A List of Diagnoses for Chronic Fatigue with Chronic Pain

This article is a general list about some causes or differential diagnoses of chronic fatigue with chronic pain. It was compiled by myself over time taking care of patients over the years and I simply wanted to share it with others. I wish I had access to this type of list list when I started practicing medicine. It is not meant to be an all inclusive list. It was written in outline and fragmented phrasing to minimize the verbage to make it easier to read and to be more efficient for people looking for answers quickly. The list states a specific diagnosis with some diagnostic tests related to it and selected basic information and selected online references. Medical abbreviations are used to minimize text and can be looked up on the internet easily. This information is general information and not specific medical information for any individual. Please look more into these ideas if you need to find answers and please account for the fact that some of this information may change over time or be wrong. Also, please see your medical provider for specific individualized medical care.

1. Celiac disease: (celiac comprehensive panel and HLA (HLA DQ2 and DQ8) Celiac typing- 30% general population have this HLA type, but 97% of people with celiac have it-so lack of HLA type mainly helps with ruling it out/negative predictive value, GI biopsy?, more false negatives if patient not actively on gluten free diet , may get elevated LFTs with celiac too, http://www.emedicine.com/med/topic308.htm, http://www.aafp.org/afp/20021215/2259.html , http://www.enabling.org/ia/celiac/cel-hla.html#Q9

2. Sarcoidosis: (CXR-adenopathy, angiotensin converting enzyme level-60% positive), http://www.emedicine.com/emerg/topic516.htm

3. Lupus (ANA, DsDNA), RA (RF), scleroderma (panel), autoimmune diseases (CRP,ESR), Sjogrens antibodies,

4. Hemochromatosis: (transferrin saturation= iron/TIBC) >60% male, >50% females, ferritin, genetic marker (C282Y homozygotes and, possibly, C282Y/H63D compound heterozygotes, appear to be at risk for clinical iron overload). http://www.emedicine.com/MED/topic975.html

5.Mycotoxicosis:mold toxin gases causing illness (false pos. ANA more likely, often transient), blood and urine for mycotoxins are available but not reliable/ expensive), most basic labs normal, http://www.associatedcontent.com/article/225375/basics_about_mold_illness_and_mycotoxicosis.html, http://www.cdc.gov/nasd/docs/d001201-d001300/d001270/d001270.html,

6. Medication/herbal reaction/drug abuse

7. Hepatitis B and Hepatitis C: (Hep BsAg, Hep B sAb IgG, HepBcoreAb IgG, and Hepatitis C Ab). If the Hepatitis C antibody is positive, you need to confirm the diagnosis with a Hepatitis C RNA level. The antibody test alone can not let you diagnoses Hepatitis C infection definitively.

8. Hypothyroidism :(TSH, Free T3, Free T4, reverse T3-which competes with T3 but not do anything-one type called Wilson's syndrome)

9. Vitamin D (25-hydroxy) level (Vitamin D deficiency can cause pains/myalgias, weakness, and depression, associated with schizophrenia, cancers, MS, autoimmune disease, weakened immunity), http://www.neuro.wustl.edu/NEUROMUSCULAR/nother/vitamin.htm#vitd

10. Lyme disease: lyme panel, Elisa with western blot reflex or just western blot done by some, 50% do not remember being bitten by tick. This testing is not very accurate and you can get false positives and false negatives.

11. Depression: may be result of frustration of chronic undiagnosed medical problems too.

12. Vitamin A toxicity http://www.neuro.wustl.edu/NEUROMUSCULAR/nother/vitamin.htm#vitd

13. B12 deficiency: (B12, folate, methylmalonic acid-high in B12 def., nutritional homocysteine level)-neuropathic pain, but not assoc. with joint pain but nerve pains), http://www.neuro.wustl.edu/NEUROMUSCULAR/nother/vitamin.htm#vitd

14. Mg deficiency:, check RBC Mg (99% of Mg is in cells and only 1% in blood), Mg serum

15. Polymyalgia rheumatica: ESR

16. MVP (mitral valve prolapse): echocardiogram

17. Withdrawal from certain medications

18. Addison's disease: (ACTH stimulation, aldosterone level, free cortisol level/urine, C-17 hydroxylase deficiency usually presents by adolescents and delayed maturity

19. TB- tuberculosis

20. VINDICATEM is a mnemonic for differential diagnosis of any problem ( Vascular, Inflammatory/Idiopathic, Neoplasm, Degenerative/Drugs, Infection, Congenital, Allergy/Autoimmune, Tumor/Trauma, Environmental, Metabolic)

