We have all looked after patients who cause feelings of despair and anxiety when we see their names on our appointment sheets.
They are always tired. They have never been well since ‘I had that virus, Doc’. Tasks that were easily completed before their illness are now beyond their capabilities.
Short-term memory can be so poor that they forget the names of good friends. They wake up feeling it is time to retire. Their muscles are extremely weak. Attempts to engage in muscle-strengthening exercises result in days of extreme exhaustion.
Exposure to noise can be painful, and tinnitus is often present. Driving a car can be very difficult, especially in rainy weather when the flickering windscreen wipers can result in dizziness, mental fatigue and nausea. Attempts to concentrate for short periods can result in extreme brain fatigue. Numerous other symptoms may be present.
We investigate them with the usual full blood examination, thyroid function, monospot and so on, and all are normal. We tell our patients that they must have had a ‘virus’ and dismiss them, predicting a speedy recovery. But they return repeatedly with the same symptoms.
In desperation, we refer them to an appropriate specialist who finds little evidence of any disorder. The next port of call is the psychiatrist who diagnoses depression.
Such patients often turn to practitioners of alternative medicine.
MY OWN CASE (DR ROBERT LOPIS)
So much more relevant was my experience—I found myself on the other side of the desk. A simple respiratory tract infection that I had contracted while on holiday gave me insight into the ‘chronic fatigue syndrome’.
Before my illness I was very fit, playing tennis twice a week and enjoying my general practice in Sydney.
A few weeks after my chest infection resolved, I developed palpitations and shortness of breath at rest. Fearing a viral cardiomyopathy, I consulted a cardiologist who found my heart to be normal. Within a few days I developed fasciculation in several muscle groups. A hastily arranged visit to a neurologist, and a prolonged electromyelography (EMG) and examination, revealed normal nerve, neuromuscular junction and muscle function. However, to walk 20 m was a major ordeal.
After six weeks of enforced rest, I returned part-time to work. Consulting for two hours a day left me exhausted, and I was forced to examine patients while sitting in a chair on wheels. Rising from a sitting position was extremely difficult and tiring. I rearranged my consulting room and bought thick plastic mats to cover the carpet so that I could slide along in the chair. I sat to examine patients on the couch. I could not even hold my stethoscope against the patient’s back for more than a few seconds before muscle fatigue set in. My legs felt as if they had tight elastic bands around them, and any short walk was followed by the predictable muscle twitches.
I persevered with my practice, but my quality of life was extremely poor. A few hours work in the surgery each day necessitated complete rest for the remainder of the day. This ensured I could manage the following day.
The battery of routine blood tests proved normal, but in reality I was a semi-invalid. I had to be seated to throw a few balls to my son. Watching television made me giddy and the noise and movement of children made me feel so ill that I had to prevent any children coming to play with my boys.
Four months into my illness, I was referred to a specialist with an interest in the chronic fatigue syndrome. He commented that my history was classic and ordered further tests, including T4 and T8 lymphocytes and cell-mediated skin tests.
I was relieved when these tests came back abnormal as I was starting to question myself (as everyone with this illness does when they are told that all the basic tests are normal!).
Another eight weeks of complete rest did not improve my health. I was desperate. My specialist offered me intravenous gamma globulin, which I gratefully accepted. (At this stage I would have tried anything.)
To my surprise, routine observations on my admission to hospital revealed I had a fever of 38.2 °C. After four of the ten bottles of gamma globulin had been administered, my temperature returned to normal and I have not felt ‘fuzzy’ since. One can only understand this type of sensation when one has experienced it.
I am delighted to report that I have continued to make slow progress since my infusion and, 16 months after becoming ill, I feel about 90 per cent normal. I can even manage a limited number of house calls. I still need to rest every lunch hour and require 9 to 10 hours of sleep every night.
DISCUSSION AND LESSONS LEARNED
I urge all practitioners to accept that ‘chronic fatigue’ patients have genuine symptoms. This disease can cause depression, but for most patients it is not caused by depression. I acknowledge that a depressed patient can develop the chronic fatigue syndrome in the same way that they can contract any other disease.
If you are unable to diagnose a patient with these symptoms, please refer them to a centre specialising in this devastating and poorly understood disease.