Letters to the Editor


Am Fam Physician. 2003 Jan 15;67(2):252.

Differential Diagnosis for Chronic Fatigue Syndrome

to the editor: I have just read the recent article on chronic fatigue syndrome (CFS).1 While the authors present an excellent framework for the evaluation and management of patients with chronic fatigue, they have overlooked a differential diagnosis. Celiac disease, also known as gluten-sensitive enteropathy (GSE), may present as CFS25 and is highly treatable.

A study2 reported that 2 percent of 100 patients who met diagnostic criteria for CFS actually had occult GSE. Neither patient reported symptoms typical of celiac disease and both had normal hematologic and serum protein analysis. Both patients were under treatment for hypothyroidism and were euthyroid. One article3 presents a case report of a patient with occult celiac disease who fit the criteria for CFS. This author suggested that autoantibodies against endomysium (transglutaminase) and gliadin be routinely evaluated in patients presenting with chronic fatigue. Another study4 found a high prevalence of GSE in patients with vague chronic symptoms such as fatigue and lassitude.

A review article5 on celiac disease suggests that patients with fatigue should be screened for GSE. Certainly patients with iron deficiency and symptoms such as diarrhea should be evaluated for GSE. I propose that GSE be considered in the evaluation of patients who meet the criteria for CFS.


show all references

1. Craig T, Kakumanu S. Chronic fatigue syndrome: evaluation and treatment. Am Fam Physician. 2002;65:1083–90....

2. Skowera A, Peakman M, Cleare A, Davies E, Deale A, Wessely S. High prevalence of serum markers of coeliac disease in patients with chronic fatigue syndrome. J Clin Pathol. 2001;54:335–6.

3. Empson M. Celiac disease or chronic fatigue syndrome—can the current CDC working case definition discriminate? Am J Med. 1998;105:79–80.

4. Hin H, Bird G, Fisher P, Mahy N, Jewell D. Coeliac disease in primary care: case finding study. BMJ. 1999;318:164–7.

5. Fasano A. Celiac disease: the past, the present, the future. Pediatrics. 2001;107:768–70.

Letters to the Editor

in reply: Thank you to Dr. Nelsen for bringing up this item. This would increase our differential diagnosis that must be included to successfully exclude diseases that may mimic chronic fatigue syndrome.

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This series is coordinated by Kenny Lin, MD, MPH, Associate Deputy Editor for AFP Online.



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