Sick Building Syndrome: Tired and Stuffy? Think of Your House or Your Office.

BuildingSick building syndrome is a term coined to describe symptoms associated with a structure such as an office building or house. The illness is characterized by fatigue, headache and upper-respiratory symptoms (cough, scratchy sore throat, sinus problems, etc.) Although the symptoms usually resolve when a person leaves the offending structure symptoms can persist.
The lack of fresh air is associated with respiratory tract irritation, fatigue and headaches. An office building has numerous irritants, the most pernicious of which are volatile organic chemicals. Sources of irritants include off-gassing from carpet chemicals, copying machines, insecticides, cleaning compounds, etc. Engineers are aware of the need for fresh air and are required to provide a certain inflow from external air ducts. However, there is a great temptation to reduce the external air input in cold winter months or hot summer days in an effort to reduce energy consumption.
Additionally, air taken from outside vents isn’t necessarily “fresh air.” I have investigated building where the external air intake was very close to the exhaust of diesel trucks that unload supplies for the building.
Mold is an additional and quite severe cause of troublesome building-associated symptoms. It can often be suspected by the characteristic odor of mold and is often noted in buildings with excessive humidity or history of water leaks.
The emphasis on energy conservation that started in the 1970s and construction advances have resulted in buildings and homes that can be almost air-tight. Most new office buildings do not have windows that can be opened. Additionally, the modern home can have very little fresh air intake in hot or cold months when trying to save on heating or air conditioning costs.
There is no specific test for sick building syndrome. Definitely suspect this illness as a cause of upper-respiratory complaints that clear up after you leave the building. If you feel well on weekends and poorly during the work week a building with poor air quality might be the cause. Similarly, if you feel better when you are absent from your home and have a return of symptoms when living in the home an investigation into the air quality might be quite helpful.
A symptom that is more subtle that is more subtle than a typical building-associated cough or runny nose is fatigue. Of course, fatigue in the workplace or home can be due to innumerable physical or psychological causes. However, keep in mind that that poor air quality can cause serious fatigue.
Careful observation of symptoms, the timing of the symptoms and the location can help determine in an office building or home is the cause.


Chronic Lyme Disease

Lyme disease is usually divided into three stages: early localized disease, early disseminated disease and late Lyme disease. The first stage is characterized by the characteristic rash with or without systemic symptoms such as fever, body aches and joint pains. Early disseminated disease is characterized by rashes and/or neurologic symptoms and/or heart problems. Late Lyme disease is associated with arthritis, usually involving one or a few large joints, particularly the knee, and/or neurological problems. The neurological problems can involve the brain, the covering of the brain or a specific nerve possibly creating headaches, paralysis, or nerve pain. Arthritis symptoms, particularly if only the knee is involved, can appear to be a solitary problem, with no clue that the problem is caused by Lyme disease.

Early disseminated disease occurs weeks to several months after the initial infection from the tick bite. These symptoms can be the first manifestation of Lyme disease since 20% of people with the disease do not recall any rash and approximately 25% of people with the disease do not recall a tick bite.

Late Lyme disease occurs months to years after the tick bite and, as in the case with early disseminated Lyme disease, the history of a rash or tick bite might not be present or a history of having had the earlier stages of Lyme disease. The symptoms include arthritis, predominantly of the large joints, especially the knees. Neurological symptoms can also occur.

Symptoms usually resolve gradually, as they do in most infectious diseases, after a full course of antibiotics. Post-Lyme disease syndrome refers to symptoms such as headache, muscle pain, joint pain and fatigue that persist, but generally resolve after six months to one year.

A confusing issue develops when a person who has, by all accounts, been successfully treated for Lyme disease suffers continuing health problems that do not resolve with time. This situation has been termed chronic Lyme disease by some and is the subject of much dispute.

Briefly, certain doctors and advocacy groups maintain that, in these situations, the symptoms are caused by Lyme disease that failed to be eradicated by the standard treatments. Medical authorities counter that the persisting symptoms are due to another illness that, perhaps, was triggered by Lyme disease.

The “other illness” suggested is often either fibromyalgia or chronic fatigue syndrome. Both usually respond poorly to any one of a number of medications or treatments traditionally employed. Many, if not most, physicians suspect that fibromyalgia and chronic fatigue syndrome are, at the root, psychological problems.

You can imagine how frustrated a person feels who had been totally healthy, was bitten by a tick, became ill with Lyme disease, failed to improve after treatment, and is now told he has a psychological illness! Personally, I think that the development of symptoms compatible with fibromyalgia or chronic fatigue syndrome after Lyme disease is further proof that these illnesses are not psychological.

