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October 8, 1997, Vol 278, No. 14 >
ARTICLE | October 8, 1997

A 56-Year-Old Woman With Chronic Fatigue Syndrome FREE

Anthony L. Komaroff, MD
[+] Author Affiliations

This conference took place at the Medicine Grand Rounds of the Beth Israel Deaconess Medical Center, West Campus, Boston, Mass, on June 11, 1997.

Reprints: Erin E. Hartman, MS, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, East Campus, 330 Brookline Ave, LY318, Boston, MA 02215.

Clinical Crossroads at Beth Israel Deaconess Medical Center is produced and edited by Thomas L. Delbanco, MD, and Jennifer Daley, MD; Erin E. Hartman, MS, is managing editor. Clinical Crossroads section editor: Margaret A. Winker, MD, Senior Editor, JAMA.


JAMA. 1997;278(14):1179-1185. doi:10.1001/jama.1997.03550140071043
Text Size: A A A
Published online
Article
References

Dr Delbanco:  Ms H is a 56-year-old educator currently on medical leave of absence. She has an 11-year history of chronic fatigue that at times has been disabling. She has commercial managed care health insurance through her work.Prior to her illness, Ms H was well, a successful and energetic teacher who was physically very active. In 1986 she developed the sudden onset of profound fatigue, about 1 month after a flulike illness characterized by fever, chills, myalgias, and sore throat. She thought she had infectious mononucleosis, but laboratory tests did not confirm the diagnosis. Titers for Epstein-Barr infection were found to be elevated soon thereafter. Since that time, she has noted extraordinary weakness, finding herself able to walk only a few blocks, followed by exhaustion that forces her to spend many hours in bed. She often finds herself unable to concentrate. She reports she periodically has had "swollen glands"

REFERENCES

1 +
Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB.  Chronic fatigue in primary care: prevalence, patient characteristics, and outcome . JAMA . 1988;;260:929-934.
2 +
Fukuda K, Straus SE, Hickie I, et al.  The chronic fatigue syndrome: a comprehensive approach to its definition and study . Ann Intern Med . 1994;;121:953-959.
3 +
Komaroff AL, Fagioli LR, Geiger AM, et al.  An examination of the working case definition of chronic fatigue syndrome . Am J Med . 1996;;100:56-64.
4 +
Buchwald D, Umali P, Umali J, Kith P, Pearlman T, Komaroff AL.  Chronic fatigue and the chronic fatigue syndrome . Ann Intern Med . 1995;;123:81-88.
5 +
Dobbins JG, Randall B, Reyes M, Steele L, Livens EA, Reeves WC.  The prevalence of chronic fatiguing illnesses among adolescents in the United States . J Chronic Fatigue Syndrome . 1997;;3:15-27.
6 +
Bates DW, Schmitt W, Buchwald D, et al.  Prevalence of fatigue and chronic fatigue syndrome in a primary care practice . Arch Intern Med . 1993;;153:2759-2765.
7 +
Powell R, Dolan R, Wessely S.  Attributions and self-esteem in depression and chronic fatigue syndrome . J Psychosom Res . 1990;;34:665-673.
8 +
Demitrack MA, Dale JK, Straus SE, et al.  Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome . J Clin Endocrinol Metab . 1991;;73:1224-1234.
9 +
Vercoulen JHMM, Swanink CMA, Zitman FG, et al.  Randomised, doubleblind, placebo-controlled study of fluoxetine in chronic fatigue syndrome . Lancet . 1996;;347:858-861.
10 +
Hickie I, Lloyd A, Wakefield D, Parker G.  The psychiatric status of patients with the chronic fatigue syndrome . Br J Psychiatry . 1990;;156:534-540.
11 +
Kruesi MJP, Dale J, Straus SE.  Psychiatric diagnoses in patients who have chronic fatigue syndrome . J Clin Psychiatry . 1989;;50:53-56.
12 +
Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ.  Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis . J Gen Intern Med . 1991;;6:277-285.
13 +
Buchwald D, Cheney PR, Peterson DL, et al.  A chronic illness characterized by fatigue, neurologic and immunologic disorders, and active human herpesvirus type 6 infection . Ann Intern Med . 1992;;116:103-113.
