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Practice

Fatigue: a practical approach to diagnosis in primary care

Jacques Cornuz, Idris Guessous and Bernard Favrat
CMAJ March 14, 2006 174 (6) 765-767; DOI: https://doi.org/10.1503/cmaj.1031153
Jacques Cornuz
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Idris Guessous
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Bernard Favrat
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  • Diagnose and adios
    David J Barton
    Posted on: 27 March 2006
  • Hypocortisolism as a possible cause of chronic fatigue
    Riccardo Baschetti
    Posted on: 20 March 2006
  • Infections and chronic fatigue
    Prasanta Padhan
    Posted on: 15 March 2006
  • Posted on: (27 March 2006)
    Page navigation anchor for Diagnose and adios
    Diagnose and adios
    • David J Barton

    Thanks to Cornuz et al for the case on fatigue in primary care. Studies in Australia have highlighted the need for a thorough history and targetted laboratory testing, noting that most tests will be "normal". I am interested in what happened next - the woman has laboratory features for coelic disease, but is it the cause of her symptoms? Did she have a biopsy, gluten free diet and re-biopsy.Did she feel better on a gluten...

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    Thanks to Cornuz et al for the case on fatigue in primary care. Studies in Australia have highlighted the need for a thorough history and targetted laboratory testing, noting that most tests will be "normal". I am interested in what happened next - the woman has laboratory features for coelic disease, but is it the cause of her symptoms? Did she have a biopsy, gluten free diet and re-biopsy.Did she feel better on a gluten free diet? If no, in my opinion, we still do not have an adequate explanation for her symptoms. We have treated ourselves, and not the patient.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Posted on: (20 March 2006)
    Page navigation anchor for Hypocortisolism as a possible cause of chronic fatigue
    Hypocortisolism as a possible cause of chronic fatigue
    • Riccardo Baschetti

    Cornuz and colleagues [1], in the Box 2 of their article, provided a list of 11 initial laboratory tests for patients with prolonged or chronic fatigue. Considering that hypocortisolism is one of the most frequently reported abnormalities of patients with chronic fatigue syndrome (CFS) [2- 5], it is surprising that none of the available tests for assessing cortisol production [2-5] was included in that list. The importance...

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    Cornuz and colleagues [1], in the Box 2 of their article, provided a list of 11 initial laboratory tests for patients with prolonged or chronic fatigue. Considering that hypocortisolism is one of the most frequently reported abnormalities of patients with chronic fatigue syndrome (CFS) [2- 5], it is surprising that none of the available tests for assessing cortisol production [2-5] was included in that list. The importance of this assessment is especially evident in the light of the virtual recovery of CFS patients treated with low-dose hydrocortisone [6]. The great efficacy of this replacement therapy shows that hypocortisolism plays a central role in CFS.

    The rationale for assessing cortisol production in patients with chronic fatigue is also based on the fact that CFS shares 43 clinical features with Addison’s disease [7,8], including hypocortisolism, chronic fatigue, and all the symptoms listed in the diagnostic criteria for CFS [7]. This impressive clinical overlap, which constitutes a similarity between two distinctly named diseases that is probably unequalled in the medical literature, suggests that CFS should practically be regarded as a mild form of Addison’s disease [7].

    Although Cornuz et al [1], in the Table 1 of their paper, correctly included Addison’s disease in the list 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 this pigmentation in patients with chronic fatigue should not mislead general practitioners to exclude hypocortisolism as a possible cause of that unremitting symptom.

    [Computer-originated word count: 250, excluding references]

    References

    1. Cornuz J, Guessous I, Favrat B. Fatigue: a practical approach to diagnosis in primary care. CMAJ 2006;174(6):765-7.

    2. Jerjes WK, Peters TJ, Taylor NF, Wood PJ, Wessely S, Cleare AJ. Diurnal excretion of urinary cortisol, cortisone, and cortisol metabolites in chronic fatigue syndrome. J Psychosom Res 2006;60:145-53.

    3. Roberts AD, Wessely S, Chalder T, Papadopoulos A, Cleare AJ. Salivary cortisol response to awakening in chronic fatigue syndrome. Br J Psychiatry 2004;184:136-41.

    4. Cleare AJ, Blair D, Chambers S, Wessely S. Urinary free cortisol in chronic fatigue syndrome. Am J Psychiatry 2001;158:641-3.

    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.

    6. Cleare AJ, Heap E, Malhi GS, Wessely S, O'Keane V, Miell J. Low- dose hydrocortisone in chronic fatigue syndrome: a randomised crossover trial. Lancet 1999;353:455-8.

    7. Baschetti R. Chronic fatigue syndrome: an endocrine disease off limits for endocrinologists? Eur J Clin Invest 2003;33:1029-31.

    8. Baschetti R. Chronic fatigue syndrome, pregnancy, and Addison disease [letter]. Arch Intern Med 2004;164:2065.

    9. Kendereski A, Micic D, Sumarac M, Zoric S, Macut D, Colic M, et al. White Addison's disease: what is the possible cause? J Endocrinol Invest 1999;22:395-400.

    10. Soule S. Addison's disease in Africa--a teaching hospital experience. Clin Endocrinol 1999;50:115-20.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
  • Posted on: (15 March 2006)
    Page navigation anchor for Infections and chronic fatigue
    Infections and chronic fatigue
    • Prasanta Padhan

    Dear Editor,

    Recent reports and publications indicate that in addition to viral infections, chronic fatigue syndrome(CFS) patients have other chronic infections caused by other intracellular bacteria .For example,patients with Lyme dsease,caused by intracellular Borrelia infections, have been diagnosed with CFS. Also, CFS patients can have intracellular Chlamydia species and mycoplasmal infections. Brucellosis...

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    Dear Editor,

    Recent reports and publications indicate that in addition to viral infections, chronic fatigue syndrome(CFS) patients have other chronic infections caused by other intracellular bacteria .For example,patients with Lyme dsease,caused by intracellular Borrelia infections, have been diagnosed with CFS. Also, CFS patients can have intracellular Chlamydia species and mycoplasmal infections. Brucellosis and tuberculosis are also an important cause of chronic fatigue.Hence these patients should be screened for the above infections while evaluating for aetiology of chronic fattigue.

    Conflict of Interest:

    None declared

    Show Less
    Competing Interests: None declared.
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Canadian Medical Association Journal: 174 (6)
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Vol. 174, Issue 6
14 Mar 2006
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Fatigue: a practical approach to diagnosis in primary care
Jacques Cornuz, Idris Guessous, Bernard Favrat
CMAJ Mar 2006, 174 (6) 765-767; DOI: 10.1503/cmaj.1031153

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Fatigue: a practical approach to diagnosis in primary care
Jacques Cornuz, Idris Guessous, Bernard Favrat
CMAJ Mar 2006, 174 (6) 765-767; DOI: 10.1503/cmaj.1031153
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