Chronic Fatigue Immune Dysfunction Syndrome

DRG Category:	947
Mean LOS:	4.8 days
Description:	MEDICAL: Signs and Symptoms With Major CC

Chronic fatigue immune dysfunction syndrome (CFIDS), or chronic fatigue syndrome (CFS), is a unique, controversial, and poorly understood chronic disease that has a sudden onset and lasts for at least 6 months. It is a multiple symptom disease that affects the immune and neurological systems and suggests chronic mononucleosis. The pathophysiology of the syndrome is unclear, but the immune system is upregulated, or stimulated, and the levels of antibodies, especially immunoglobulin G, are increased.

CFIDS has been mentioned throughout history but only recently has been defined for adults as a distinct disorder. It is characterized by debilitation, chronic fatigue, and a duration of at least 6 months and often much longer; it causes impaired overall physical and mental functioning. The Centers for Disease Control and Prevention (CDC) criteria have been formulated to standardize diagnosis and include cognitive difficulties, pharyngitis, lymphadenopathy, muscle pain, joint pain, headache, sleep disturbance, poor sleep, and postexercise malaise. Like many chronic illnesses, CFIDS is often accompanied by depression.

CFIDS is different from but related to fibromyalgia, a condition that generally occurs in young or middle-aged females and is manifested by pain, stiffness, fatigue, disrupted sleep, and problems with cognition. As compared to the development of CFIDS, fibromyalgia is related to genetic vulnerability and abuse or other traumatic experiences that occur during brain development (childhood) and persistent stress or distress.

Causes

The cause of CFIDS is unknown but is probably related to an infectious process such as Epstein-Barr viral infection with immune manifestations. Researchers are investigating whether or not the disease is a syndrome triggered by a virus with multiple contributing factors such as age, gender, toxic exposure, stress, and perhaps a precipitating event (recent trauma or surgery). Other possible causative agents include Chlamydia pneumoniae.

Genetic considerations

Although genetic predisposition has been suggested and polymorphisms in genes associated with serotonin synthesis, transport, signaling, and catabolism have been investigated, genetic influences remain unclear at this time.

Gender, ethnic/racial, and life span considerations

CFIDS is more prevalent in females than in males, and it tends to affect persons between the ages of 25 and 50. However, it may be underdiagnosed in children and the elderly. There are no known racial and ethnic tendencies.

Global health considerations

CFIDS exists worldwide, but the prevalence is uncertain because of the lack of consistent definitions. In the United States, up to 4 million people may have CFIDS, but more recent statistics indicate that as much as 2% of the population is affected. Experts believe that this prevalence statistic is likely also applicable to global populations.

Assessment

History

Establish a history of the sudden onset of flu-like symptoms accompanied by intense fatigue that does not resolve within 6 months. Determine if the patient has experienced any other symptoms of a neurological or psychological nature. Ask the patient if she or he has been exposed to a toxin or has recently experienced stress. Determine if the patient’s occupation involves interaction with the public. It is important to remember that symptoms can vary widely with CFIDS.

Physical examination

The most common symptoms include prolonged fatigue, difficulties with short-term memory, and verbal dyslexia. Assessment of the CFIDS patient may reveal flu-like symptoms such as sore throat, low-grade fever, chills, muscular pain, and swollen, painful lymph nodes. Neurological assessment findings may include sensitivity to light, headache, inability to think clearly or concentrate, memory loss, sleep disorders, equilibrium problems, and depression.

Psychosocial

Patients with CFIDS are often depressed because of the stress of dealing with a chronic, debilitating illness that affects their total lifestyle. Anxiety and mood swings are common, and there are increased rates of divorce and suicide among these patients. Assess the effect of the disease on the patient’s job and childcare responsibilities.

Diagnostic highlights

There is no definitive method of diagnosing CFIDS, but the CDC sets forth diagnostic criteria (Box 1). The CDC recommends the following diagnostic tests: complete blood count, serum electrolytes, liver function tests, thyroid function tests, erythrocyte sedimentation rate, cortisol level, and antinuclear antibody test.

