Helen Salisbury: When will we be well again?BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2490 (Published 23 June 2020) Cite this as: BMJ 2020;369:m2490
All rapid responses
The article “Helen Salisbury: When will we be well again?” should be distributed to all heathcare practitioners. Chronic fatigue is an important and distressing symptom in rheumatic (1) and other diseases (2) as well as in the complex multisystem disease myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) (3). It is poorly covered by many medical school curricula. At last there is positive news: a medical education course on ME/CFS (4) has been set up and is freely accessible https://www.studyprn.com/p/chronic-fatigue-syndrome.
Chronic fatigue is common in the general population, with a prevalence in adults of 30%; ME/CFS has a prevalence of 1% (3). There is clear evidence of a genetic basis to chronic fatigue with heritability estimates of 50% (5) and detectable metabolomic abnormalities are seen in patients’ blood (6, 7). Covid-19 can, like many flu-like illnesses, lead to unpleasant malaise and severe, acute fatigue (8) but also to chronic fatigue with prevalence around 10% at 3 months. Post-viral fatigue studies have shown IL-6 and IL-10 in the acute phase to predict the development of subsequent chronic fatigue (9). That the same pro-inflammatory mediators are seen in the cytokine storm of severe covid-19 infection suggests a pattern of immune activation that requires urgent and immediate investigation (10).
The covid-19 epidemic will provide a considerable ongoing burden to healthcare services and the chronic fatigue element must not go unrecognised, lacking as it does at present validated and accepted biomarkers. An urgent and coherent response by the medical community is required with early recognition, support, advice and evidence-based management as best we can provide it given the novel virus. It seems likely that patients will present in increased numbers with chronic fatigue to all forms of medical practice worldwide.
1. Almeida C, Choy EH, Hewlett S, et al. Biologic interventions for fatigue in rheumatoid arthritis. Cochrane Database Syst Rev 2016(6):CD008334. doi: 10.1002/14651858.CD008334.pub2 [published Online First: 2016/06/09]
2. Mohandas H, Jaganathan SK, Mani MP, et al. Cancer-related fatigue treatment: An overview. J Cancer Res Ther 2017;13(6):916-29. doi: 10.4103/jcrt.JCRT_50_17 [published Online First: 2017/12/15]
3. van't Leven M, Zielhuis GA, van der Meer JW, et al. Fatigue and chronic fatigue syndrome-like complaints in the general population. Eur J Public Health 2010;20(3):251-7. doi: 10.1093/eurpub/ckp113
4. Sandler CX, Lloyd AR. Chronic fatigue syndrome: progress and possibilities. Med J Aust 2020 doi: 10.5694/mja2.50553 [published Online First: 2020/04/06]
5. Buchwald D, Herrell R, Ashton S, et al. A twin study of chronic fatigue. Psychosom Med 2001;63(6):936-43.
6. Freidin MB, Wells HRR, Potter T, et al. Metabolomic markers of fatigue: Association between circulating metabolome and fatigue in women with chronic widespread pain. Biochim Biophys Acta 2018;1864(2):601-06. doi: 10.1016/j.bbadis.2017.11.025
7. Tomas C, Newton J. Metabolic abnormalities in chronic fatigue syndrome/myalgic encephalomyelitis: a mini-review. Biochem Soc Trans 2018;46(3):547-53. doi: 10.1042/BST20170503
8. Borges do Nascimento JI, Cacic N, Abdulazeem MH, et al. Novel Coronavirus Infection (COVID-19) in Humans: A Scoping Review and Meta-Analysis. Journal of Clinical Medicine 2020;9(4) doi: 10.3390/jcm9040941
9. Russell A, Hepgul N, Nikkheslat N, et al. Persistent fatigue induced by interferon-alpha: a novel, inflammation-based, proxy model of chronic fatigue syndrome. Psychoneuroendocrinology 2019;100:276-85. doi: 10.1016/j.psyneuen.2018.11.032
10. Vaninov N. In the eye of the COVID-19 cytokine storm. Nature Reviews Immunology 2020 doi: 10.1038/s41577-020-0305-6
Competing interests: No competing interests
Dear Editor, working in inner London where we saw some of the earliest cases of coronavirus in the UK we are now seeing patients like those described by Salisbury who were only mildly unwell at the time, if at all. There are not many but are of all ages. The picture reminds me of patients I saw in the mid 1980s with tiredness and muscle pain on the slightest exertion, but more severe. The term the patients used was ME, which became Chronic Fatigue Syndrome which described their situation more accurately. Most of my patients learned to slow down, something that they found difficult, and increase their exercise gradually. They almost all returned to living a normal life, though it took up to a year to do so. They did much better than the patients I am seeing with the same label now.
What can we say today to our patients? That we do not know what will happen, but there is always hope. Take a medium term view. Trying to do too much too quickly is counterproductive. Ask "can I do more than I did two weeks ago?" because it will be slow. Michael Mayne wrote "A Year Lost and Found" in 1987, towards the end of his recovery and it gives a good perspective. We can't make promises, and none of us have a magic wand, but we can be there and perhaps that's the most important tool in primary care.
Competing interests: No competing interests