Excessive fatigue - could this be CFS?

[flutter7]

I'm a 25yr old female, experiencing excessive fatigue for the past 10yrs. This began after developing glandular fever from the Epstein-Barr Virus. Ever since, I have had problems maintaining a normal sleep-wake cycle. I have tried many things to change this, yet I always slip back into this pattern. I have periods where I sleep for days and others where I still feel tired after sleeping for 10+hrs. I always felt I was a deep sleeper and slept quite well. I also experience hot flushes, which come and go. Even though I did not feel depressed, my doctor thought I could have depression and trialled numerous antidepressants over the years, in the hope it would cure my fatigue. However they didn’t.

Six months ago, I had a sleep study, where I was diagnosed with moderate sleep apnoea due to hypopnoeas, particularly during REM sleep. Sleep architecture showed a deficit of REM sleep with severe sleep fragmentation found.  ECG maintained sinus rhythm with some sinus arrhythmia related to the arousals. Mean hypopnoea was 24.8 sec; longest hypopnoea was 47.7sec with 48.5 arousals per hour.

I then trialled CPAP, and a follow up sleep study showed that this treated my hypopnoeas. However, I have found no relief from my fatigue.  I have had further testing done which shows I am still anaemic (I have been anaemic since I was 10yrs old and have taken iron supplements ever since.  It was only after contracting the Epstein-Barr Virus at 15yrs that I felt fatigued anyway).  I have mild diffuse enlargement of my thyroid, however all my blood tests for my thyroid levels have come back normal.  Earlier last year I was diagnosed with seronegative spondyloarthropathy after having blood tests and a bone scan.  I am also HLA B27 positive.  My ESR and CRP have been up for the past few years, most recently my ESR got to 24 and CRP to 9.

My Dr's do not feel any of this could be causing the high levels of fatigue I have been experiancing. I'm lost for answers and want to sort this out.

[Steven Y Park, MD]

Your sleep apnea is most likely due to multiple areas of narrowing and collapse from your nose to your tongue. Treating your nose may be useful of you're stuffy. If you have a hard time breathing through your nose, see an ENT doctor to take care of that problem, as this can affect the effectiveness of CPAP treatment. In most cases opening up your nose won't cure sleep apnea.

Chronic fatigue syndrome is a generic description of any medical condition that leads to chronic fatigue. In your case, the EBV virus probably triggered it (by enlarging your lymphoid tissues like your tonsils) but is not what's continuing to cause your fatigue. In your case, due to your already narrowed airways (since you know you have sleep apnea), the extra swelling in your throat causes a vicious cycle where continued apneas or hypopneas bring up minimal amount of stomach juices which causes more inflammation.

Also, your nervous system is en garde all the time and very hypersensitive by definition (as evidenced by your very high arousal index). Although CPAP can help to get rid of the apneas and hypopneas, it doesn't prevent the micro-obstructions and arousals that don't get counted as apneas or hypopneas. Your hot flashes are a result of this involuntary nervous system imbalance.

As a result of your inefficient sleep and multiple arousals, a low-grade stress response is created, potentially leading to other physiologic changes, including hormonal issues (a big topic in itself).

I suggest you read some of the articles that I have posted on this site on sleep apnea and upper airway resistance syndrome.  

[flutter7]

Hi Dr Park,

Thanks for your speedy and detailed response.  I do have a stuffy nose which is always a bit runny (not allergy related).  Most of the time I have a blocked nostril, which alternates to the other side being blocked.  My father has had this too his whole life but his problem is far worse than mine.

My GP looked up my nose and said my left nostril was blocked and sent me off for a sinus CT scan, revealing a bony spur.  When I went back with my result, my GP said it's not a significant problem and refused an ENT referral.  Should I try to see someone else to get a referral or was their advice correct?  I am still waiting to see the sleep doctor for an appointment to speak about my sleep apnea and nose (been waiting 6 months - 3 more months wait).  Even though he does the sleep reports, I have only been able to deal with the sleep techs/nurses so far in regards to CPAP and advice.

What would be an effective treatment for my micro-obstructions and arousals if CPAP does not treat these?

Thankyou.

[flutter7]

I also forgot to mention that I had a CT examination of the paranasal sinuses, which showed a nasal septum bony spur which deviates to the right of the midline.  The body spur abuts the inferior nasal turbinate on the right.  I would also like to know if that could be contributing to or affecting my sleep apnoea.  Thank you.