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ENCEFALOMIELITE MIALGICA/SINDROME DA FATICA CRONICA:
Una definizione di caso clinico e linee-guida per specialisti
Compendio del Documento di Consenso Canadese.
Bruce M. Carruthers, M.D., C.M., FRCP(C)
Marjorie I. van de Sande, B. Ed., Grad. Dip. Ed.
© Copyright 2005/2006 by Carruthers B.M. and van de Sande M.I.
Tutti I diritti riservati. Nessuna parte di questo lavoro può essere riprodotta, utilizzata o trasmessa in alcuna
forma, elettronica o meccanica, compresi fotocopie, microfilm, e registrazioni, o per mezzo di qualsiasi sistema
di archiviazione e recupero di dati, o tramite qualsiasi altro mezzo senza l’autorizzazione preventiva degli
autori. Nello sforzo di sensibilizzare i medici sul Documento di Consenso ed assicurarci che i pazienti
ricevano adeguata diagnosi e appropriato trattamento nel momento opportuno, gli autori possono prendere in
considerazione richieste di riproduzione di questo documento, sempre che si soddisfino tutte le seguenti
condizioni . Questo documento deve essere riprodotto nella sua interezza, senza alcuna aggiunta,
cancellazione o cambiamento del documento e del suo contenuto in alcun modo; nessuna persona,
organizzazione, impresa, università o altro possono trarne profitto; e gli autori sono accreditati come
fonte. Nella vostra richiesta scritta di riprodurre questo documento dichiarate che accettate tutte le condizioni
di cui sopra e indicate come intendete usare questo documento.
I preparativi per questo lavoro sono stati affrontati con grande cura per divulgare dati e informazioni affidabili.
Ciò nonostante, gli autori non sono responsabili per qualunque errore contenuto in esso o per le conseguenze
che possono risultare dall’uso del materiale o delle informazioni qui contenute. Questo lavoro non pubblicizza
alcun prodotto commerciale.
Dati del Catalogo delle pubblicazioni della Biblioteca nazionale del Canada:
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Clinical Case Definition and Guidelines for Medical
Practitioners. An Overview of the Canadian Consensus Document. Carruthers, Bruce M., van de Sande,
Marjorie I. ISBN: 0-9739335-0-X
Copertina morbida, carta alcalina. Include le affiliazioni degli autori, indice dei contenuti, 1. Encefalomielite
Mialgica/Sindrome da fatica Cronica (ME/CFS) – Definizione Clinica/Criteri Diagnostici, 2. Diagnosi Differenziale 3.
Linee Guida Diagnostiche Cliniche 4. Linee Guida di Trattamento. Copyright 2005 by B. M. Carruthers and M. I. van de
Sande.
Pubblicato da: Carruthers & van de Sande
Stampato: 2006 Canada, United Kindom, Austrailia, New Zealand; 2007
Corrispondenza a: Dr. Bruce M. Carruthers, email: mailto:[email protected]
#2, 3657 West 16 Ave, Vancouver, B.C. V6R 3C3, Canada
Richieste di permesso di ristampa a: Marjorie van de Sande, email:mailto:[email protected]
151 Arbour Ridge Circle N.W., Calgary, Alberta T3G 3V9, Canada
Design di Copertina di Robert J. van de Sande, B. Sc, E.E.
Foto di Copertina (dall’alto verso il basso): La Scansione Xenon SPECT rivela un pronunciato peggioramento della
ipoperfusione conseguentemente all’esercizio; La scansione PET rivela un diminuito utilizzo del glucosio; la scansione
della Risonanza Magnetica con la tecnica della voxel-based morphometry indica che il volume della materia grigia del
cervello è significativamente ridotto e che c’è una media di riduzione del tessuto cerebrale dell’8%, sebbene non
distinguibile a occhio nudo [NDT: La "voxel based morphometry" (VBM) è una tecnica MRI di studio morfometrico dell'intero
cervello, completamente automatica e molto sensibile, che è in grado di individuare alterazioni strutturali regionali attraverso
un confronto voxel per voxel di due gruppi di soggetti. Voxel = un elemento di volume che rappresenta un valore di intensità
di segnale o di colore in uno spazio tridimensionale]; le due foto in fondo realizzate utilizzando la Topografia
dell’Elettroencefalogramma quantitativo (qEEG) indicano le fonti elettriche nella materia grigia (corteccia) . I pazienti
ME/CFS presentano maggiori sorgenti di frequenze-onde beta (indicate in rosso) nell’emisfero sinistro mentre i
controlli hanno maggiori sorgenti di frequenze-onde beta (indicate in verde) nell’emisfero destro nelle regioni
cerebrali frontale e temporale superiore. Le ridotte fonti dei pazienti nell’emisfero destro possono essere causate
dall’interferenza della regolazione inibitoria del cervello sinistro sull’emisfero destro durante il processo cognitivo.
