A 12-year-old girl is referred by her general practitioner with a history of excessive tiredness. She was previously fit and well and performed well in a competitive athletics club. Over the last 3 months she has had difficulty in participating in normal school and home activities. She complains of feeling tired shortly after starting any exercise and has stopped doing all sports. On return from school she has been going to bed very early in the evening. Her overnight sleep pattern has been disrupted. Her appetite is reduced. She has some pain symptoms affecting muscles of legs and lower back. Over the last 6 weeks she has not attended a full school day and has missed a total of 4 weeks completely as she has felt too tired to attend on waking. She has struggled to maintain contact with her friends and has missed several social events.
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(a) What illness problems need to be considered in this situation?
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The history is suggestive of chronic fatigue syndrome, which is debilitating fatigue of long duration in which routine investigations have failed to identify any other pathological cause. Other causes of this sort of presentation include:
• Haematology/oncology—anaemia, leukaemia, lymphoma
• Autoimmune—systemic lupus erythematosus, dermatomyositis
• Infection—tuberculosis, hepatitis, Epstein–Barr virus
• Drug-related—substance abuse, excessive anti-epileptic medication
• Endocrine—diabetes, Addison’s, hypothyroid
• Gastrointestinal—coeliac disease, inflammatory bowel disease
• Psychiatric—depression, eating disorder
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(b) What further history is important?
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Detailed history of the family and school background is important.
Is there a history of illness affecting a close relative? What are the family and child’s beliefs about the illness mechanism and approach to management?
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(c) What investigations should be performed?
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Full blood count and film, ESR, CRP, blood glucose, blood biochemistry, creatinine kinase, thyroid function, viral antibody titres to Epstein–Barr virus. Urine analysis for blood protein, infection.
These are the initial screening investigations. Other investigations may be indicated if there are specific features in the history or examination.
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(d) What management approach should be used?
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The following steps are helpful in managing chronic fatigue:
• If possible the process of investigation should be concluded quickly and alternative diagnoses excluded.
• The diagnosis should be communicated carefully so that child and family understand what is known about the condition and the uncertainty about the aetiology. It is helpful to explain that this is a pattern of illness that is not well understood but is seen repeatedly in a large number of young people and adults.
• A combined approach of work with a team including paediatrician, physiotherapist and mental health staff is helpful to address the physical and psychological issues together. Gradual ‘pacing’ of activity and exercise to build up tolerance is recommended.
• Psychological support to help understand any background problems and cope with the social withdrawal and anxiety related to the illness is often helpful. Work with school to enable progressive staged re-inclusion alongside physical rehabilitation. In some situations specialist pain team advice can be helpful.
