Main diagnostic criteria and guidelines

Discussion in 'Diagnostic Criteria and Naming Discussions' started by Cheshire, Oct 22, 2017.

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  1. Cheshire

    Cheshire Moderator Staff Member

    Diagnostic criteria

    There are numerous diagnostic criteria for ME and CFS. Below are links to the articles defining the main ones.

    Post-exertional malaise (PEM) is now considered by most researchers to be a core symptom of ME/CFS. Some diagnostic criteria (Holmes, Oxford and Fukuda criteria) that do not require it, have thus been criticised for not diagnosing the right disease population. The Oxford criteria are the most problematic. Largely used in the psychosocial research field, they have been described as "flawed" and unreliable (as they "include people with other conditions") by the NIH, who added they should be retired.

    The Holmes criteria (CDC)
    Chronic fatigue syndrome: a working case definition.
    Holmes GP, Kaplan JE, Gantz NM, Komaroff AL, Schonberger LB, Straus SE, Jones JF, Dubois RE, Cunningham-Rundles C, Pahwa S, et al.
    Ann Intern Med.
    Link to article

    1. New onset of persistent or relapsing, debilitating fatigue or easy fatigability in a person who has no previous history of similar symptoms, that does not resolve with bedrest, and that is severe enough to reduce or impair average daily activity below 50% of the patient's premorbid activity level for a period of at least 6 months.
    2. Other clinical conditions that may produce similar symptoms must be excluded by thorough evaluation, based on history, physical examination, and appropriate laboratory findings. (see complete exclusion list in the article)


    Mild fever, sore throat, painful lymph nodes, muscle weakness and myalgia, headaches, arthralgia, neuropsychologic complaints, sleep disturbance, rapid onset.
    PEM described as: Prolonged (24 hours or greater) generalized fatigue after levels of exercise that would have been easily tolerated in the patient's premorbid state.
    PEM, described as "fatigue" following low level effort, is a "minor criteria".

    The Oxford criteria
    A report--chronic fatigue syndrome: guidelines for research.
    Sharpe MC, Archard LC, Banatvala JE, Borysiewicz LK, Clare AW, David A, Edwards RH, Hawton KE, Lambert HP, Lane RJ, et al
    J R Soc Med.
    Link to article
    Severe disabling fatigue of at least a 6-month duration that affects both physical and mental functioning, and that is present for more than 50% of the time.
    Other symptoms may be associated (mainly myalgia, sleep and mood disturbances).

    Exclusion criteria:

    Psychiatric disorders that can cause fatigue (but not uncomplicated major depression).
    PEM is not required.

    The Fukuda criteria (CDC)
    The Chronic Fatigue Syndrome: A Comprehensive Approach to Its Definition and Study
    K Fukuda Steven E Straus Ian Hickie Michael Sharpe Anthony L Komaroff
    American College of Physicians
    Link to article

    1. Clinically evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reducation in previous levels of occupational, educational, social, or personal activities.

    2. The concurrent occurrence of four or more of the following symptoms:
    • substantial impairment in short-term memory or concentration;
    • sore throat;
    • tender lymph nodes;
    • muscle pain;
    • multi-joint pain without swelling or redness;
    • headaches of a new type, pattern, or severity;
    • unrefreshing sleep; and
    • post-exertional malaise lasting more than 24 hours.
    These symptoms must have persisted or recurred during 6 or more consecutive months of illness and must not have predated the fatigue.
    PEM is optional.

    The London criteria
    London criteria for M.E., Report from The National Task Force on Chronic Fatigue Syndrome (CFS), Post Viral Fatigue Syndrome (PVFS), Myalgic Encephalomyelitis (ME).
    EG Dowsett, E Goudsmit, A Macintyre, C Shepherd, et al.
    Link to article

    Major Criteria (mandatory and present for at least 6 months)
    1. Identifiable viral illness immediately preceding the development of M.E./PVFS.
    2. Exercise-induced fatigue precipitated by trivially small exertion – physical or mental – relative to the patient’s previous exercise tolerance. Pain and coarse fasciculations in exercised muscles is common. These symptoms may sometimes be immediate or delayed for a few hours and may persist for several days.
    3. Impairment of short-term memory and loss of powers of concentration, usually coupled with other neurological and psychological disturbances such as emotional lability, nominal dysphasia, disturbed sleep patterns, vertigo or tinnitus.
    4. Fluctuation of symptoms, usually precipitated by either physical or mental exercise (see b) above.

    Minor Criteria
    (see list in the link).
    Immunological (Symptoms suggesting persistent viral infection).
    PEM is mandatory.

    The Canadian Consensus Criteria (CCC)
    Myalgic encephalomyelitis/chronic fatigue syndrome. Clinical working case definition, diagnostic and treatment protocols.
    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, A. C. Peter Powles, Jeffrey A. Sherkey & Marjorie I. van de Sande
    J Chronic Fatigue Syndr
    Link to article

    1. Fatigue:
    2. Post-Exertional Malaise and/or Fatigue:
    3. Sleep Dysfunction:
    4. Pain:
    5. Neurological/Cognitive Manifestations
    6. At least one symptom from two of the following categories (see article for complete list):
    • a. Autonomic Manifestations
    • b. Neuroendocrine Manifestations
    • c. Immune Manifestations
    7. The illness persists for at least six months.
    PEM is mandatory.

    The International Consensus Criteria (ICC)
    Myalgic encephalomyelitis: International Consensus Criteria
    B. M. Carruthers, M. I. van de Sande, K.L. De Meirleir, N. G. Klimas, G. Broderick, T. Mitchell, D. Staines, A. C. P. Powles, N. Speight, R. Vallings, L. Bateman, B. Baumgarten-Austrheim, D.S. Bell, N. Carlo-Stella, J. Chia, A. Darragh, D. Jo, D. Lewis, A.R. Light, S. Marshall-Gradisbik, I. Mena, J.A. Mikovits, K. Miwa, M. Murovska, M.L. Pall & S. Stevens
    Journal of Internal Medicine
    Link to article

    A. Post exertional neuroimmune exhaustion (PENE)
    B. At least one symptom from three neurological impairment categories
    • Neurocognitive impairments
    • Pain
    • Sleep disturbance
    • Neurosensory perceptual and motor disturbances)
    C. At least one symptom from three immune/gastro-intestinal/genitourinary impairment categories
    D. at least one symptom from energy metabolism/transport impairments categories

    See article for comprehensive list
    PEM, called PENE (Post-exertional neuroimmune exhaustion), is mandatory.

    The Institute of Medicine (IOM) criteria
    Beyond myalgic encephalomyelitis/chronic fatigue syndrome. Redefining an illness.
    Institute of Medicine.
    Link to brief report
    1. A substantial reduction or impairment in the ability to engage in pre-illness levels of occupational, educational, social, or personal activities, that persists for more than 6 months and is accompanied by fatigue, which is often profound, is of new or definite onset (not lifelong), is not the result of ongoing excessive exertion, and is not substantially alleviated by rest, and
    2. Post-exertional malaise, and
    3. Unrefreshing sleep

    At least one of the two following manifestations is also required:
    1. Cognitive impairment or
    2. Orthostatic intolerance
    PEM is mandatory.

    The DePaul Questionnaire is not a diagnostic criteria per se, but is nonetheless a usefull diagnostic tool, developped by Pr. Leonard Jason.
    Link to questionnaire


    CDC (Center for Disease Control) - USA

    NICE (National Institute for Health and Care Excellence) - UK
    Last edited: Oct 27, 2017
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