Questo opuscolo è un compendio di Encefalomielite Mialgica/Sindrome della Fatica
Cronica:
Definizione Clinica Operativa di Caso, Linee Guida Diagnostiche e di Trattamento
Un Documento di Consenso Bruce M Carruthers, Anil Kumar Jain, Kenny L De Meirleir, Daniel L
Peterson, Nancy G Klimas, A Martin Lerner, Alison C Bested, Pierre Flor-Henry, Pradip Joshi, AC
Peter Powles, Jeffrey A Sherkey, Marjorie I van de Sande.
Journal of Chronic Fatigue Syndrome 11(1):7-115, 2003. ISBN: 0-7890-227-9 © Haworth Medical Press Inc.
Questo giornale è disponibile presso Haworth Document Delivery Service: Phone (Canada & USA) 800-722-5857. E-mail
address: [email protected]
http://www.HaworthPress.com
(QFHIDORPLHOLWH 0LDOJLFD6LQGURPH GHOOD )DWLFD &URQLFD
Affiliazioni degli autori del Documento di Consenso canadese
Bruce M. Carruthers, MD, CM, FRCP(C): Specialist in Internal Medicine, Vancouver, B.C., Canada
Anil Kumar Jain, B Sc, MD: Ottawa Hospital, Ottawa, ON, Canada
Kenny L. De Meirleir, MD, Ph D: Professor of Physiology and Medicine (KDM, IC, PDB); Director of the
Human Performance Laboratory and member of the Vakgroep Internal Medicine; Vrije Universiteit
Brussel, Brussels, Belgium
Daniel L. Peterson, MD: Specialist in Internal Medicine, Affiliate of the Sierra Internal Medicine Associates,
Incline Village, NV, USA; ME/CFS researcher and clinician; a board member of the American
Association of Chronic Fatigue Syndrome; and member of the International Chronic Fatigue Syndrome
Study Group
Nancy G. Klimas, MD: Clinical Professor of Medicine in Microbiology/Immunology/Allergy and Psychology,
University of Miami School of Medicine; Co-Director, E.M. Papper Laboratory of Clinical Immunology,
University Miami School of Medicine; Director of AIDS Research and Co-Director of AIDS Clinical
Research Unit, Miami VA Medical Center, Miami, FL, USA
A. Martin Lerner, MD, PC, MACP: Clinical Professor of Internal Medicine, Wayne State University School
of Medicine; William Beaumont Hospital, Royal Oak, MI, USA
Alison C. Bested, MD, FRCP(C): Haematological Pathologist; Environmental Health Clinic; Sunnybrook &
Women’s College Health Sciences Centre, Toronto, ON, Canada.
Pierre Flor-Henry, MB, Ch B, MD, Acad DPM, FRC, CSPQ: Clinical Director, General Psychiatry;
Director, Clinical Diagnostics and Research Centre; Clinical Professor of Psychiatry, University of
Alberta, Edmonton, AB, Canada
Pradip Joshi, BM, MD, FRCP(C): Clinical Associate Professor, Memorial University of Newfoundland, St.
John’s, NF, Canada
A. C. Peter Powles, MRACP, FRACP, FRCP(C), ABSM: Professor Emeritus, Faculty of Health Sciences,
McMasters University, Hamilton, ON; Professor, Faculty of Medicine, University of Toronto; Chief of
Medicine and Sleep Disorder Consultant, St Joseph’s Health Centre, Toronto; Sleep Disorder Consultant
at the Sleep Disorder Clinic at St. Joseph’s Healthcare, Hamilton, and Central West Sleep Affiliation,
Paris, ON, Canada
Jeffrey A. Sherkey, MD, CCFP(C): Formerly in Family Medicine, University Health Network, Toronto, ON,
Canada. We sincerely regret that Dr. Sherkey has since passed away.
