Abstracts of IACFS/ME conferences 22-25 sept.2011 in Ottawa 2

Session: DIAGNOSING CFS/ME; DIFFICULT CLINICAL CASES

Session Chair: Nancy Klimas, M.D.

Case Presentations by: Charles Lapp, M.D., Lucinda Bateman, MD, Rosamund Vallings, MNZM, MB BS, Derek Enlander, M.D.

Nancy Klimas M.D.

Abstract

In this workshop, experts will present difficult cases, and discuss the diagnostic and management implications. Cases may include “look alike cases” that presented with the signs and symptoms of ME, but in fact were found to be caused by another disorder; complex management issues; medication use and medication intolerance and other issues of interest to the practicing clinician.

Related conditions such as Gulf War Illness will be included in the case discussion. The workshop will welcome interchange with the clinicians attending the session. Basic scientists may also hear in this discussion some of the issues that trigger further research ideas. Charles Lapp, M.D., Lucinda Bateman, MD, Rosamund Vallings, MNZM, MB BS, and Derek Enlander, M.D. will present cases that will serve as a platform for discussion.

Rosamund Vallings MB BS

Case study - A Cautionary Tale

This is a case study of a female with a long history of Chronic Fatigue Syndrome, which followed a typical relapsing and remitting course over many years. She was often very ill interspersed with bouts of reasonably good health. She was admitted to hospital aged 60 during a very serious “relapse” and died a week after admission This study serves to remind us of the importance of ongoing surveillance and the need to focus on other diagnostic possibilities over time.

 

Lucinda Bateman MD

Case Study Patient 1:

39 year old male attorney who was ill for 15 years with mild CFS, then became unable to work.

Healthy and very physically active in youth. Fitness conscious. Married at age 23 in 1993.

1994. First child born. Ankle fracture required surgery. Completed college while working in family business. Family business turmoil. Brother commits suicide. Gradually developed unusual fatigue, frequent sore throat and swollen glands, low grade fevers, then pain in the shoulders and sternum. Became less able to exercise vigorously.

1995-2001: Completed college and law school (PCP said he was "just depressed" and thought the challenge would cheer him up). Two more kids born. Marital discord. Low function at times due to severe fatigue, achiness, sore throats, low grade fevers, hot flashes, night sweats and cognitive difficulties. Missed class often to stay in bed and stayed in bed on weekends. Often too ill to mow the small lawn and other times he could play basketball but end up in bed afterward.

2001-2007: Worked as an attorney. More stable but continued chronic symptoms and reduced activity tolerance. Managed basic work hours, could weights but not aerobic exercise, and continued to have fatigue, achiness, brain fog and night sweats. Diagnosed with hyperthyroidism, post surgical hypothyroidism, hypogonadism, hyperlipidemia and obstructive sleep apnea. All were treated. Compliant with CPAP.

2008: Busy period of work. Wife in hospital. Vestibular neuronitis with severe vertigo. Resolved in a few weeks. After this he was progressively less able to maintain a normal work schedule. Cognitive dysfunction made analytical work difficult. After another negative workup to rule out causes of fatigue, the firm partners encouraged him to apply for medical disability leave. 2 year LTD awarded for depression/anxiety.

2009: Full evaluation was done by a CFS specialist. CFS diagnosis confirmed.

MEDS: Synthroid, Lipitor, Androgel, CPAP

Physical Exam:

BMI 35 (muscular habitus with mild obesity)

BP 138/95, pulse 80, supine; BP 140/95, Pulse 100, standing at 3 min (later BPs 140/90- 150/100)

0/18 fibromyalgia tender points.

Lab: Normal except Vitamin D 22 (subsequently supplemented without improvement)

Does not meet criteria for MDD or any other exclusionary mental health condition.

Symptoms: fatigue and cognitive problems, unrefreshing sleep, headaches, mild myalgia and arthralgia, marked activity intolerance with post-exertion relapse, few infection/immune symptoms. Able to complete ADLs, do light household activities, run light errands 2-3 times in a week, and walk on a treadmill for 5-7 minutes, 3 mph, 2-3 times per week on better days. He was able to drive the truck to 3 day family hunting trip, but unable to participate [stayed in the campground] and went home early. Vigorous, sustained physical activity, or intense cognitive tasks result in relapse symptoms of 1-3 days duration. Sad about losing his career and anxious about the financial support of his family.

