Comprehensive Approach to Fatigue Evaluation in a Patient Who Emigrated from Ethiopia as a Child
A thorough fatigue workup for a patient who emigrated from Ethiopia as a child must include specific testing for endemic diseases, nutritional deficiencies, and parasitic infections alongside standard fatigue evaluation protocols. 1
Initial Assessment
Quantify Fatigue Severity
- Use a 0-10 numeric rating scale:
- 0 = no fatigue
- 1-3 = mild fatigue (requires education only)
- 4-6 = moderate fatigue (requires evaluation)
- 7-10 = severe fatigue (requires prompt evaluation) 1
Focused History
- Onset, pattern, duration, and change over time
- Associated or alleviating factors
- Interference with daily function and activities
- Patient's self-assessment of potential causes 1
- Immigration history: age at immigration, living conditions in Ethiopia, access to healthcare before immigration
- Family history of endemic diseases from Ethiopia
Laboratory Workup
First-Line Testing
- Complete blood count with differential (to assess for anemia, infection, hematologic malignancies) 1
- Comprehensive metabolic panel (to evaluate electrolytes, renal and liver function) 1
- Thyroid-stimulating hormone (TSH) testing 1
- Urinalysis 1
- Fasting blood glucose or glycohemoglobin 1
- Serum calcium and magnesium 1
Additional Testing Based on Ethiopian Origin
- Parasitic infection screening:
- Stool ova and parasites (three samples)
- Serology for schistosomiasis
- Malaria thick and thin smears
- Tuberculosis screening:
- Interferon-gamma release assay (IGRA) or tuberculin skin test
- Chest radiograph (PA and lateral) 1
- Nutritional assessment:
- Vitamin B12, folate levels
- Vitamin D levels
- Iron studies (ferritin, iron, TIBC)
- HIV testing
Evaluation of Common Contributing Factors
Medical Conditions
- Anemia (particularly iron deficiency, common in Ethiopian populations)
- Endocrine disorders (thyroid dysfunction, diabetes)
- Chronic infections (tuberculosis, parasitic infections, HIV)
- Autoimmune conditions
- Sleep disorders (obstructive sleep apnea, insomnia) 1, 2
Psychological Factors
- Depression and anxiety screening
- Post-traumatic stress disorder assessment (particularly if immigration was related to conflict or trauma)
- Acculturation stress assessment 1
Lifestyle Factors
- Sleep hygiene evaluation
- Physical activity assessment
- Nutritional intake and dietary patterns
- Substance use (alcohol, caffeine, khat) 2
Medication Review
- Current medications that may cause fatigue
- Over-the-counter supplements and traditional remedies 1
Special Considerations for Immigrants from Ethiopia
- Parasitic infections may persist for years after immigration
- Latent tuberculosis is common in Ethiopian immigrants
- Nutritional deficiencies may be present due to dietary patterns
- Cultural beliefs about illness may influence symptom reporting and treatment adherence
Management Approach
- Address identified medical conditions first
- Manage pain, emotional distress, and sleep disturbances
- Review and modify medications with sedating side effects 1
- Implement structured physical activity plan with stretching and aerobic exercise (unless ME/CFS is suspected) 1, 2
- Provide education about fatigue patterns and energy conservation
- Consider cognitive behavioral therapy for chronic fatigue 1
- Treat depression if present with selective serotonin reuptake inhibitors 1, 3
Follow-up
- Schedule regular follow-up visits rather than sporadic urgent appointments 3
- Reassess fatigue severity at each visit
- Monitor response to interventions
- Adjust treatment plan based on response
Common Pitfalls to Avoid
- Failing to consider parasitic infections that may be endemic to Ethiopia
- Overlooking cultural factors that may influence symptom reporting
- Assuming fatigue is psychosomatic without thorough medical evaluation
- Recommending aggressive exercise without ruling out ME/CFS (which can worsen with exercise due to post-exertional malaise) 1, 2
- Dismissing fatigue as normal without thorough evaluation
Remember that previously undiagnosed cancer accounts for only 0.6% of fatigue cases, and other organic causes represent only about 4.3% 1, but the Ethiopian background warrants special attention to infectious and nutritional causes that may be more prevalent in this population.