Marjorie I. van de Sande, B Ed, Grad Dip Ed: Consensus Coordinator; Advisor to the National ME/FM
Action Network, Canada
Ringraziamenti per il Documento di Consenso Canadese a:
Lydia Neilson, MSM, Presidente, e il National ME/FM Action Network, per essere stati i primi a indirizzare
verso lo sviluppo di una definizione clinica e dei protocolli di diagnosi e di trattamento per la FMS. Il National
ME/FM Action Network, Canada www.mefmaction.net
Il Ministero della sanità canadese, per aver stabilito i “Termini di riferimento” ed aver selezionato il Gruppo di
esperti per il Consenso Crystaal, per aver sponsorizzato il Seminario del Gruppo di esperti per il
consenso senza alcun diretto coinvolgimento
James McSherry, MB, ChB, CCFP, FCFP, FABMP, FAAFP, che era un membro del Gruppo di esperti per il
Consenso ed ha contribuito al processo di revisione ma non non è stato in grado di partecipare alla
riunione di Consenso. Ci rammarichiamo sinceramente che il Dr. Mc Sherry sia venuto a mancare nel
frattempo.
Kim D. Jones, RNC, Ph D, FNP, fisiologa dell’esercizio, per il suo contributo alla sezione sull’esercizio.
Kerry Ellison, OT (non-practicing), per il suo contributo alla gestione/trattamento per i pazienti e per
l’appendice sulla valutazione della invalidità occupazionale
Hugh Scher, LLP, for his contribution to the assessing disability section
Ulteriori Ringraziamenti per questo Compendio
Il Gruppo di esperti del Consenso per la ME/CFS, per la revisione di questo compendio.
Robert J. van de Sande, B. Sc. E.E., per il design di copertina e la formattazione dell’opuscolo
Foto in copertina (ristampate con autorizzazione): Dr. Floris de Lange - sMRI voxel-based
morphometry scan; Dr.Pierre Flor-Henry – qEEG topography; PET & Xenon SPECT scans: Goldstein
JA. “Chronic Fatigue Syndromes:The Limbic Hypothesis”. pp. vi, ix © 1993 Haworth Medical Press.
Available from document delivery service: 1-800-HAWORTH [email protected]
Judith A. Brock, MA, per la lettura delle bozze
Questa traduzione e la sua pubblicazione sono state autorizzate dagli autori per scopi non di lucro.
Traduzione italiana: Daniela Salaris
A cura di: Gualtiero Zucconi
Si ringrazia la Dott.ssa Nicoletta Carlo Stella per la Revisione
ii
Carruthers, van de Sande
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SVILUPPO DEL DOCUMENTO DI CONSENSO CANADESE
INTRODUZIONE
Classificazione
Eziologia
EPIDEMIOLOGIA
Prevalenza
Decorso Naturale
LINEE GUIDA DIAGNOSTICHE
DEFINIZIONE CLINICA OPERATIVA DI CASO ME/CFS
Esclusioni
Patologie Associate
Note Applicative
SEGNI E SINTOMI
1. Fatica
2. Malessere e/o fatica post-sforzo
3. Disfunzione del sonno
4. Dolore
5. Manifestazioni Neurologiche –Cognitive
6. Manifestazioni del Sistema Nervoso Autonomo
7. Manifestazioni Neuroendocrine
8. Manifestazioni Immunitarie
Caratteristiche della ME/CFS nei giovani
VALUTAZIONE CLINICA NELLA ME/CFS
Differenze fra ME/CFS e FMS.
