A 35-Year-Old Woman With Fatigue and Joint Pain

Zain Ul Abideen Asad, MD, MBBS


May 09, 2017


This patient's predominant symptom is fatigue that is limiting her social and occupational life. It is accompanied by a number of other symptoms, including recurrent headaches, inability to concentrate, muscle stiffness, and joint pain. This combination is hard to explain with a single diagnosis.

Many physicians have investigated her condition but have failed to make a definitive diagnosis. Chronic medical conditions, including hypothyroidism, HIV, and viral hepatitis were ruled out by diagnostic tests.

The difference between chronic fatigue syndrome and fibromyalgia is the intensity of fatigue and pain. Chronic fatigue syndrome involves severe fatigue and mild pain; fibromyalgia involves severe pain and mild fatigue. Also, fibromyalgia is accompanied by tenderness in multiple areas of the body (Figure 2).

Chronic fatigue syndrome is a diagnosis of exclusion. Fatigue is one of the most common presenting symptoms among patients and is often due to an existing organic illness; however, if results of the physical examination and diagnostic tests are normal, chronic fatigue syndrome should be considered.

According to the Centers for Disease Control and Prevention's 1994 case definition, chronic fatigue syndrome is defined as fatigue that lasts for long than 6 months that is not explained by an existing medical condition. This fatigue must affect activities of living or work and be accompanied by at least four out of the following eight symptoms:

  • Muscle pain;

  • Joint pain without swelling or erythema;

  • Headache of new type or severity;

  • Frequent or recurring sore throat;

  • Painful lymphadenopathy of cervical or axillary region;

  • Postexertional malaise lasting more than 1 day;

  • Impairment of concentration or short-term memory; and

  • Unrefreshing sleep.

In 2015, the Institute of Medicine renamed this condition "systemic exertion intolerance disease" (SEID).[1] Diagnosis requires the presence of three major symptoms, as follows:

  • A substantial reduction or impairment in the ability to engage in preillness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest;

  • Postexertion malaise; and

  • Unrefreshing sleep.

Diagnosis also requires at least one of the two following manifestations:

Prevalence estimates for chronic fatigue syndrome vary widely, from 0.23% to 2.6% in some studies.[2,3] It is more than four times more common in women (373 per 100,000) than men (83 per 100,000).[2] The discrepancy between different prevalence estimates is due to lack of a consensus on the definition, pathogenesis, and symptoms; the mainly subjective nature of the diagnostic criteria; and variation in the types of questionnaires used.


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