Journal Club:

Article: Orthostatic intolerance in adolescent chronic fatigue syndrome. Stewart J, Gewitz MH, Weldon A, Arlievsky N, Li K, Munoz J. Pediatrics 1999; 103:116-121.

Review by David S. Bell, MD, FAAP

Published in Lyndonville News, July 2000

Summary: The purpose of the study was to establish the relationship between CFS and orthostatic intolerance (OI) in a group of adolescents diagnosed with CFS by the CDC criteria. 26 adolescents with CFS were compared to adolescents evaluated for simple faint and healthy controls using blood pressure and pulse measurements on a tilt table. Only one CFS patient had normal values, the remainder having severe orthostatic symptoms combined with syncope, orthostatic tachycardia, and orthostatic hypotension. 72% of the CFS patients had abnormal physical examination during head up tilt consisting of blue and swollen legs suggestive of excessive venous pooling. The results on this testing showed clear differences between the three groups.

Discussion and Opinion: Orthostatic intolerance is clearly becoming an area where objective findings correlate with subjective symptoms in defining an illness that has loosely been termed chronic fatigue syndrome. Perhaps, of greatest importance is that now there exists a possibility that specific subgroups of CFS may be defined, an area that was never very productive when abnormal immunology was used to stratify patients. Most importantly, studies in this area may help define more rational diagnostic criteria for the illness.

Hypotension was defined as >30 mmHG drop in systolic blood pressure, and orthostatic tachycardia was defined as >30 bpm increase in pulse. Systematic analysis of narrowing of pulse pressure was not done in this paper, but I feel that it is possible that further differentiation from normal adolescents and fainters will be possible with this addition. It remains to be seen whether results with the "poor man's tilt" described by Dr. Streeten will be the same, but casual review of about thirty adolescents done in our office shows striking similar results. (This test requires no tilt table and is carried out by monitoring pulse and BP during quiet standing).

Healthy adolescents will faint on tilt table testing, and 23% did so in this study. However the episodes differed from syncope of CFS as the healthy controls had syncope characterized by a decrease in blood pressure and decreased pulse known as vasodepressor or cardioinhibitory syncope. "Fainters" who are otherwise healthy had similar episodes. Of the CFS patients, only one had had a true syncopal event prior to the study, a detail that I would agree with. Most CFS patients will have lightheadedness and dizziness on change of position, but rarely lose consciousness.

The importance of this study is great. It is no longer appropriate for anyone to say that there are no objective abnormalities found in adolescents with CFS. 96% of adolescents with the diagnosis of CFS had the symptoms of orthostatic intolerance (fatigue, dizziness, weakness, headache, sweating, nausea and vomiting) combined with observed abnormalities (confusion, loss in tone, syncope, and excessive venous pooling) while demonstrating objective abnormalities in pulse in blood pressure.

Return to the Lyndonville News Archive

Return to the CFS Page

Home	News	Forum	Contribute	Store	Articles	Links	Help
The Pediatric Network website and forum are run by Mary Robinson and Rebecca Moore. When you follow links on our site to Amazon.com and make purchases, a portion of the sales cost supports our work. Visit our store for shopping suggestions:  gifts for kids or parents, tools for adapting activities, medical and special education books, coping strategies, and more.

Disclaimer: The views in this website and forum are the feelings and opinions of the individual authors and do not necessarily reflect all of the current theories that are being explored and published. Ask your doctor or other health care provider about all medical information that you consider applying to your situation, including the information you read in our website and forum. We take no responsibility for the decisions you or your family members make about medical care. It is up to you to verify that the information you read is correct and applies to your unique situation.