Differenze fra ME/CFS e disordini psichiatrici
LINEE GUIDA PER IL TRATTAMENTO
Obiettivi
Linee Guida
STRATEGIE DI AUTO-AIUTO
ESERCIZIO AUTOGESTITO
GESTIONE DEI SINTOMI E TRATTAMENTO
1. Disturbi del Sonno
2. Dolore
3. Fatica
4. Manifestazioni Cognitive
5. Manifestazioni del Sistema Nervoso Autonomo
6. Manifestazioni Neuroendocrine
7. Manifestazioni del Sistema Immunitario
Donazioni di Sangue
Immunizzazione
APPENDICE
3URILOR GHOOD 6HYHULWj GHL 6LQWRPL H GHOOD *HUDUFKLD GHOOD 6HYHULWj
Profilo del Sonno e del Dolore
Valutazione della Disabilità Occupazionale
Riferimenti/Note
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Diagnostic and Treatment Protocols. Journal of Chronic Fatigue Syndrome 11(1):7-116, 2003. © Copyright 2003, Haworth
Press Inc., Article available from The Haworth Document Delivery Service: [email protected]
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E’ importante riconoscere gli elementi caratteristici della ME/CFS, così come escludere spiegazioni
alternative per i sintomi dei pazienti
A. ANAMNESI: Deve essere stesa un’accurata anamnesi, con una descrizione completa dei sintomi del
paziente così come della loro severità e del loro impatto funzionale, prima di provare a classificarli
1. CONCENTRARSI SUI PRINCIPALI SINTOMI DELLA ME/CFS: compresi il malessere post-sforzo,
la fatica, i disturbi del sonno, il dolore e i sintomi neurologico/cognitivi, del sistema nervoso
autonomo ed endocrini e le disfunzioni immunitarie. Esaminare il decorso dei sintomi, con una
speciale attenzione al peggioramento dei sintomi dopo lo sforzo, al prolungato recupero e al
decorso fluttuante.
2. DISAGI ATTUALI ED EVENTI CHE AGGRAVANO/MIGLIORANO
• Data del’insorgenza
• Eventi scatenanti o prodomici
• Sintomi al momento della insorgenza
• Progressione dei sintomi
• Durata dei sintomi
• Gerarchia della qualità e della gravità dei sintomi attuali
• Peggioramento dei sintomi con lo sforzo: sintomi che richiedono un recupero prolungato
• Sintomi secondari e aggravatori
• Energia/Fatica (buona 100%): giorni buoni______%; giorni brutti_____%.
• Qualità del Sonno: Buona_______, moderata______, scarsa________
• Severità del dolore: assente______, media_____,moderata____, severa__
• Pesantezza totale della severità dei sintomi e livello corrente della funzionalità fisica
3. STORIA DEI TRATTAMENTI: terapie attuali, passate, prescritte e no, allergie/sensibilità
4. STORIA DELLE SENSIBILITA’ E DELLE ALLERGIE: comprese nuove sensibilità e allergie e
cambiamenti nello status di quelle preesistenti
5. ANAMNESI remota: malattie precedenti, esposizioni a tossine ambientali, sul lavoro e altre
6. ANAMNESI familiare
7. ANALISI DEI SISTEMI: Molti sintomi coinvolgono più di un sistema anatomico. Fare attenzione ai
[sistemi]
• Muscoloscheletrico: mialgia, debolezza muscolare o artralgia.
• CNS( sistema nervoso centrale): Fatica con peggioramento post-sforzo, disagi neurocognitivi,
cefalee, disturbi del sonno.
• ANS (sistema nervoso autonomo) e CARDIORESPIRATORIO: palpitazioni, dispnea da
esercizio, sintomi suggestivi di ipotensione neuronalmente mediata (NMH), sindrome di
tachicardia posturale ortostatica, intolleranza posturale ortostatica ritardata, vertigini, presincope,
disturbi respiratori, estremo pallore
• ANS E TGE e GU: disturbi intestinali o vescicali con o senza IBS (sindrome dell’intestino
irritabile)
• NEUROENDOCRINO: perdita della stabilità termostatica, intolleranza a caldo e/o freddo, marcati
cambiamenti di peso, perdita della adattabilità e tolleranza allo stress e lento recupero, labilità
emozionale.
• IMMUNITARIO: malessere generale, sensazione influenzale, mal di gola ricorrente,
ipersensibilità a cibi, farmaci e sostanze chimiche.