14 +
Natelson BH, Cohen JM, Brassloff I, Lee H-J.  A controlled study of brain magnetic resonance imaging in patients with the chronic fatigue syndrome . J Neurol Sci . 1993;;120:213-217.
15 +
Ichise M, Salit IE, Abbey SE, et al.  Assessment of regional cerebral perfusion by 99Tcm-HMPAO SPECT in chronic fatigue syndrome . Nucl Med Commun . 1992;;13:767-772.
16 +
Schwartz RB, Komaroff AL, Garada BM, et al.  SPECT imaging of the brain: comparison of findings in patients with chronic fatigue syndrome, AIDS dementia complex, and major unipolar depression . AJR Am J Roentgenol . 1994;;162:943-951.
17 +
Bou-Holaigah I, Rowe PC, Kan J, Calkins H.  The relationship between neurally mediated hypotension and the chronic fatigue syndrome . JAMA . 1995;;274:961-967.
18 +
Freeman R, Komaroff AL.  Does the chronic fatigue syndrome involve the autonomic nervous system? Am J Med . 1997;;102:357-362.
19 +
Demitrack MA, Gold PW, Dale JK, Krahn DD, Kling MA, Straus SE.  Plasma and cerebrospinal fluid monamine metabolism in patients with chronic fatigue syndrome: preliminary findings . Biol Psychiatry . 1992;;32:1065-1077.
20 +
Bakheit AMO, Behan PO, Dinan TG, Gray CE, O'Keane V.  Possible upregulation of hypothalamic 5-hydroxytryptamine receptors in patients with postviral fatigue syndrome . BMJ . 1992;;304:1010-1012.
21 +
Cleare AJ, Bearn J, Allain T, et al.  Contrasting neuroendocrine responses in depression and chronic fatigue syndrome . J Affect Disord . 1995;;35:283-289.
22 +
Furman JMR.  Testing of vestibular function: an adjunct in the assessment of chronic fatigue syndrome . Rev Infect Dis . 1991;;13( (suppl 1) ):S109-S111.
23 +
Ash-Bernal R, Wall C III, Komaroff AL, et al.  Vestibular function test anomalies in patients with chronic fatigue syndrome . Acta Otolaryngol . 1995;;115:9-17.
24 +
Sandman CA, Barron JL, Nackoul K, Goldstein J, Fidler F.  Memory deficits associated with chronic fatigue immune dysfunction syndrome . Biol Psychiatry . 1993;;33:618-623.
25 +
McDonald E, Cope H, David A.  Cognitive impairment in patients with chronic fatigue: a preliminary study . J Neurol Neurosurg Psychiatry . 1993;;56:812-815.
26 +
Schmaling KB, DiClementi JD, Cullum CM, Jones JF.  Cognitive functioning in chronic fatigue syndrome and depression . Psychosom Med . 1994;;56:383-388.
27 +
DeLuca J, Johnson SK, Beldowicz D, Natelson BH.  Neuropsychological impairments in chronic fatigue syndrome, multiple sclerosis, and depression . J Neurol Neurosurg Psychiatry . 1995;;58:38-43.
28 +
Marcel B, Komaroff AL, Fagioli LR, Kornish RJ, Albert MS.  Cognitive deficits in patients with chronic fatigue syndrome . Biol Psychiatry . 1996;;40:535-541.
29 +
Krupp LB, Jandorf L, Coyle PK, Mendelson WB.  Sleep disturbance in chronic fatigue syndrome . J Psychosom Res . 1993;;37:325-331.
30 +
Buchwald D, Pascualy R, Bombardier C, Kith P. Sleep disorders in patients with chronic fatigue . Clin Infect Dis . 1994;;18:568-572.
31 +
Morriss R, Sharpe M, Sharpley AL, Cowen PJ, Hawton K, Morris J.  Abnormalities of sleep in patients with chronic fatigue syndrome . BMJ . 1993;;306:1161-1164.
32 +
Landay AL, Jessop C, Lennette ET, Levy JA.  Chronic fatigue syndrome: clinical condition associated with immune activation . Lancet . 1991;;338:707-712.
