Severe exertion intolerance may be chronic fatigue syndrome
DEAR DR. ROACH: My husband is tired all the time. He functions but frequently has to sit to recoup his energy, even after a shower.
He is diabetic and has been for over 10 years. He does not take insulin and manages to keep his A1C within 7.1 to 6.9. He weighs 207 pounds, and he's 6 feet, 1 inch tall and 75 years old.
His bloodwork always comes back normal, and a nuclear stress test came back negative. We have discussed this chronic fatigue with our family doctor. His only explanation is possibly low testosterone (the low end of normal).
We know that some if not all of his medications list fatigue as a side effect, but we cannot persuade our doctor to do further tests. My husband does have an appointment with a cardiologist in May for a consultation and any suggestions, and also a checkup in six months with our family doctor.
My concern is his medications and the fact that they are generic. I have read many stories about generic drugs and problems with their effectiveness. -- J.C.
ANSWER: Fatigue, which is the sensation of feeling tired, is a nonspecific symptom and a complaint that's commonly heard by general doctors. It can be related to many diseases, as disparate as multiple sclerosis to heart failure, anemia to depression, and chronic infection to sleep disturbances. However, your husband notes a severe intolerance to exertion, which makes me suspect systemic exertion intolerance disorder, also called myalgic encephalomyelitis or chronic fatigue syndrome. Poor sleep, difficulty thinking or concentrating, and having worse symptoms with standing also go along with this diagnosis. There is yet no lab test for confirmation. The diagnosis is made after considering other causes, and testing for those that make sense after a careful history and exam.
Diabetes, when not well controlled, may lead to chronic fatigue. I'm not so concerned with generic medications as I am about too many or the wrong ones, so a careful review of medications is appropriate.
I have previously recommended a graded exercise program for this condition; however, the study that led to this recommendation had several significant issues; many people will actually have worsening of their post-exercise fatigue, so exercise must be used very cautiously and on an individualized basis. Cognitive behavioral therapy has had some benefit, but we desperately need better treatments.
DEAR DR. ROACH: Is it possible to suffer and maybe die from a broken heart? We all have many life events that change our lives dramatically. -- M.A.K.
The first condition is rare, and it's called takotsubo cardiomyopathy (the condition was first described in Japan: "takotsubo" means "octopus trap" in Japanese, reflecting the characteristic appearance of the heart on echocardiogram; "cardiomyopathy" is a nonspecific term for something that's gone wrong with the heart muscle). This condition accounts for 1% to 2% of all suspected cases of heart attack based on EKG and blood tests. It is much more common in women (80%) and is most often diagnosed in a person's 60s or 70s.
About 28% of people with takotsubo cardiomyopathy have emotional stress as the precipitating factor, while 36% had a physical trigger (such as infection or surgery), 8% had both physical and emotional triggers, and 28% had no identifiable trigger.
However, even people without this catastrophic condition have increased risk of heart disease and death after one (or especially more than one) stressful life event. It's important for ourselves, and for our loved ones, to be especially vigilant of our own physical and emotional health after stressful life events, such as death or serious illness of a spouse, loss of a job or major violence.
Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.
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