes in the neck. However, physical appearance may be normal.

No tests are specifically diagnostic for CFS. The minimal battery of tests should include all of the following (with further tests indicated on an individual basis).

• Complete blood count with leukocyte differential
• Erythrocyte sedimentation rate
• Serum alanine aminotransferase, total protein, albumin, globulin, calcium, alkaline phosphastase, phosphorus, glucose, blood urea nitrogen, electrolytes, and creatinine
• Glucose tolerance test
• Thyroid-stimulating hormone assay
• Urinalysis
• Lyme disease titer and C-reactive protein

• Clinical interview should note any recent history of mononucleosis, hepatitis, or long-lasting influenza and family history of infectious diseases, allergies, anergy, asthma, and cancer.
• Review of lifestyle issues/medical history (include diet and drug use—alcohol, tobacco, and recreational drugs plus current medications such as antibiotics, steroids, birth control pills, and chemotherapy).
• Review of symptoms should note the occurrence of frequent sore throats and swollen glands, colds, or other infections; hormonal imbalances; menstrual irregularities; hypoglycemia; energy level; functional abnormalities of the digestive system (indigestion, gas, abdominal pain), the respiratory system (shortness of breath), and cardiovascular system (palpitations); and the mental and emotional state (foggy, confused, emotionally unstable).
• It may be helpful to test for viral infections such as Lyme disease, and for rheumatoid factor, allergies, hepatitis A and B antibodies, and HIV.

Patients require both symptomatic and emotional support.

Antidepressant and other psychoactive drugs appear to be most successful.

• The tricyclic antidepressants doxepin (Sinequan) and amitriptyline (Elavil) relieve depression, insomnia, muscle tension and pain, general fatigue, nasal congestion, gastritis, and neurologic symptoms. Side effects include dry mouth, drowsiness, constipation, tachycardia (elevated heart rate), and weight gain. Start at one-tenth to one-fourth the usual clinical dose.
• Fluoxetine (Prozac) is another antidepressant that increases brain serotonin levels, may improve energy level, and relieves fatigue but not sleep disorders. Its side effects include increased insomnia and anxiety, rashes, digestive upsets, and impaired sexual functioning.
• Benzodiazepines, such as alprazolam (Xanax), clonazepam (Klonopin), or lorazepam (Ativan), are used to treat anxiety. Their side effects are sedation, amnesia, and withdrawal symptoms (insomnia, abdominal and muscle cramps, vomiting, sweating, tremors, and convulsions).
• Aspirin, nonsteroidal anti-inflammatory drugs, or acetaminophen relieve muscle and joint pains, headache, and fever. Side effects include possible renal damage, gastrointestinal bleeding, abdominal pain, nausea, and vomiting.
• Nonsedating antihistamines relieve allergy symptoms. These include astemizole (Hismanal) and loratadine (Claritin). Side effects are drowsiness, fatigue, and headache.
• Histamine blockers, such as cimetidine (Tagamet) and ranitidine (Zantac), block production of stomach acid, stimulate T-cell function, and improve energy.
• For antihypotensive therapy, fludrocortisone (Florinef) is currently being tested in clinical trials; side effects are elevated blood pressure and fluid retention.
• Gammaglobulin therapy is given intramuscularly two to three times per month for passive immunity. It is expensive (as much as $1,000 per treatment), with no clear evidence of efficacy. Side effects are nausea, dizziness, transient flu-like symptoms, headache, and low blood pressure.
• Transfer factor triggers an active immune response.
• Alpha-interferon enhances immune function.
• Ampligen is a synthetic nucleic acid product that stimulates interferon production. It is experimental.

Following nutritional guidelines and using herbs and homeopathic remedies as needed may be effective in alleviating the debilitating symptoms of chronic fatigue and strengthening overall vitality. Counseling, support groups, meditation, yoga, and progressive muscle relaxation are stress management techniques that may be helpful for people with CFS.

• Avoid refined foods, sugar, caffeine, alcohol, saturated fats, dairy products, and gluten-containing grains.
• Increase fresh vegetables, legumes, whole grains (non-gluten), protein, and essential fatty acids (nuts, seeds, and cold-water fish).
• Beta-carotene (50,000 IU/day) to strengthen immune function.
• Vitamin C (1,000 mg three to six times/day) to increase endurance.
• B-complex (50 to 100 mg/day or 2 ml IM one to two times/week) with additional B6 (100 mg/day) and B5 (100 to 250 mg/day) to reduce the effects of stress.
• Magnesium aspartate (400 to 1,000 mg/day) to support energy production.
• L-Carnitine (330 mg one to three times/day) supports energy production in the cells.

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

A tincture of adaptogenic herbs may help increase resistance to stress and strengthen the immune system. These herbs include Siberian ginseng (Eleutherococcus senticosus), schizandra berry (Schizandra chinensis), ashwaganda root (Withania somnifera), gotu kola (Centella asiatica), and astragalus root (Astragalus membranaceus). Take 20 to 30 drops bid to tid. Adaptogens are generally safe to take long-term and may need to be taken for four to six months for maximum benefit. Some people may require several days respite from ginseng after several weeks of use.

Herbs that support overall vitality and relieve the effects of exhaustion include the following: Licorice root (Glycyrrhiza glabra), lomatium root (Lomatium dissectum), skullcap (Scutellaria lateriflora), passionflower (Passiflora incarnata), lavender (Lavandula angustifolia), and rosemary leaf (Rosmarinus officinalis). Take 20 to 30 drops bid to tid. Licorice root is contraindicated in hypertension.

Essential oils of jasmine, peppermint, and rosemary are calming and restorative and may be used in aromatherapy. Place several drops in a warm bath, an atomizer, or cotton ball.

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency.

Chronic fatigue syndrome is related to deficiencies in multiple organ systems which can be addressed with acupuncture treatment. It could be used with custom formulations of Chinese herbs.

Therapeutic massage is helpful in reducing stress-related symptoms, improving circulation, and increasing the overall sense of well-being.

Schedule follow-up visits every three to six months or whenever there is an exacerbation of the condition or new symptoms. Patients taking psychoactive drugs or speculative therapies should be monitored closely.

• Depression
• Continuing morbidity

One-third of patients recover quickly (within months), one-third recover within two years, and one-third suffer at least some degree of long-term disability.

The effects of herbs in pregnancy have not been fully investigated and treatment should be undertaken only with physician supervision. High doses of vitamin C should be avoided.

Castro M. The Complete Homeopathy Handbook. New York, NY: St Martin's Press; 1990.

Fukuda K, et al. The chronic fatigue syndrome: a comprehensive approach to its definition and study. Ann Intern Med. 1994;121:953-959.

Management of CFS: Pharmacologic therapy and nonpharmacologic therapy. Centers for Disease Control and Prevention. Accessed at www.cdc.gov/ncidod/diseases/cfs/mgmt1.htm on January 4, 1999.

Noble J, ed. Textbook of Primary Care Medicine. 2nd ed. St Louis, Mo: Mosby-Year Book, Inc; 1996:918-922.

Scalzo R. Naturopathic Handbook of Herbal Formulas. 2nd ed. Durango, Colo: Kivaki Press; 1994:S/A18-S/A19.

Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing; 1988:418-421.