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Clinically evaluated, medically unexplained fatigue of at least six months' duration, that is of new onset, is not a result of ongoing exertion, not substantially alleviated by rest, and substantially reducing previous levels of activity is called chronic fatigue syndrome (CFS). 1 The diagnosis of CFS is based on patient history and exclusion of other diagnosable medical or psychiatric illnesses. Many therapies have been suggested in CFS but none has been found to be consistently effective. 2
The pathogenesis of CFS is poorly understood. A close connection between impairment of autonomic functions and CFS has been demonstrated, and can be assessed with the head-up tilt test. 3 Since dysautonomic cardiovascular reactivity is frequently present in CFS patients, we hypothesised that therapies directed at the autonomic nervous system may also improve fatigue symptoms.
CASE REPORT
A 26 year old man was referred to the CFS clinic, complaining of fatigue with sudden onset eight months before, associated with headache, unrefreshing sleep, sore throat, enlarged palpable submandibular lymph nodes, diffuse muscle discomfort, and joint pain. The fatigue was substantially reducing his previous levels of occupational, educational, social, and personal activities. Body temperature was normal. The patient was not taking medications or illicit drugs. There were normal findings on physical examination and routine laboratory tests; thyroid stimulating hormone, serological tests for hepatitis B and C, HIV, Epstein-Barr virus and cytomegalovirus, chest radiography, abdominal ultrasound, electrocardiography, and echocardiography were also normal. Psychiatric examination did not reveal a past or current disorder. The diagnosis of CFS was established based on the Centers for Disease Control definition criteria.). Prior studies showed that patients with CFS usually exhibit a HIS greater than -0.98.. After three months of treatment (visit 6 in fig 2), while taking 7.5 mg midodrine daily, the HIS was -1.98 (within normal range). Significant remission of fatigue occurred a few weeks later and the patient returned to regular activities. Two months later the patient underwent surgery for perforated duodenal ulcer. Midodrine treatment was discontinued. Recovery from surgery was uneventful, however, fatigue became disturbing and HIS +8.29 was noted (visit 8 in fig 2). Ten mg midodrine daily was prescribed, and was followed by normalisation of the HIS...