CDC Criteria for CFIDS

CDC definition of CFIDS stipulates that a patient must fulfill two major criteria: eight symptoms or six symptoms and two physical signs.

The patient has new-onset, persistent to relapsing, debilitating fatigue without a previous history of such symptoms. The fatigue does not resolve with bedrest and, for at least 6 months, is severe enough to reduce or impair average daily activity to a level less than 50% of what it was before the illness.
The fatigue is not explained by the presence of other evident medical or psychiatric illness.

Mild fever or chills
Sore throat
Painful adenopathy, posterior or anterior, cervical or axillary
Generalized muscle weakness
Myalgia
Prolonged generalized fatigue after previously tolerated levels of physical activity
Generalized headaches
Migratory arthralgia without swelling or redness
Neuropsychological complaints
Sleep disturbance

Low-grade fever
Nonexudative pharyngitis
Palpable or tender anterior or posterior cervical or axillary lymph nodes

Primary nursing diagnosis

Diagnosis

Activity intolerance related to muscle and joint pain, fatigue

Outcomes

Energy conservation; Coping; Knowledge: Disease process; Mood equilibrium; Symptom severity; Health beliefs: Perceived control

Interventions

Energy management; Counseling; Exercise promotion; Hope instillation; Security management; Security enhancement; Presence

Planning and implementation

Collaborative

Because there is currently no known cure, treatment of CFIDS is symptomatic. Some patients experience relief of the symptoms by avoiding environmental irritants and certain foods.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
NSAIDs	Varies by drug	May reduce inflammation, thus reducing symptoms	Efficacy uncertain

Other Medications: Most medications have proved ineffective. Nonsedating antihistamines, anti-anxiety agents such as alprazolam, and tricyclic antidepressants may be helpful. Experimental treatments include the antiviral acyclovir and selected immunomodulating agents, such as intravenous gamma globulin, Ampligen, transfer factor, and others.

Independent

It is important to set realistic goals when planning care with the CFIDS patient. Teach patients not to overexert themselves. It is believed that stress can prolong the disease or result in an exacerbation. Relaxation and stress-reducing techniques such as hypnosis, massage, biofeedback, and meditation may be useful if sleep patterns are altered. Explain that although the symptoms tend to wax and wane, they are often debilitating and may last for months or even years. The patient therefore needs to reduce his or her activities when symptoms are more pronounced but also needs to avoid bedrest, which has no proven therapeutic value for CFIDS patients. Encourage a graded exercise program and provide an appropriate referral for continuing exercise. Stress the need to progress slowly with exercise to avoid overfatigue. Referring the patient and family to counseling and support groups may assist in developing appropriate coping skills for dealing with a chronic, debilitating illness.

Evidence-Based Practice and Health Policy

Lattie, E.G., Antoni, M.H., Fletcher, M.A., Penedo, F., Czaja, S., Perdomo, D., …Klimas, N. (2012). Stress management skills, neuroimmune processes and fatigue levels in persons with chronic fatigue syndrome. Brain, Behavior, and Immunity, 26(6), 849–858.

Targeted interventions to improve stress management skills may reduce symptoms associated with CFIDS.
For example, in a study among 117 individuals diagnosed with chronic fatigue syndrome, greater perceived stress management skills was associated with less fatigue (p = 0.019). However, the effect that stress management had on fatigue decreased as the levels of emotional distress increased.

Documentation guidelines

Physical findings: Activity tolerance, pain, vital signs, range of motion
Degree of discomfort: Location, frequency, duration, response to analgesia
Response to medication therapy, rest, and relaxation
Emotional response: Coping strategies, support from significant others, signs of depression or hopelessness

Discharge and home healthcare guidelines

Instruct the patient to report any increase in physical symptoms or suicidal thoughts to the primary caregiver. Instruct the patient to obtain assistance as necessary to complete self-care activities and to meet family responsibilities. Teach the patient the proper route, dosage, and side effects to monitor with all medications. Make necessary plans for referrals and follow-up appointments.