B. ESAME FISICO: esame fisico standard, con attenzione verso:
• Sistema Muscolo scheletrico: compreso l’esame dei tender point della Fibromialgia (appendice 6).
Esaminare le articolazioni per infiammazioni, ipermobilità e movimenti limitati. Forza muscolare:
____________, Tender Point positivi _____/18. Soddisfa i criteri della FMS_______, MPS_____
• CNS: compreso l’esame dei riflessi (l’esame dei riflessi durante flessioni e estensioni del collo può
accentuare le anomalie scaturite dai cambiamenti mielopatici cervicali).______________ Tandem
walk : in avanti_______, all’indietro________Romberg test__________________
• Cognitive: abilità nel ricordare domande, affaticamento cognitivo ( per esempio serial 7 subtraction)
e interferenze cognitive (per esempio serial 7 subtraction e tandem fatti contemporaneamente)
• Sistema Cardiovascolare: Aritmie, pressione sanguigna (BP) ( prima da sdraiati), BP
(immediatamente dopo essersi alzati)
• Sistema TGE: aumentati rumori intestinali, gonfiori addominali e/o sensibilità
• Sistema endocrino: disfunzioni della tiroide, surrenale e ipofisi
• Sistema Immunitario: sensibile linfoadenopatia nelle regioni cervicale, ascellare e inguinale
(specialmente in fase acuta
Arrossamenti a mezza luna nella fossa tonsillare
C. PROTOCOLLO DI LABORATORIO E INVESTIGATIVO: deve essere fatto un accurato collegamento.
• Test di laboratorio di routine: Emocromo, VES , Calcio, Potassio, Magnesio, Glicemia, elettroliti
del plasma, TSH,elettroforesi sierica proteica, Proteina C-reattiva, ferritina, creatinina, fattore
8
Carruthers, van de Sande
8QD 'HILQL]LRQH &OLQLFD Gi &DVR H /LQHH *XLGD SHU 0HGLFL 6SHFLDOLVWL
reumatico, anticorpi antinucleo (ANA), Creatinofosfochinasi e funzionalità epatica, così come le
analisi delle urine di routine.
TEST AGGIUNTIVI: in aggiunta ai test di laboratorio di routine, devono essere fatti test aggiuntivi
su una base individuale che dipende dalla anamnesi del paziente, dalla valutazione clinica, gli esami
di laboratorio, i fattori di rischio e le condizioni patologiche concomitanti.
•
Ulteriori test di laboratorio: livelli diurni di cortisolo, cortisolo libero nelle urine delle 24 ore; ormoni
che comprendono Testosterone libero, livelli di B12 e folati, DHEA solfato, screen del 5-HIAA,
ecografia addominale, esami feci per ricerca di uova e parassiti, attività delle cellule NK,
citofluorimetria per l’attività dei linfociti, Western Blot test per la malattia di Lyme, radiografia del
torace, PPD test e HIV. Fate il test immunitario per l’RNase – L da 37-kDa.
•
Analisi della funzionalità cerebrale differenziale e test statico: per quelli con diverse positività
neurologiche.
•
Radiografie o Risonanza Magnetica di cervello e midollo spinale: per escludere la Sclerosi
Multipla (MS) e atri disordini neurologici primari. Interpretazione della Risonanza Magnetica: è
importante cercare cambiamenti che sono facilmente ignorati come gonfiori dinamici /ernie
del disco o stenosi minore, che possono essere importanti per la patogenesi.
•
Test del Tilt Table: ( Se indicato, testare prima di dare farmaci per l’intolleranza ortostatica)
•
Studiare il Sonno: per mostrare una diminuzione del tempo trascorso nella fase 4 del sonno o
escludere disfunzioni del sonno curabili.
•
qEEG, Scansioni SPECT e PET e Spettrografia: se indicati
•
Monitoraggio Holter delle 24 ore: l’oscillazione ripetuta delle onde T di inversione e/o delle onde
T piatte durante il monitoraggio delle 24 ore. Nota: questo elemento non può essere descritto o
incluso se ci sono cambiamenti aspecifici delle onde T
_____ ME/CFS: se la presentazione del paziente soddisfa i criteri per la ME/CFS, classificate la diagnosi
come ME/CFS, eccetto quando sono presenti altre specifiche esclusioni.
