What is Chronic Fatigue Syndrome?

Chronic Fatigue Syndrome (CFS) also known as Myalgic encephalomyelitis (ME) is a serious, chronic, and enfeebling disease that currently has no specific cure. It was originally coined by the US Center for Disease Control in 1988 and is characterized by symptoms not limited to excessive exhaustion or fatigue, cognitive problems, gastrointestinal issues, sleep disturbance, muscle and joint pain, vertigo, post-exertional malaise (PEM), weakened immune system and paraesthesia (abnormal sensation such as numbness).

CFS is an often neglected disease. According to the Institute of Medicine 2015, 836,000 to 2.5 million Americans have CFS. Among the cases, less than 20% reported that they received a diagnosis from a practitioner. CFS is also more common in adults between the ages of 40 to 60 but adolescents and children are also susceptible to it. Generally, women are at a higher risk of CFS compared to men with a reported estimated ratio of 4 to 1. The underlying pathogenesis and etiology of CFS remain poorly understood. However, several studies have linked factors such as genetics, infection, physical or emotional trauma, and environmental toxins to the development of CFS. In addition, the pathophysiological changes that occur during CFS have been shown to affect the neurological, mitochondrial, immunological, and endocrine systems.

Chronic Fatigue Syndrome Symptoms

Chronic Fatigue Syndrome (CFS) is a complex condition marked by prolonged and unexplained exhaustion that persists for at least six months, even with sufficient rest. This fatigue is often debilitating and interferes with daily activities. Other common symptoms include:

• Sleep disturbances, such as difficulty falling asleep or staying asleep.
• Persistent headaches of varying intensity.
• Muscle and joint discomfort, often without noticeable swelling or redness.
• Cognitive difficulties, including trouble focusing, memory lapses, and difficulty processing information.

Additional symptoms that some individuals may experience include:

• Visual disturbances, such as sensitivity to light or blurry vision.
• Temperature regulation issues, including night sweats or chills.
• Swollen lymph nodes, typically in the neck or armpits.
• Gastrointestinal issues, such as bloating, gas, constipation, or diarrhea, similar to irritable bowel syndrome (IBS).
• Mood-related symptoms, including irritability, anxiety, and mood swings.
• Neurological sensations, such as tingling or numbness in the hands, feet, or face.
• Episodes of dizziness or fainting, are often linked to low blood pressure or poor circulation.

CFS symptoms often fluctuate in severity, with periods of improvement followed by relapses. Many individuals experience post-exertional malaise (PEM), where physical or mental exertion worsens symptoms, sometimes for days or weeks. Because CFS shares symptoms with other illnesses, it is often difficult to diagnose and requires careful medical evaluation.

Gut Health and Chronic Fatigue

Our bodies are often said to be made of more microbial cells and genes than human. Many of these microorganisms reside in our gastrointestinal tract where they form a community referred to as the gut microbiota. An alteration in the gut microbiota composition and function, described as “dysbiosis” has been implicated in several diseases including CFS. The most typical features of a dysbiotic state are reduced microbiota diversity, an increased abundance of pathogenic microbes, and a reduction in the abundance of commensal or beneficial microbes. With the recent advances in high throughput DNA-sequencing technologies and the decline in sequencing cost, researchers can gain more insight into the gut microbiome and as a result, the roles of the gut microbiome in CFS have been increasingly studied. Most importantly, in relation to the gastrointestinal symptoms and co-morbidities such as inflammatory bowel disease (IBD) and irritable bowel syndrome (IRS) observed in CFS patients.

There are two major possible roles of the gut microbiome in the pathogenesis of CFS; First, through alterations in the microbiota composition. Studies have reported a reduced gut microbiota diversity in CFS patients and a reduced abundance of commensals such as Bifidobacterium, Eubacterium, and Faecalibacterium species (also reported to be reduced in inflammatory bowel disease). These bacterial groups, especially Faecalibacterium prausnitzii, are known to produce butyrate, a short-chain fatty acid with anti-inflammatory properties, which plays a crucial role in maintaining gut barrier integrity. Similarly, CFS patients reporting more fatigue appear to have less abundant F. prausnitzii establishing the potential for a direct connection between CFS and the gut microbiome. Studies have also reported an increased abundance of Enterocloster bolteae and Ruminococcus gnavus in CFS patients which are also associated with autoimmune disease and inflammatory bowel disease. The implication of dysbiosis in CFS transcends the imbalance in the relative abundance of various gut bacteria groups; it impacts regulatory pathways that are connected with neural signalling, immune function, and energy metabolism, which may be evidenced through symptoms that CFS patients present.