33 +
Caligiuri M, Murray C, Buchwald D, et al. Phenotypic and functional deficiency of natural killer cells in patients with chronic fatigue syndrome . J Immunol . 1987;;139:3306-3313.
34 +
Morrison LJA, Behan WMH, Behan PO.  Changes in natural killer cell phenotype in patients with post-viral fatigue syndrome . Clin Exp Immunol . 1991;;83:441-446.
35 +
Bates DW, Buchwald D, Lee J, et al.  Clinical laboratory test findings in patients with chronic fatigue syndrome . Arch Intern Med . 1995;;155:97-103.
36 +
Konstantinov K, von Milecz A, Buchwald D, Jones J, Gerace L, Tan EM.  Autoantibodies to nuclear envelope antigens in chronic fatigue syndrome . J Clin Invest . 1996;;98:1888-1896.
37 +
Peakman M, Deale A, Field R, Mahalingam M, Wessely S.  Clinical improvement in chronic fatigue syndrome is not associated with lymphocyte subsets of function or activation . Clin Immunol Immunopathol . 1997;;82:83-91.
38 +
Dinerman H, Steere AC.  Lyme disease associated with fibromyalgia . Ann Intern Med . 1992;;117:281-285.
39 +
Marmion BP, Shannon M, Maddocks I, Storm P, Penttila I.  Protracted debility and fatigue after acute Q fever . Lancet . 1996;;347:977-978.
40 +
Yalcin S, Kuratsune H, Yamaguchi K, Kitani T, Yamanishi K.  Prevalence of human herpesvirus 6 variants A and B in patients with chronic fatigue syndrome . Microbiol Immunol . 1994;;38:587-590.
41 +
Patnaik M, Komaroff AL, Conley E, Ojo-Amaize EA, Peter JB.  Prevalence of IgM antibodies to human herpesvirus 6 early antigen (p41/38) in patients with chronic fatigue syndrome . J Infect Dis . 1995;;172:1364-1367.
42 +
Zorzenon M, Rukh G, Botta GA, Colle R, Barsanti LA, Ceccherini-Nelli L.  Active HHV-6 infection in chronic fatigue syndrome patients from Italy: new data . J Chronic Fatigue Syndrome . 1996;;2:3-12.
43 +
Cunningham L, Bowles NE, Lane RJM, Dubowitz V, Archard LC.  Persistence of enteroviral RNA in chronic fatigue syndrome is associated with the abnormal production of equal amounts of positive and negative strands of enteroviral RNA . J Gen Virol . 1990;;71:1399-1402.
44 +
Gow JW, Behan WMH, Clements GB, Woodall C, Riding M, Behan PO.  Enteroviral RNA sequences detected by polymerase chain reaction in muscle of patients with postviral fatigue syndrome . BMJ . 1991;;302:692-696.
45 +
Swanink CMA, Melchers WJG, Van Der Meer JWM, et al.  Enteroviruses and the chronic fatigue syndrome . Clin Infect Dis . 1994;;19:860-864.
46 +
DeFreitas E, Hilliard B, Cheney PR, et al.  Retroviral sequences related to human T-lymphotropic virus type II in patients with chronic fatigue immune dysfunction syndrome . Proc Natl Acad Sci USA . 1991;;88:2922-2926.
47 +
Khan AS, Heneine WM, Chapman LE, et al.  Assessment of a retrovirus sequence and other possible risk factors for the chronic fatigue syndrome in adults . Ann Intern Med . 1993;;118:241-245.
48 +
Nakaya T, Takahashi H, Nakamura Y, et al.  Demonstration of Borna disease virus RNA in peripheral blood mononuclear cells derived from Japanese patients with chronic fatigue syndrome . FEBS Lett . 1996;;378:145-149.
49 +
Bode L, Durrwald R, Rantam FA, Ferszt R, Ludwig H.  First isolates of infectious human Borna disease virus from patients with mood disorders . Mol Psychiatry . 1996;;1:200-212.
50 +
Suhadolnik RJ, Reichenbach NL, Hitzges P, et al.  Upregulation of the 2-5A synthetase/RNase L antiviral pathway associated with chronic fatigue syndrome . Clin Infect Dis . 1994;;18( (suppl 1) ):S96-S104.