21. Food allergies or sensitivityies: (check both IgE and IgG). For example, wheat, dairy, and eggs are relatively common (IgG elevated) and may result in fatigue and pains. Elimination diet should be done over 4-6 weeks. In 6-9 months after abstaining from the specific food, IgG intolerated foods may be introduced again without problems for some and IgG can be rechecked serially too. IgE elevations can cause allergy symptoms and abdominal pains. http://www.tldp.com/issue/174/IgG%20Food%20Allergy.html, http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1774223

22. Xenobiotic or biotoxin exposures: for example pesticides, formaldehyde, medications, solvents, chlorox, http://www.epa.gov/ebtpages/pollsoilcontaminanarsenic.html, http://www.epa.gov/pesticides/index.htm, http://www.ilpi.com/msds/

23. Ankylosing spondylitis (HLA-B27)

24. Sleep Apnea

25. Multiple Sclerosis (muscle pains or spasms are possible)

26. Infections: EBV, CMV, HIV, Babesiosis, Trichinosis, Ehrlichiosis, serum sickness, Brucellosis

27. Heavy metals-blood, urine 24 hour collection, hair (limited accuracy), stool, (lead, arsenic, and chronic mercury poisoning can present with chronic fatigue and pain), need to consider chelation challenge if high risk to rule out heavy metal toxicity , remember the non-excretors will need chelation challenge to mobilize metals http://www.emedicine.com/emerg/topic237.htm, http://www.atsdr.cdc.gov/toxpro2.html, http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?TOXLINE, http://hsc.unm.edu/pharmacy/poison/Presentations/Heavy%20Metals.pdf, http://www.heavymetaldetox.net/Explore%20Article%20on%20HMD.pdf, http://www.heavymetaldetox.net/Research%20Articles/Research%20Articles.htm, http://www.detoxmetal.com/NewFiles/ResrchArticls.html, http://www.detoxamin.com/heavymetalsources.html,

28.Special Diet for pain: Consider no nightshade plants (tomatoes, potatoes, eggplant, peppers, spices, etc) diet and less carbohydrates for better pain control. http://arthritis.about.com/b/2006/09/25/nightshade-vegetables-should-people-with-arthritis-avoid-nightshade-foods.htm. I have not personally had much success with this diet and my patients.

29. Hypogonadism , Free testosterone level is more accurate than total level in overweight people, consider routinely checking free testosterone (not total only), specifically between 8-9am when testosterone is supposed to be at its peak. Chronic pain patients on narcotics can develop low testosterone which increase fatigue, need to check free testosterone at peak 8-9am. I usually do a randomly timed test due to convenience and if it is low or borderline will get 8-9am am level again and to confirm with LH and FSH.

30. Panhypopituitary

31. Multiple Chemical Sensitivity (MCS)

32. Hormonal inbalances: Consider checking estradiol, progesterone, DHEA-S, pregnenolone, free testosteronne, LH, FSH, Free T3, Free T4, Reverse T3 ratio, TSH, Free cortisol or 24 hour urine cortisol, Aldosterone, other pituitary hormones, and others

33. Get detailed occupational (lead, arsenic, formaldehyde, mold, computer ink or carbonless paper, hobby), home, medication, herbal, and exposure history. Do problems correlate with starting new job or moving to new home. Are symptoms better on non-work days? Do symptoms start every afternoon at work? What was different when the problem started? New furniture, new appliances, new carpet, new painting, etc.?, http://www.medscape.com/viewarticle/535428, http://www.epa.gov/, http://npic.orst.edu/RMPP/rmpp_ch3.pdf, http://www.echt.chm.msu.edu/BlockIII/Docs/CoreComp/OccupationalEnvironmentExpHistory.pdf,

34. Morgellon's Disease: This disorder involves rashes and fibers that come out of skin, and is also associated with fatigue, arthritis or pains, psychiatric diseases (depression, bipolar, anxiety), and other symptoms. It is currently being investigated by CDC. http://www.morgellons.org/

35. Consider referring to environmental medicine specialist, http://www.aaemonline.org/ and holistic medicine specialist, http://www.holisticboard.org/D/locate_physician.html and naturopathic doctor, acupuncturist and herbalist, etc

36. Useful websites: emedicine, wrongdiagnosis.com- allows you to enter multiple symptoms and get a differential diagnosis from it, http://symptoms.wrongdiagnosis.com/, AAFP, http://www.neuro.wustl.edu/NEUROMUSCULAR/nother/vitamin.htm#vitd, http://www.rarediseases.org/

If you had to read this list, then that means you or someone you care about needs help. I hope you find that help and never give up hope.

Please post comments about other diagnoses to "complete" the list.

Aloha, Bradley E. Hope MD