Medical mystery: Unexplained fatigue after a European trip

Two weeks after returning from a summer in Italy, Barbara Veltri began to feel debilitating fatigue. The 61-year-old complained of pain in multiple joints, and her hair was noticeably dry and brittle. Before and during the trip, she was symptom-free.

Veltri’s regular doctor assumed jet lag was to blame, and recommended she take over-the-counter analgesics for the pain, and prescribed sleep aids for the fatigue. The medications did not help what she described as “life disruptive” pain.

Veltri came to me with her pain symptoms. I suspected a medical cause, other than primary pain or orthopedic, and recommended she get a full blood workup.

Diagnosis and treatment of fatigue, which can be chronic, may be difficult, as it is a common complaint. The fatigue can be accompanied by depression, pain, and emotional distress, all of which Veltri was experiencing. Often, these symptoms can be attributed to overwork, both physical and psychologic in nature. Other diseases, such as diabetes or heart and lung ailments, can exacerbate the symptoms and sometimes result in a delay of a true diagnosis. Additionally, chronic fatigue may be caused by infection with the Epstein-Barr virus, causing chronic pain, tension headaches, or multi-joint pain.

Chronic fatigue, or adrenal fatigue syndrome, was first coined by James Wilson, a chiropractor. Various over-the-counter supplements have been prescribed or recommended for this syndrome, with inconsistent success.

Adrenal disease and hormonal imbalances can also result in the symptoms Veltri was experiencing. Frustrated, she returned to her regular doctor. He tested for Epstein-Barr infection, and a complete blood profile, including a thyroid panel and a cortisol level. All her results came back as normal, except the cortisol level, which was extremely low. This proved to be a key piece of information in finding a diagnosis.

Low cortisol levels can indicate improper adrenal gland function, and are often associated with fatigue. There can be many causes of adrenal dysfunction. Her physician prescribed an oral corticosteroid, prednisone, which helped her energy level immediately. He instructed her to slowly taper the dose down over the course of six weeks. This, combined with the over-the-counter analgesics for the joint pain, helped Barbara begin to feel better.

She was then instructed to go to an endocrinologist for further testing, including an abdominal CAT scan, and a brain MRI. Results from the tests ruled out the presence of an adrenal tumor and brain tumor. Also, they ran a blood test called an ACTH stimulation test, which was abnormal. ACTH (Adrenocorticotropic hormone) is produced in the pituitary gland, located in the brain. ACTH then recruits the adrenal glands to release a hormone called cortisol.

Barbara wasn’t making enough of her own cortisol, so either the pituitary gland or the adrenal gland was not working properly. Because the MRI had already ruled out a tumor of the pituitary gland, it was determined that the adrenal gland itself was not functioning properly.

Further testing would need to be done to determine what exactly was wrong with the adrenal gland, as there are various reasons why it can fail in producing hormones. Addison’s disease, which President John F. Kennedy famously had, is one cause, requiring lifelong hormonal supplementation.

Addisonian patients typically also have other blood abnormalities, including electrolyte imbalances, caused by both layers of the adrenal glands not working. This did not appear to be the case with Veltri, as her other blood values were normal.

Finally, one last blood test determined that Veltri had autoimmune antibodies detected in her blood, known as antinuclear antibodies (ANA). She was definitively diagnosed with autoimmune adrenalitis. These antibodies helped rule out other autoimmune diseases that could cause her symptoms, including not just Addison’s disease, but also multiple sclerosis and fibromyalgia. In Veltri’s case, only the cortex of her adrenal gland was attacked, unlike both parts of the gland seen under attack with Addison’s disease.

Veltri responded to replacement hormones to correct her cortisol levels, and the dose was gradually tapered and then discontinued. Autoimmune adrenalitis is not always a lifelong disease, and she seems to be in remission. She initially had blood cortisol levels rechecked every three months, all coming back as normal. Now Veltri is rechecked every six months, and she has not had a flare-up in two years.

Alfred Mauro is director emeritus of Jersey City Medical Center Anesthesia and Pain Management. He can be reached at almauro@optonline.net.