CMAJ • August 15, 2006; 175 (4). doi:10.1503/cmaj.1060098.
© 2006 CMA Media Inc. or its licensors
All editorial matter in CMAJ represents the opinions of the authors and not necessarily those of the Canadian Medical Association.
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Letters

Chronic fatigue

Riccardo Baschetti

Medical Inspector of the Italian State Railways (retired), Fortaleza (CE), Brazil

Jacques Cornuz and colleagues,1 in Box 2 of their case report, list 11 initial laboratory tests for patients with prolonged or chronic fatigue. Given that hypocortisolism is one of the most frequently reported abnormalities of patients with chronic fatigue syndrome,2–5 it is surprising that none of the available tests for assessing cortisol production2–5 was included. The importance of this assessment is especially evident in light of the virtually complete recovery of patients with chronic fatigue who are treated with low-dose hydrocortisone.6

Another rationale for assessing cortisol production in patients with chronic fatigue is the fact that this condition shares 43 clinical features with Addison's disease,7,8 including hypocortisolism, chronic fatigue, and all of the symptoms listed in the diagnostic criteria for chronic fatigue.7 This impressive clinical overlap between 2 distinctly named diseases suggests that in practical terms, chronic fatigue should be regarded as a mild form of Addison's disease.7

Although Cornuz and colleagues, in Table 1 of their paper, correctly mention Addison's disease as one of the major underlying causes of fatigue, they should have remarked that "pigmentation in skin creases, scars and buccal mucosa"1 is far from being a constant feature of Addison's disease.9,10 Therefore, the absence of such pigmentation in patients with chronic fatigue should not mislead general practitioners to exclude hypocortisolism as a possible cause of that unremitting symptom.

REFERENCES

  1. Cornuz J, Guessous I, Favrat B. Fatigue: a practical approach to diagnosis in primary care. CMAJ 2006;174(6):765-7.[Free Full Text]
  2. Jerjes WK, Peters TJ, Taylor NF, et al. Diurnal excretion of urinary cortisol, cortisone, and cortisol metabolites in chronic fatigue syndrome. J Psychosom Res 2006;60:145-53.[CrossRef][Medline]
  3. Roberts AD, Wessely S, Chalder T, et al. Salivary cortisol response to awakening in chronic fatigue syndrome. Br J Psychiatry 2004;184:136-41.[Abstract/Free Full Text]
  4. Cleare AJ, Blair D, Chambers S, et al. Urinary free cortisol in chronic fatigue syndrome. Am J Psychiatry 2001;158:641-3.[Abstract/Free Full Text]
  5. Scott LV, Medbak S, Dinan TG. Blunted adrenocorticotropin and cortisol responses to corticotropin-releasing hormone stimulation in chronic fatigue syndrome. Acta Psychiatr Scand 1998;97:450-7.[Medline]
  6. Cleare AJ, Heap E, Malhi GS, et al. Low-dose hydrocortisone in chronic fatigue syndrome: a randomised crossover trial. Lancet 1999;353:455-8.[CrossRef][Medline]
  7. Baschetti R. Chronic fatigue syndrome: an endocrine disease off limits for endocrinologists? Eur J Clin Invest 2003;33:1029-31.[CrossRef][Medline]
  8. Baschetti R. Chronic fatigue syndrome, pregnancy, and Addison disease [letter]. Arch Intern Med 2004;164:2065.[Free Full Text]
  9. Kendereski A, Micic D, Sumarac M, et al. White Addison's disease: What is the possible cause? J Endocrinol Invest 1999;22:395-400.[Medline]
  10. Soule S. Addison's disease in Africa — a teaching hospital experience. Clin Endocrinol 1999;50:115-20.[CrossRef][Medline]




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