_____ FATICA CRONICA IDIOPATICA: fatica cronica che non soddisfa i criteri per ME/CFS o che ha una
spiegazione alternativa.
SINTOMI NUOVI: Le persone con ME/CFS possono sviluppare altri problemi medici.
I nuovi sintomi devono essere appropriatamente investigati.
Carruthers BM, Jain AK, De Meirleir KL, Peterson DL, Klimas NG, Lerner AM, Bested AC, Flor-Henry P, Joshi P, Powles ACP, Sherkey
JA, van de Sande MI. MYALGIC ENCEPHALOMYELITIS/CHRONIC FATIGUE SYNDROME: Clinical Working Case Definition,
Diagnostic and Treatment Protocols. Journal of Chronic Fatigue Syndrome 11(1):7-116, 2003, pp.105-6. © Copyright 2003, Haworth
Press Inc., Journal of Chronic Fatigue Syndrome. Available from Haworth Document Delivery Service: 1-800-722-5857,
[email protected] www.HaworthPress.com Patient Evaluation Worksheet reprinted slightly condensed, with permission.
Una diagnosi chiara ha spesso un considerevole beneficio terapeutico, dato che riduce l’incertezza e
orienta la terapia. Una diagnosi precoce può aiutare nel ridurre l’impatto della ME/CFS.
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Carruthers BM, Jain AK, De Meirleir KL, Peterson DL, Klimas NG, Lerner AM, Bested AC, Flor-Henry P, Joshi P,
PowlesACP, Sherkey JA, van de Sande MI. Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: Clinical
Working Case Definition, Diagnostic and Treatment Protocols. J CFS 11(1):7-115, 2003.
Patarca-Montero R, Mark T, Fletcher M, Klimas NG. The immunology of chronic fatigue syndrome.
J CFS 6(3/4):59-107, 2000.
De Meirleir K, Bisbal C, Campine I, et al. A 37 kDa 2-5A binding protein as a potential biochemical marker for chronic
fatigue syndrome. Am J Med 108(2):99-105, 2000.
Vojdani A, Choppa PC, Lapp CS. Downregulation of RNase L inhibitor correlates with upregulation of interferon-induced
proteins (2-5A synthetase and RNase L) in patients with chronic fatigue immune dysfunction syndrome.
J
Clin Lab Immunol 50(1):1-16, 1998.
Kaushik N, Fear D, Richards SCM, et al. Gene expression in peripheral blood mononuclear cells from patients with
chronic fatigue syndrome.
J Clin Pathol 58:826-832, 2005.
Jason LA, Richman JA, Rademaker AW, et al. A community-based study of Chronic Fatigue Syndrome.
Arch Intern Med 159:2129-2137, Oct. 1999.
Joyce J, Hotopf M, Wessely S. The prognosis of chronic fatigue and chronic fatigue syndromes: a systematic review.
QJ Med 90:223-233, 1997.
Jason LA, Torres-Harding SR, Jurgens A, Helgerson J. Comparing the Fukuda et al. Criteria and the Canadian Case
Definition for Chronic Fatigue Syndrome. J CFS 12(1):37-52, 2004.
Jason L, in Munson P, editor. Stricken: Voices from the Hidden Epidemic of Chronic Fatigue Syndrome. Haworth
Press, New York 2000, p 4.
Snell CF, Vanness JM, Stayer DR, Stevens SR. Exercise capacity and immune function in male and female patients
with chronic fatigue syndrome (CFS). In Vivo 19(2):387-90, Mar-Apr. 2005.
van de Sande MI. ME/CFS and post-exertional malaise and exercise. Quest #60, National ME/FM Action Network,
2003.
Fukuda K, Straus SE, Hickie I, et al. Chronic Fatigue Syndrome: a comprehensive approach to its definition and study.
Annals Med 121:953-959, 1994.
De Becker P, Roeykens J, Reynders M, et al. Exercise capacity in chronic fatigue syndrome. Arch Intern Med
160(21):3270-3277, Nov. 27, 2000.