51 +
Manu P, Matthews DA, Lane TJ.  The mental health of patients with a chief complaint of chronic fatigue . Arch Intern Med . 1988;;148:2213-2217.
52 +
Kessler LG, Cleary PD, Burke JD.  Psychiatric disorders in primary care . Arch Gen Psychiatry . 1985;;42:583-587.
53 +
Gerber PD, Barrett J, Manheimer E, Whiting R, Smith R.  Recognition of depression by internists in primary care . J Gen Intern Med . 1989;;4:7-13.
54 +
Schor JB. The Overworked American. The Unexpected Decline of Leisure . New York, NY: Basic Books; 1992;.
55 +
Schluederberg A, Straus SE, Peterson P, et al.  Chronic fatigue syndrome research . Ann Intern Med . 1992;;117:325-331.
56 +
Goldenberg DL, Felson DT, Dinerman H.  A randomized, controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia . Arthritis Rheum . 1986;;29:1371-1377.
57 +
Buchwald D, Goldenberg DL, Sullivan JL, Komaroff AL.  The 'chronic, active Epstein-Barr virus infection' syndrome and primary fibromyalgia . Arthritis Rheum . 1987;;30:1132-1136.
58 +
Goldenberg DL, Simms RW, Geiger A, Komaroff AL.  High frequency of fibromyalgia in patients with chronic fatigue seen in a primary care practice . Arthritis Rheum . 1990;;33:381-387.
59 +
Peterson PK, Shepard J, Macres M, et al.  A controlled trial of intravenous immunoglobulin G in chronic fatigue syndrome . Am J Med . 1990;;89:554-560.
60 +
Lloyd AR, Hickie I, Brockman A, et al.  Immunologic and psychologic therapy for patients with chronic fatigue syndrome . Am J Med . 1993;;94:197-203.
61 +
Sharpe M, Hawton K, Simkin S, et al.  Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial . BMJ . 1996;;312:22-26.
62 +
Deale A, Chalder T, Marks I, Wessely S.  Cognitive behavior therapy for chronic fatigue syndrome . Am J Psychol . 1997;;154:408-414.
63 +
Wessely S, Butler S, Chalder T, David A.  The cognitive behavioural management of the post-viral fatigue syndrome . In: Jenkins R, Mowbray JF, eds. Post Viral Fatigue Syndrome . Chichester, England: John Wiley & Sons; 1991;:305-334.
64 +
Fulcher KY, White PD.  Randomized controlled trial of graded exercise in patients with the chronic fatigue syndrome . BMJ . 1997;;314:1647-1652.
65 +
Ware NC.  Suffering and the social construction of illness: the delegitimation of illness experience in chronic fatigue syndrome . Med Anthropol Q . 1992;;6:347-361.
66 +
McGarry F, GOw J,Behan PO.  Enterovirus in the chronic fatigue syndrome . Ann Intern Med . 1994;;120:972-973.

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Interactive Graphics

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Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Kroenke K, Wood DR, Mangelsdorff AD, Meier NJ, Powell JB.  Chronic fatigue in primary care: prevalence, patient characteristics, and outcome . JAMA . 1988;;260:929-934.
2 +
Fukuda K, Straus SE, Hickie I, et al.  The chronic fatigue syndrome: a comprehensive approach to its definition and study . Ann Intern Med . 1994;;121:953-959.
3 +
Komaroff AL, Fagioli LR, Geiger AM, et al.  An examination of the working case definition of chronic fatigue syndrome . Am J Med . 1996;;100:56-64.
4 +
Buchwald D, Umali P, Umali J, Kith P, Pearlman T, Komaroff AL.  Chronic fatigue and the chronic fatigue syndrome . Ann Intern Med . 1995;;123:81-88.
5 +
Dobbins JG, Randall B, Reyes M, Steele L, Livens EA, Reeves WC.  The prevalence of chronic fatiguing illnesses among adolescents in the United States . J Chronic Fatigue Syndrome . 1997;;3:15-27.
6 +
Bates DW, Schmitt W, Buchwald D, et al.  Prevalence of fatigue and chronic fatigue syndrome in a primary care practice . Arch Intern Med . 1993;;153:2759-2765.