Secondly, the gut microbiome contributes to CFS through bacterial translocation which refers to a situation where bacteria from the gut cross through loose epithelial linings and intestinal tight junctions into the bloodstream. The immune system detects the presence of these bacteria and initiates a cascade of immune response leading to chronic inflammation. Interestingly, studies have found that CFS patients have higher levels of lipopolysaccharides (LPS)which are endotoxins found on the outer membrane of bacterial cells and are known to drive inflammation. Therefore, it is likely that the high plasma LPS levels seen in CFS patients may be due to the increased amounts of LPS-producing bacteria in their gut ecosystem. Similarly, given the role of LPS in neuroinflammation, the neurological and cognitive impairment seen in CFS patients, could potentially be LPS-induced.

With increasing evidence associating the gut microbiome with CFS, oral prebiotics and probiotics are currently being investigated for the restoration of gut abnormalities seen in CFS. However, more studies are required to further understand this biota-condition relationship. An important question is to ask whether the changes in the gut balance is a cause or consequence of CFS. Additionally, CFS, like other gut-associated conditions are strongly connected to dysbiosis. Teasing out the nature of dysbiosis that is particular to CFS, will strengthen therapeutic leads being developed to improve the health outcomes of CFS patients.

Chronic Fatigue Syndrome Treatments

Chronic Fatigue Syndrome (CFS) is a complex condition, and treatment focuses on symptom management rather than a cure. The goal is to improve daily functioning and enhance quality of life. While some individuals recover partially, others may continue to experience symptoms long-term. Treatment plans are personalized and often include a combination of the following:

1. Improving Sleep Quality: A structured sleep routine plays a crucial role in reducing fatigue and improving overall restfulness for individuals with chronic fatigue syndrome (CFS). Before considering medications, healthcare providers often emphasize the importance of practicing good sleep hygiene. This includes maintaining a consistent sleep schedule by going to bed and waking up at the same time each day. Daytime naps should be limited to no more than 30 minutes to avoid interfering with nighttime sleep. The bedroom environment should be optimized for rest by removing distractions such as electronic devices and using the space exclusively for sleep and intimacy.
2. Medications for Symptom Management: Although there is no definitive cure for CFS, medications may be used to help manage its symptoms. Pain relievers, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can alleviate muscle and joint pain. Antidepressants, particularly tricyclic antidepressants, can be beneficial for addressing sleep disturbances, fatigue, and chronic pain, while selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) may be prescribed to manage depression and pain. In cases where a viral infection is suspected as a contributing factor, antiviral medications might be recommended. Some individuals may also benefit from intravenous immunoglobulin (IVIG) therapy, which helps support immune function, or corticosteroids to reduce fatigue and inflammation. Research into new medications is ongoing, with clinical trials exploring potential treatment options to alleviate symptoms and improve the quality of life for those affected by CFS.
3. Managing Activity Levels: Managing activity levels is another essential aspect of CFS treatment, as physical and mental exertion can significantly worsen symptoms in what is known as post-exertional malaise (PEM). To counteract this, a strategy called pacing is often recommended. Pacing involves understanding individual energy limits and balancing activities with adequate periods of rest. Overexertion can lead to symptom flare-ups, making it essential for individuals to identify their personal "safe zone" and remain within those boundaries. Keeping a journal to track daily activities and symptom patterns can help recognize limits and adjust routines accordingly. Healthcare providers can assist patients in setting realistic physical and mental limits to prevent overexertion while ensuring a manageable level of daily function. While high-intensity aerobic exercises may worsen symptoms, gentle movements such as stretching or light walking at a comfortable pace may be beneficial for some individuals.
4. Gut Health and the Microbiome in CFS Treatment: Emerging research suggests that gut health plays a crucial role in CFS, as many individuals experience digestive issues such as bloating, irritable bowel syndrome (IBS), and food sensitivities. An imbalance in gut bacteria may contribute to inflammation, immune dysfunction, and energy metabolism problems.

To support gut health, the following strategies may be recommended:

• Probiotics and Prebiotics: Taking probiotic supplements or consuming fermented foods like yogurt, kefir, and sauerkraut may help restore beneficial gut bacteria. Prebiotic-rich foods such as garlic, onions, and asparagus can also support gut flora.
• Anti-inflammatory Diet: A diet rich in whole foods, healthy fats, lean proteins, and fiber can help reduce inflammation and support overall well-being. Avoiding processed foods, excessive sugar, and artificial additives may also be beneficial.
• Identifying Food Sensitivities: Some people with CFS experience worsening symptoms after consuming gluten, dairy, or high-sugar foods. Keeping a food diary can help identify triggers.
• Hydration and Gut Motility: Drinking enough water and consuming fiber-rich foods can help prevent constipation and support digestion. Herbal teas such as ginger or peppermint may also aid in soothing digestive discomfort.

By addressing gut health, individuals with CFS may experience improvements in energy levels, immune function, and overall symptom management.