Inbar O, Dlin R, Rotstein A, et al. Physiological responses to incremental exercise in patients with chronic fatigue
syndrome. Med Sci Sports Exer 33(9):1463-1470, Sept. 2001.
Goldstein J. A. Chronic Fatigue Syndrome: The Limbic Hypothesis. Haworth Medical Press, Binghampton NY 1993,
pg. 116.
Streeten DH. Role of impaired lower-limb venous innervation in the pathogenesis of the chronic fatigue syndrome.
Amer J Med Sci 321:163-167, Mar. 2001.
Goldstein JA. CFS and FMS: Dysregulation of the limbic system. FM Network Oct 1993, pp 10-11
La Manca JJ, Sisto SA, DeLuca J, et al. Influence of exhaustive treadmill exercise on cognitive functioning in chronic
fatigue syndrome. Am J Med 105(3A):59S-65S, Sept 27, 1998.
De Becker P, McGregor N, De Meirleir K. A definition-based analysis of symptoms in a large cohort of patients with
chronic fatigue syndrome. J Inter Med 250:234-240, 2001.
Boda WL, Natelson BH, Sisto SA, Tapp WN. Gait abnormalities in patients with the chronic fatigue syndrome. J
Neurol Sci 131(2):156-161, Aug. 1995.
Fischer B, Le Bon O, Hoffmann G, et al. Sleep anomalies in the chronic fatigue syndrome. A comorbidity study.
Neuropsychobiol 35(3): 115-122, 1997.
Moldofsky H. Fibromyalgia, sleep disorder and chronic fatigue syndrome. CIBA Foundation Symp 173:262-279,
1993
Bennett RM. Fibromyalgia, chronic fatigue syndrome, and myofascial pain. Cur Opin Rheum 10(2):95-103, 1998.
Tirelli U, Chierichetti F, Tavio M, et al. Brian positron emission tomography (PET) in chronic fatigue syndrome:
preliminary data [in process citation]. Amer J Med 105(3A):trS-t8S, Sept. 28, 1998.
Costa DC, Tannock C, Brostoff J. Brainstem perfusion is impaired in chronic fatigue syndrome. Q J Med 88:767-773,
1995.
Ichise M, Salit I, Abbey S, et al. Assessment of regional cerebral perfusion by Tc-HMPAO SPECT in Chronic Fatigue
Syndrome. Nuclear Med Commun 13:767-772, 1992
Lange G, Wang S, DeLuca J, Natelson BH. Neuroimaging in chronic fatigue syndrome. Am J Med 105(3A):50S-53S,
1998.
Buchwald D, Cheney PR, Peterson DL, et al. A chronic illness characterized by fatigue, neurologic and immunologic
disorders, and active human herpes virus type 6 infection. Ann Intern Med 116(2):103-113, 1992.
8Q &RPSHQGLR GHO 'RFXPHQWR GL &RQVHQVR &DQDGHVH
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29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
de Lange F, Kalkman J, Bleijenberg G, et al. Gray matter volume reduction in the chronic fatigue syndrome.
NeuroImage 26:777-781, 2005.
Okada T, Tanaka M, Kuratsune H, et. Al. Mechanisms underlying fatigue: A voxel-based morphometric study of
chronic fatigue syndrome. BMC Neurol 4: 14, 2004.
Mahurin RK, Buchwald DS, et al. AACFS 5th International Research & Clinical Confer., Seattle, Jan. 2001, 088.
Lange G, Stefferner J, Cook DB, et al. Objective evidence of cognitive complaints in Chronic Fatigue Syndrome: A
BOLD fMRI study of verbal working memory. Neuroimage 26(2):513-24, Jun 1, 2005.
Flor-Henry P, Lind J, Morrison J, et al. Psychophysiological and EEG findings in chronic fatigue syndrome. [Abstract]
Presented at IPEG International Pharmaco-EEG Society-11th Biennial Congress on Pharmaco-EEG, Vienna,
Austria 2000 Sept 1-3. Published in Klinische Neurophyiologie 32(1):46-65, 2001.
Lange G, Holodny AI, Lee HJ, et al. Quantitative assessment of cerebral ventricular volumes in chronic fatigue
syndrome. Appl Neuropsychol 8(1):23-30, 2001.