Does he meet CFS criteria?

Does he have OI/POTS? If so, how should it be treated?

Should his blood pressure be treated with a medication?

Should he be on Lipitor?

How should his metabolic syndrome be addressed?

He is maximizing testosterone to maintain muscle mass. Testosterone levels top normal. Is this OK?

What else can be done for him?

 

Lucinda Bateman MD

Case Study Patient 2:

25 year old woman with severe CFS/FM. Married 1 year. No children.

Childhood: Born with cord around neck but seemed to recover. Dyslexia in elementary school. Bitten by a monkey in Brazil and

got rabies shots.

Youth: Soccer and swim teams. Played violin. Diagnosed with auditory processing disorder.

College: Age 17 in 2003. ROTC Air Force 40 hours/week. Major in aerospace engineering 20 cr hr/ semester. Worked 10 hours/week. 4 hours sleep/night not uncommon.

2004-2005: Gradual onset sleep disturbance, generalized weakness and fatigue, concentration difficulties, abdominal pain. After ROTC boot camp (32 days) she never recovered and developed total body aching.

Spring 2006: Failed many courses due to inability to function. Quit ROTC. Quit school. Tried to go on a mission to Hong Kong.

Worsened and came home due to "seizures"[shaking tremor attacks] and worsening pain.

June 2007: CFS/FM Evaluation

Primary symptoms: Abdominal pain, nausea/dizziness (vertiginous and OI), fatigue/weakness, seizure-like episodes when too tired.

Additional symptoms: constant headache, attention/concentration, disturbed sleep, night sweats, sore throats, numbness and tingling (shoulders, arms, feet)

MEDS:

Armour thyroid 15 mg bid (for "fatigue"---later d/c), B12 po, fish oil 1 gm bid, multivitamin

EXAM: BMI 25. BP 90/64 Pulse 72 supine. BP 88/58 Pulse 88 standing at 3 min. Pharynx mildly erythematous with moderately large tonsils. Toes are cool with delayed capillary refill. 11/18 TP

Testing: SF36 scores very low except for emotional well being.

Pain diagram: whole body sparing lower legs.

Symptom scores: 9-10 for pain, fatigue, cognition. 7-8 headache, sleep. 4-6 mood.

2007-2011: Interval diagnoses and treatment

Interstitial cystitis. Dysmenorrhea and chronic pelvic pain. GERD/IBS.

Eczema, allergies, reflux related asthma. Mild.

Neurology, urology, gyn consults. Brain MRI, EEG, Tilt table test, PSG, echo all normal.

CURRENT MEDS: amitriptyline 50 mg qhs (for IC), Savella 100 mg bid (mildly improved pain), zolpidem 10 mg q hs, Lortab 7.5/ bid PRN, alprazolam 1 mg qd, Vit D, Vit C, Mag, Calcium, multiple vitamin. Push oral fluids and sodium. OCP

MEDICATIONS that were not tolerated or not helpful:

Fatigue: Adderall, Nuvigil, Ritalin

Pain: cyclobenzaprine, desipramine, Lyrica, gabapentin, zonisamide, Cymbalta, tramadol, NSAIDS, APAP

Sleep: melatonin, Lunesta, temazepam, Seroquel, trazodone

Currently able to spend about 1-2 hours out of reclining position daily. Makes jewelry at home.

The only intervention that controls pain is activity limitation.

How can pain be improved?

Can function be improved?

Doesn’t get along with in-laws. Should she try to convince them she is a good choice for their son?

Should she pursue her dream of having a family…i.e. get pregnant?

What should she be advised about medications during pregnancy?

 

Charles W. Lapp, M.D.

Case Study

In this workshop, experts will present difficult cases, and discuss the diagnostic and management implications. Cases may include “look alike cases” that presented with the signs and symptoms of ME, but in fact were found to be caused by another disorder; complex management issues; medication use and medication intolerance and other issues of interest to the practicing clinician.

Related conditions such as Gulf War Illness will be included in the case discussion. The workshop will welcome interchange with the clinicians attending the session. Basic scientists may also hear in this discussion some of the issues that trigger further research ideas. Charles Lapp, M.D., Lucinda Bateman, MD, Rosamund Vallings, MNZM, MB BS, and Derek Enlander, M.D. will present cases that will serve as a platform for discussion.

Abstract Unavailable from Dr. Enlander

 

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