A Nineteen Year Old Ballerina with Sleep Apnea:
An Unusual Presentation
by Dr. Andrew Pugliese
Introduction
For nearly twenty years there has been an association between Chronic Fatigue Syndrome (CSF) and Epstein Barr virus (EBV) titers; however, the clinical significance has been debatable. In most instances, most patients with CFS do recall a febrile illness prior to their fatigue symptoms beginning. Recent findings suggest that post-infectious fatigue can be associated with CFS. The following case demonstrates an indirect relationship between acute EBV or infectious mononucleosis and CFS.
Case Report
A nineteen year old ballerina presented with a three-year history of overwhelming fatigue that began at the age of sixteen after having documented mononucleosis. According to the patient and her mother, she could sleep for ten hours which was not restorative, eat breakfast and return to bed. Despite this, the patient was able to finish high school and continue with her ballet career. The patient was also auditioning for a dance troupe in New York City and was concerned with her ability to keep up if she was accepted.
Over the past three years, she had seen many different specialists with the only laboratory finding being elevated Epstein-Barr titers. Since no other laboratory findings could be associated with her symptoms in most instances the diagnosis was Chronic Fatigue Syndrome or Chronic Epstein-Barr. This was the reason for the patient to come to an infectious disease practice to see about the possibility of anti-viral therapy.
Physical exam revealed a petite age-appropriate woman though slightly frustrated who was engaging and pleasant. The only pertinent physical finding was 4+ bilateral tonsillar hypertrophy.
Diagnosis & Management:
During follow-up, the patient raised concerns about the feasibility of using CPAP with her demanding schedule and how awkward she felt using the machine. She was then referred to an otolaryngology for possible tonsillectomy, which was performed. Since then the patient has been able to continue with her ballet career and significantly less fatigue.
Discussion:
Chronic Fatigue Syndrome (CFS) was first described in 1988, and has been described as a debilitating disease with symptoms of fatigue, myalgias and sleep disturbances. Since its origin, CFS has gone through several evolutionary changes including being called the “yuppie flu” and Chronic Epstein-Barr Syndrome. The name became the standard based on the fact that most patients had elevated EBV serologies. Recent studies, however, have suggested that other pathogens such as enteroviruses, parvovirus B19, Coxiella burnetti and Chlamydia pneumoniae may be involved.
In many instances, because of the debilitating fatigue which has a significant impact on social, educational, personal and occupational status CFS has been misdiagnosed as depression. Despite investigating this disease now for over twenty years there is still controversy on pathogenesis and clinical definition. Though it appears that the central nervous system is involved it is not clear whether or not these findings are cause or consequences of the disease as well as genetics and the immune system.
One common complaint with CFS is sleep disturbances. One study found that 20% of patients initially diagnosed with CFS had an underlying sleep disorder. Another study found that certain specifics were related to subtle undiagnosed sleep-disordered breathing in patients with CFS.
In the case being described, I believe the patient’s chronic fatigue was indirectly caused by infectious mononucleosis. In this case mononucleosis caused irreversible tonsillar hypertrophy which leads to the subsequent obstruction and sleep apnea.
Reasons why OSA was not considered in this patient I believe is three-fold:
- OSA due to tonsillar hypertrophy is well described in the pediatric literature, not the adult.
- The patient is not the stereotypical adult we would suspect sleep apnea in.
- There is a recent phenomenon described in the medical literature known as, “diagnosis momentum”, where the diagnosis is passed from clinician to clinician and never questioned.
It is possible that in this case, some “diagnostic momentum” occurred.
In conclusion, we as clinicians must be vigilant towards atypical presentations, especially when the patient appears healthy and athletic. By avoiding stereotypes and not engaging in “diagnostic momentum” it is possible for us to help many patients diagnosed with chronic fatigue.
Cited:
[1] Antibodies to Epstein-Barr virus in patients with chronic fatigue. Matthews DA, Lane TJ, Manu P. South Med J. 1991 Jul; 84(7):832-40.
[2] Post-infective and chronic fatigue syndromes precipitated by viral and non-viral pathogens: a prospective cohort study. Hickie I, Davenport T, Wakefield D, Vollmer-Conna U, Cameron B, Vernon SD, Reeves WC, Llyod A. BMJ. 2006 Sep 16; 333(7568): 575.
[3] Fibromyalgia and Chronic Fatigue Syndrome: An Update for Athletic Trainers. Cramer CR, J Athl Train. 1998 Oct; 33(4): 359-361.
[4] Serologic and virologic epidemiology of Epstein-Barr virus: relevance to chronic fatigue syndrome. Sumaya CV. Rev Infect Dis 1991 Jan-Feb; 13 Suppl S19-25.
[5] Chronic Fatigue Syndrome Devanur LD, Kerr JR. J Clin Virol. 2006 Nov; 37(3): 139-50.
[6] A Systemic Review of Chronic Fatigue Syndrome: Don’t Assume its Depression. Griffith JP, Zarrouf FA. Prim Care Companion J Clin Psychiatry. 2008; 10(2): 120-8.
[7] Chronic fatigue syndrome: an update focusing on phenomenology and pathophysiology. Cho HJ, Skowera A, Cleare A Wessely S. Curr Opin Psychiatry. 2006 Jan; 19(1):67-73.
[8] Ibid.
[9] A population-based study of the clinical course of chronic fatigue syndrome. Nisenbaum R, Jones JF, Unger ER, Reyes M, Reeves WC. Health Qual Life Outcomes. 2003 Oct. 3;1:49.
[10] Chronic Fatigue, Unrefreshing Sleep and Nocturnal Polysomnography, Sleep Med 2006 Sep;7(6):513-20.
[11] Mindful Medicine: Don’t Let Emotion Impede Right Diagnosis, Groopman J, Hartzband P. ACP Internist, Sept. 2008 Vol. 28, No.8, pg. 5