7 +
Powell R, Dolan R, Wessely S.  Attributions and self-esteem in depression and chronic fatigue syndrome . J Psychosom Res . 1990;;34:665-673.
8 +
Demitrack MA, Dale JK, Straus SE, et al.  Evidence for impaired activation of the hypothalamic-pituitary-adrenal axis in patients with chronic fatigue syndrome . J Clin Endocrinol Metab . 1991;;73:1224-1234.
9 +
Vercoulen JHMM, Swanink CMA, Zitman FG, et al.  Randomised, doubleblind, placebo-controlled study of fluoxetine in chronic fatigue syndrome . Lancet . 1996;;347:858-861.
10 +
Hickie I, Lloyd A, Wakefield D, Parker G.  The psychiatric status of patients with the chronic fatigue syndrome . Br J Psychiatry . 1990;;156:534-540.
11 +
Kruesi MJP, Dale J, Straus SE.  Psychiatric diagnoses in patients who have chronic fatigue syndrome . J Clin Psychiatry . 1989;;50:53-56.
12 +
Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ.  Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis . J Gen Intern Med . 1991;;6:277-285.
13 +
Buchwald D, Cheney PR, Peterson DL, et al.  A chronic illness characterized by fatigue, neurologic and immunologic disorders, and active human herpesvirus type 6 infection . Ann Intern Med . 1992;;116:103-113.
14 +
Natelson BH, Cohen JM, Brassloff I, Lee H-J.  A controlled study of brain magnetic resonance imaging in patients with the chronic fatigue syndrome . J Neurol Sci . 1993;;120:213-217.
15 +
Ichise M, Salit IE, Abbey SE, et al.  Assessment of regional cerebral perfusion by 99Tcm-HMPAO SPECT in chronic fatigue syndrome . Nucl Med Commun . 1992;;13:767-772.
16 +
Schwartz RB, Komaroff AL, Garada BM, et al.  SPECT imaging of the brain: comparison of findings in patients with chronic fatigue syndrome, AIDS dementia complex, and major unipolar depression . AJR Am J Roentgenol . 1994;;162:943-951.
17 +
Bou-Holaigah I, Rowe PC, Kan J, Calkins H.  The relationship between neurally mediated hypotension and the chronic fatigue syndrome . JAMA . 1995;;274:961-967.
18 +
Freeman R, Komaroff AL.  Does the chronic fatigue syndrome involve the autonomic nervous system? Am J Med . 1997;;102:357-362.
19 +
Demitrack MA, Gold PW, Dale JK, Krahn DD, Kling MA, Straus SE.  Plasma and cerebrospinal fluid monamine metabolism in patients with chronic fatigue syndrome: preliminary findings . Biol Psychiatry . 1992;;32:1065-1077.
20 +
Bakheit AMO, Behan PO, Dinan TG, Gray CE, O'Keane V.  Possible upregulation of hypothalamic 5-hydroxytryptamine receptors in patients with postviral fatigue syndrome . BMJ . 1992;;304:1010-1012.
21 +
Cleare AJ, Bearn J, Allain T, et al.  Contrasting neuroendocrine responses in depression and chronic fatigue syndrome . J Affect Disord . 1995;;35:283-289.
22 +
Furman JMR.  Testing of vestibular function: an adjunct in the assessment of chronic fatigue syndrome . Rev Infect Dis . 1991;;13( (suppl 1) ):S109-S111.
23 +
Ash-Bernal R, Wall C III, Komaroff AL, et al.  Vestibular function test anomalies in patients with chronic fatigue syndrome . Acta Otolaryngol . 1995;;115:9-17.
24 +
Sandman CA, Barron JL, Nackoul K, Goldstein J, Fidler F.  Memory deficits associated with chronic fatigue immune dysfunction syndrome . Biol Psychiatry . 1993;;33:618-623.
25 +
McDonald E, Cope H, David A.  Cognitive impairment in patients with chronic fatigue: a preliminary study . J Neurol Neurosurg Psychiatry . 1993;;56:812-815.
26 +
Schmaling KB, DiClementi JD, Cullum CM, Jones JF.  Cognitive functioning in chronic fatigue syndrome and depression . Psychosom Med . 1994;;56:383-388.
