Chapter 23 Fatigue and generalised weakness

Case 23.1

1. What disorder do you think she was diagnosed with 1 year ago?

The illness 1 year ago is typical of acute hepatitis.

2. How would you relate her symptoms during that time with the disease process?

Acute hepatitis is characterised by swelling of hepatocytes, which cause obstruction to the biliary canaliculi. Consequently, there is disruption to the flow of bile out of the liver, causing a lack of bilirubin (and hence absence of the pigment stercobilin) in the digestive tract. Without stercobilin, the stools remain pale. The build up of bilirubin in the blood causes discolouration of skin and mucous membranes (which presents as jaundice), and is excreted via the urinary tract, causing a darkening of the urine.

The discomfort felt in the upper abdomen is a result of the swollen liver acutely stretching the capsule of the liver, stimulating pain.

3. What are the possible causes of her current complaints?

• Chronic hepatitis (especially from Hepatitis B or C).

• Cirrhosis of the liver (probably too short a timeframe, but may be a possibility).

• A completely unrelated disorder (her symptoms are non-specific, and may relate to pathology anywhere in the body). The weight loss, if unintentional, is a concern.

Case 23.2

1. Explain what is meant by ‘shifting dullness’. What is its significance?

Shifting dullness is a sign elicited when an individual has ascites (an accumulation of fluid in the peritoneal cavity). It is possible to elicit the sign of shifting dullness as this fluid is freely mobile within the cavity. When a person with ascites lies on their back, the fluid collects equally in both flanks. When they roll on to one side, the fluid collects on that side.

With the person on their back, percuss the abdomen, starting in the middle and working away from the midline until you reach the point where the percussion note becomes dull. You are now over the fluid. Keeping your finger on this point, have them role over towards you. Wait for a few seconds, and percuss again over the same spot. If they have ascites, the fluid will have run towards the side they have rolled onto and the percussion note should change from dull to hollow.

2. Why was the patient specifically examined for spider naevi, caput medusa, gynaecomastia, hepatomegaly and splenomegaly?

These signs may be indicators of liver dysfunction and portal hypertension. Spider naevi and gynaecomastia are usually a consequence of excess circulating oestrogen (the liver normally metabolises this hormone, and if the liver is dysfunctional, the levels will hence rise). Caput medusae represent dilation of portal-systemic anastomoses, which are a result of the increase in pressure in the portal venous system. Splenomegaly occurs in portal hypertension due to congestion of the sinusoids which result from an increase in pressure in the portal and splenic veins.

Hepatomegaly may or may not be present, as cirrhosis (the most common cause of portal hypertension) often causes a shrinkage in the size of the liver.

3. What do you think the examiner was looking for on the patient’s hands?

Stigmata of liver disease (eg: clubbing, palmar erythema, ‘liver nails’ and Dupytren’s contracture).

4. What is your differential diagnosis?

Liver dysfunction is still the most likely problem, even considering the lack of typical liver stigmata. Bruising is common in liver dysfunction, as is ascites and jaundice. The history of a ‘reasonable’ alcohol intake is suggestive of a patient denying his true intake.

He may have an intra-abdominal malignancy (which may cause ascites), involving either the liver, biliary tract or pancreas (which may cause jaundice). Pancreatic carcinoma should be considered, even in the absence of pain (often a late symptom).

Case 23.3

2. Do these foods have anything in common with each other? How might they cause her symptoms?

Some are members of the genus Brassica (cabbage, cauliflower, brussel sprouts, broccoli). Although these vegetables are believed to have anti-cancer properties, they can result in the formation of excessive intestinal gas. This can cause distension of the intestine, which stimulates pain receptors.

Stone fruit are from the genus Prunus.

3. What are the criteria for a major depressive episode?

The American Psychiatric Association DSM IVTR criteria are outlined in reference 2 at the end of this chapter.

4. How do tricyclic depressants work? Why do you think that a few different types had to be tried?

They work by blocking the re-uptake of either serotonin or noradrenaline to the pre-synaptic neurone, thus making more of the neurotransmitter available for transmission of nerve impulses (re-uptake is a mechanism which helps us to avoid over-stimulation of neurones).