Bruno RL, et al. Polio Encephalitis and brain generator model of Post Viral Fatigue. 3CFS 2(2,3):5-27, 1996
Streeten DH, Tomas D, Bell DS. The Roles of orthostatic hypotension, orthostatic tachycardia and subnormal
erythrocyte volume in the pathogenesis of the chronic fatigue syndrome. Am J Med 320(1):1-8, Jul 2000.
Peckerman A, LaManca JJ. Dahl KA, et al. Abnormal impedance cardiography predicts symptom severity in Chronic
Fatigue Syndrome. Amer Med Science 326(2):55-60, Aug 2003.
Codero DL, Sisto SA, Tapp WN, et al. Decreased vagal power during treadmill walking in patients with chronic fatigue
syndrome. Clin Auton Res 6(6):329-333, 1994.
Demitrack MA, Crofford LJ. Evidence for and pathophysiologic implications of hypothalamic-pituitary-adrenal axis
dysregulation in fibromyalgia and chronic fatigue syndrome. Ann N Y Acad Sci 840:684-697, May 1, 1998.
Lerner AM, Zervos M, Dworkin HJ, et al. New cardiomyopathy: pilot study of intravenous Ganciclovir in a subset of
the chronic fatigue syndrome. Infec Dis in Clin Pract 6:110-117, 1997.
Ablashi DV, Eastman HB, Owen CB, et al. Frequent HHB-6 antibody and HHV-6 reactivation in multiple sclerosis MS)
and Chronic fatigue syndrome (CFS) patients. J Clin Virol 16(3):179-191, May 1 2000.
Roelens S, Herst CV, D’Haese A, et al. G-actin cleavage parallels 2-5A-Dependent RNase L cleavage in peripheral
blood mononuclear cells-relevance to a possible serum-based screening test. J CFS 8(3/4):63-82, 2001.
Maher K, Klimas N, Fletcher MA. Flow cytometric measurement of perforin and natural killer cell activity. AACFS Fifth
International Research & Clinical Conference, Seattle, Jan. 2001, #47
TEACH-ME Task Force. TEACH-ME: A Sourcebook for Teachers of Young People with Myalgic Encephalomyelitis/
Chronic Fatigue Syndrome and Fibromyalgia Syndrome. Second Edition. National ME/FM Action Network, 2005.
www.mefmaction.net
Dowsett EG, Colby J. Long-term sickness absence due to ME/CFS in UK schools: an epidemiological study with
medical and educational implications. 3CFS 3(2):29-42, 1997.
Sharpe MC, in Demitrak MA, Abbey SE (editors). Chronic Fatigue Syndrome. Guilford Press, NY 1996, pp. 248.
Wessley S, Nimnuan C, Sharp M. Functional somatic syndromes: one or many? Lancet 354(9182):936-939,
Sept 11, 1999.
Komaroff AL. The biology of the Chronic Fatigue Syndrome. Amer Med 108:99-105, Feb 2000.
Sheperd C. Pacing and exercise in chronic fatigue syndrome. Physiother 87(8):395-396, Aug. 2001.
De Meirleir K, De Becker P, Campine I. Blood transfusion and chronic fatigue syndrome. (Abstract) Presented at the
CFS Conference, Sydney, Australia,1999.
Waylonis GW, Ronan PG, Gordon C. A profile of fibromyalgia in occupation environments. Am iPhys Med Rehabil
73:112- 115, 1994.
Questo breve compendio fornisce soltanto i punti cardine da:
Myalgic Encephalomyelitis/ Chronic Fatigue Sindrome: Clinical Working Case Definition,
Diagnostic and Treatment Protocols. A Consensus Document.
Carruthers BM, Jain AK, De Meirleir KL, Peterson DL, Klimas NG, Lerner AM, Bested AC,
Flor-Henry P, Pradip Joshi, Powles ACP, Sherkey JA, van de Sande MI.
Journal of Chronic Fatigue Sindrome 11(1):7-115, 2003.
Il Documento di Consenso Completo è fortemente raccomandato come manuale informativo
per medici generici.
20
Carruthers, van de Sande
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