27 +
DeLuca J, Johnson SK, Beldowicz D, Natelson BH.  Neuropsychological impairments in chronic fatigue syndrome, multiple sclerosis, and depression . J Neurol Neurosurg Psychiatry . 1995;;58:38-43.
28 +
Marcel B, Komaroff AL, Fagioli LR, Kornish RJ, Albert MS.  Cognitive deficits in patients with chronic fatigue syndrome . Biol Psychiatry . 1996;;40:535-541.
29 +
Krupp LB, Jandorf L, Coyle PK, Mendelson WB.  Sleep disturbance in chronic fatigue syndrome . J Psychosom Res . 1993;;37:325-331.
30 +
Buchwald D, Pascualy R, Bombardier C, Kith P. Sleep disorders in patients with chronic fatigue . Clin Infect Dis . 1994;;18:568-572.
31 +
Morriss R, Sharpe M, Sharpley AL, Cowen PJ, Hawton K, Morris J.  Abnormalities of sleep in patients with chronic fatigue syndrome . BMJ . 1993;;306:1161-1164.
32 +
Landay AL, Jessop C, Lennette ET, Levy JA.  Chronic fatigue syndrome: clinical condition associated with immune activation . Lancet . 1991;;338:707-712.
33 +
Caligiuri M, Murray C, Buchwald D, et al. Phenotypic and functional deficiency of natural killer cells in patients with chronic fatigue syndrome . J Immunol . 1987;;139:3306-3313.
34 +
Morrison LJA, Behan WMH, Behan PO.  Changes in natural killer cell phenotype in patients with post-viral fatigue syndrome . Clin Exp Immunol . 1991;;83:441-446.
35 +
Bates DW, Buchwald D, Lee J, et al.  Clinical laboratory test findings in patients with chronic fatigue syndrome . Arch Intern Med . 1995;;155:97-103.
36 +
Konstantinov K, von Milecz A, Buchwald D, Jones J, Gerace L, Tan EM.  Autoantibodies to nuclear envelope antigens in chronic fatigue syndrome . J Clin Invest . 1996;;98:1888-1896.
37 +
Peakman M, Deale A, Field R, Mahalingam M, Wessely S.  Clinical improvement in chronic fatigue syndrome is not associated with lymphocyte subsets of function or activation . Clin Immunol Immunopathol . 1997;;82:83-91.
38 +
Dinerman H, Steere AC.  Lyme disease associated with fibromyalgia . Ann Intern Med . 1992;;117:281-285.
39 +
Marmion BP, Shannon M, Maddocks I, Storm P, Penttila I.  Protracted debility and fatigue after acute Q fever . Lancet . 1996;;347:977-978.
40 +
Yalcin S, Kuratsune H, Yamaguchi K, Kitani T, Yamanishi K.  Prevalence of human herpesvirus 6 variants A and B in patients with chronic fatigue syndrome . Microbiol Immunol . 1994;;38:587-590.
41 +
Patnaik M, Komaroff AL, Conley E, Ojo-Amaize EA, Peter JB.  Prevalence of IgM antibodies to human herpesvirus 6 early antigen (p41/38) in patients with chronic fatigue syndrome . J Infect Dis . 1995;;172:1364-1367.
42 +
Zorzenon M, Rukh G, Botta GA, Colle R, Barsanti LA, Ceccherini-Nelli L.  Active HHV-6 infection in chronic fatigue syndrome patients from Italy: new data . J Chronic Fatigue Syndrome . 1996;;2:3-12.
43 +
Cunningham L, Bowles NE, Lane RJM, Dubowitz V, Archard LC.  Persistence of enteroviral RNA in chronic fatigue syndrome is associated with the abnormal production of equal amounts of positive and negative strands of enteroviral RNA . J Gen Virol . 1990;;71:1399-1402.
44 +
Gow JW, Behan WMH, Clements GB, Woodall C, Riding M, Behan PO.  Enteroviral RNA sequences detected by polymerase chain reaction in muscle of patients with postviral fatigue syndrome . BMJ . 1991;;302:692-696.
45 +
Swanink CMA, Melchers WJG, Van Der Meer JWM, et al.  Enteroviruses and the chronic fatigue syndrome . Clin Infect Dis . 1994;;19:860-864.