Some of the tricyclics work predominantly on serotonin levels, and others on noradrenaline. Some have an effect on both. Her unique biochemical needs regarding levels of noradrenaline and serotonin would have dictated which drug she would benefit from most.

5. What type of drugs are:

a Zoloft

Zoloft is from a group of drugs known as selective serotonin re-uptake inhibitors (SSRI). It works by preventing the re-uptake of the neurotransmitter serotonin at the synaptic junction, thus making more available for nerve transmission. It is used in the treatment of depression and a number of anxiety states, including obsessive-compulsive disorder and post-traumatic stress syndrome.

b Nurofen and Nurofen Plus

Nurofen (Ibuprofen) is a ‘1st generation’ non-steroidal anti-inflammatory drug. It acts by inhibiting the enzyme cyclo-oxygenase, which is normally required to produce prostaglandins. Prostaglandins have a key role in the production of pain in the inflammatory process.

Nurofen Plus contains Nurofen plus codeine. Codeine is a weak opioid, (but a more potent analgesic than ibuprofen). Codeine attaches to opioid receptors in the brain (some is converted to morphine) and appears to alter the individual’s perception of the pain.

6. Compile a ‘problem list’ for this patient.

• Constant fatigue.

• Muscle aches and pains.

• Depression (controlled with medication).

7. Which of her symptoms do you think may be related to her depression?

All her symptoms could potentially be related to her depression. They may be:

• manifestations of her depression

• a contributing factor in the pathogenesis of her depression.

8. Is there any relationship between depression and chronic fatigue syndrome (CFS?)

Patients with CFS can have depression as part of the clinical picture — they may become depressed as a result of their illness.

It has also been suggested that psychogenic factors may have a role in the development of CFS, although there is no evidence that there is a direct cause—effect relationship between the two disorders.

CFS is often described as one of the disorders which form part of a group of conditions, collectively known as ‘functional somatic syndromes’. Most of these disorders are also hypothesised to have a psychogenic component as part of their pathogenesis.

Note: like many diseases, CFS is likely to be multifactorial in origin. Most of the scientific literature proposes that it is caused by an abnormal immunological response to an infectious agent, in predisposed individuals (genetic predisposition, psychogenic causes, neurological factors).

9. What do you need to examine in this patient?

A full examination is required in this case, due to the non-specific nature of her symptoms.

10. What information can you obtain from these findings?

Apart from the tenderness of some muscles, and the presence of a few areas of tenderness, examination is unremarkable.

11. Explain the significance of the tender trigger points.

This is a common finding, and the reason behind many consultations with physical therapists. It may be a feature of a number of pain syndromes, myofascial pain syndrome or fibromyalgia.

12. Is it possible that Jenny has fibromyalgia or CFS? Why or why not? Explain the criteria used for their diagnosis.

Diagnosis of fibromyalgia requires the presence of certain criteria. The most important include: subjective aching and/or stiffness of more than 3 months duration, with pain in each of the four quadrants of the body as well as the spine, plus point tenderness at multiple sites (musculotendinous junctions) of the body (at least 11 are required). The American College of Rheumatology has recently updated its criteria used for the diagnosis of fibromyalgia. Refer to Wolfe et al for details.^[3]

According to these criteria, and with the information available here, it is possible that Jenny may have fibromyalgia. If she does, then the diagnosis of CFS is unlikely, as CFS is a diagnosis by exclusion.

The criteria for diagnosing CFS can be found in reference 4 at the end of this chapter.

13. Does the patient need to be referred? If so, what investigations should she have?

Yes, it is important to eliminate other disorders prior to making a diagnosis of CFS, fibromyalgia or myofascial pain syndrome.

Case 23.4

1. Using only this information, list the possible causes of Warren’s erectile dysfunction. Please provide justification for your answer.

Possible cause	Justification
DDx 1: disc herniation compressing cauda equina	• Spinal pain • Erectile dysfunction • Symptom progression
DDx 2: endocrine dysfunction (eg: diabetes mellitus, thyroid disease)	• Changes in sexual performance, behaviour or libido • Fatigue • Hypersomnia • Symptom progression
DDx 3: psychological disorder	• Changes in sexual performance, behaviour or libido • Fatigue • Somnolence
DDx 4: tumour or tumour-like process	• Spinal pain • Erectile dysfunction • Fatigue • Symptom progression