46 +
DeFreitas E, Hilliard B, Cheney PR, et al.  Retroviral sequences related to human T-lymphotropic virus type II in patients with chronic fatigue immune dysfunction syndrome . Proc Natl Acad Sci USA . 1991;;88:2922-2926.
47 +
Khan AS, Heneine WM, Chapman LE, et al.  Assessment of a retrovirus sequence and other possible risk factors for the chronic fatigue syndrome in adults . Ann Intern Med . 1993;;118:241-245.
48 +
Nakaya T, Takahashi H, Nakamura Y, et al.  Demonstration of Borna disease virus RNA in peripheral blood mononuclear cells derived from Japanese patients with chronic fatigue syndrome . FEBS Lett . 1996;;378:145-149.
49 +
Bode L, Durrwald R, Rantam FA, Ferszt R, Ludwig H.  First isolates of infectious human Borna disease virus from patients with mood disorders . Mol Psychiatry . 1996;;1:200-212.
50 +
Suhadolnik RJ, Reichenbach NL, Hitzges P, et al.  Upregulation of the 2-5A synthetase/RNase L antiviral pathway associated with chronic fatigue syndrome . Clin Infect Dis . 1994;;18( (suppl 1) ):S96-S104.
51 +
Manu P, Matthews DA, Lane TJ.  The mental health of patients with a chief complaint of chronic fatigue . Arch Intern Med . 1988;;148:2213-2217.
52 +
Kessler LG, Cleary PD, Burke JD.  Psychiatric disorders in primary care . Arch Gen Psychiatry . 1985;;42:583-587.
53 +
Gerber PD, Barrett J, Manheimer E, Whiting R, Smith R.  Recognition of depression by internists in primary care . J Gen Intern Med . 1989;;4:7-13.
54 +
Schor JB. The Overworked American. The Unexpected Decline of Leisure . New York, NY: Basic Books; 1992;.
55 +
Schluederberg A, Straus SE, Peterson P, et al.  Chronic fatigue syndrome research . Ann Intern Med . 1992;;117:325-331.
56 +
Goldenberg DL, Felson DT, Dinerman H.  A randomized, controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia . Arthritis Rheum . 1986;;29:1371-1377.
57 +
Buchwald D, Goldenberg DL, Sullivan JL, Komaroff AL.  The 'chronic, active Epstein-Barr virus infection' syndrome and primary fibromyalgia . Arthritis Rheum . 1987;;30:1132-1136.
58 +
Goldenberg DL, Simms RW, Geiger A, Komaroff AL.  High frequency of fibromyalgia in patients with chronic fatigue seen in a primary care practice . Arthritis Rheum . 1990;;33:381-387.
59 +
Peterson PK, Shepard J, Macres M, et al.  A controlled trial of intravenous immunoglobulin G in chronic fatigue syndrome . Am J Med . 1990;;89:554-560.
60 +
Lloyd AR, Hickie I, Brockman A, et al.  Immunologic and psychologic therapy for patients with chronic fatigue syndrome . Am J Med . 1993;;94:197-203.
61 +
Sharpe M, Hawton K, Simkin S, et al.  Cognitive behaviour therapy for the chronic fatigue syndrome: a randomised controlled trial . BMJ . 1996;;312:22-26.
62 +
Deale A, Chalder T, Marks I, Wessely S.  Cognitive behavior therapy for chronic fatigue syndrome . Am J Psychol . 1997;;154:408-414.
63 +
Wessely S, Butler S, Chalder T, David A.  The cognitive behavioural management of the post-viral fatigue syndrome . In: Jenkins R, Mowbray JF, eds. Post Viral Fatigue Syndrome . Chichester, England: John Wiley & Sons; 1991;:305-334.
64 +
Fulcher KY, White PD.  Randomized controlled trial of graded exercise in patients with the chronic fatigue syndrome . BMJ . 1997;;314:1647-1652.
65 +
Ware NC.  Suffering and the social construction of illness: the delegitimation of illness experience in chronic fatigue syndrome . Med Anthropol Q . 1992;;6:347-361.
66 +
McGarry F, GOw J,Behan PO.  Enterovirus in the chronic fatigue syndrome . Ann Intern Med . 1994;;120:972-973.

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NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
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