I suspect that chronic Lyme disease is not due to the persistence of the Lyme organism, but that the Lyme organism has triggered some other illness. Therefore, additional antibiotics directed at Lyme would be pointless, and possibly harmful.

What to do? It is necessary to search for other illness triggered by Lyme. I have seen cases where Lyme triggers an arthritic illness. What initially was arthritis caused by the Lyme organism is now arthritis caused by another arthritic disease, itself triggered by Lyme. Look closely at the blood for autoimmune markers. If the symptoms suggest arthritis get treatment for arthritis even in the absence of confirmatory blood tests.

Persisting fatigue with or without bodily pain is usually the most troubling symptom for patients with “chronic Lyme disease.” Long courses of antibiotics are ,almost always, fruitless. A more productive approach is to start fresh, evaluating each symptom as a new issue using standard, individualized treatments as needed. For instance, despite the patient’s firm belief that persisting Lyme infection is causing severe fatigue treating fatigue with medications known to improve it can be very worthwhile. A creative and unprejudiced approach, as usual in medicine, offers the best chance for success.

Is my tiredness normal or do I have a problem?

Most fatigue is normal, reflecting inadequate sleep, overwork or stress. Normal fatigue is usually relieved by a good night’s rest or, at most, a relaxing weekend. When this is not the case, conditions and illnesses that cause fatigue should be considered.

As common in medicine, history is most important. How long has the fatigue been going on? When the onset can be traced to a lifestyle change – different work schedule, new marriage, etc. – the answer usually relates to the change with causes such as inadequate relaxation or new stresses.

When is the fatigue most apparent? Weekday fatigue absent on weekends would certainly suggest factors such as stress and overwork. One caveat: most fatigue, whatever the cause, improves with a good, relaxing weekend but, if the fatigue is due to an illness, the fatigue might improve over the weekend but should not be entirely gone.

Weekday fatigue might be the result of “sick building syndrome,” an often overlooked cause. Most office buildings built since the 1970s are sealed making it impossible to open a window. If the HVAC does not provide enough fresh air the irritation from air contaminated by building chemicals, mold, etc. causes nasal and sinus symptoms with resulting fatigue.

What about fatigue that is more noticeable on the weekend than during the work week? It happens more often than you might think. Assuming that the weekend is not loaded with a stress that is less apparent than that noted during the week, several factors are often responsible.

Obviously too much socializing, partying and drinking could well be the cause, but these are usually obvious to the person. A more subtle reason for fatigue more apparent on the weekend than during the week is, oddly, too much sleep. Many people get an “overslept” sensation when they sleep in on a Saturday or Sunday.

Fatigue due to too much sleep is a curiosity noted more commonly in patients with allergies and sinus problems than it is in the general population. People with this condition need a fixed amount of sleep and should not sleep more than the usual required hours.

Other causes of weekend fatigue would include allergic exposure that does not occur during the week. Outdoor activities with resultant exposure to airborne allergens can cause fatigue as well as typical allergy symptoms.

Of course, too much alcohol on the weekend can cause fatigue. Sometimes the relationship isn’t obvious. Some individuals have an allergic response to alcohol, particularly red wine, producing fatigue the following day after amounts that were quite reasonable.

If I’m not fatigued on a vacation does that mean my fatigue is due to stress? Not necessarily. A change in climate is quite helpful for people with fatigue related to allergies. A person might be tired in a rainy area of the country that is laden with mold but feel quite good in the clean, dry desert. Additionally, there might be some airborne irritant present at home or in the office that’s not present in the vacation home or hotel room.

When trying to find an answer for the symptom of fatigue keeping a fatigue diary can be quite helpful. Noting any activities, sleep patterns or locations that improve fatigue can offer an important clue.

Causes of Fatigue that Slip Through the Cracks

I consider fatigue caused by sinus and nasal issues to be the most common cause of otherwise unexplained chronic fatigue. I’ll describe the evidence for this opinion later but, for now, let’s consider some medical causes that can be missed.

An interesting study examined the amount of iron in the blood of women who were not anemic. Usually an iron deficiency, if severe enough, causes anemia but this study was limited to patients with mild iron deficiency, enough to be noted when examining the blood specifically for iron stores but not enough to cause anemia.

The distinction is an important one. Prior to this study physicians usually thought that iron deficiency would not cause fatigue if the deficiency was not severe enough to cause anemia. The study went on to measure the level of fatigue before and after iron replenishment. The level of fatigue dropped after the iron stores were returned to normal.

Two points are evident from this study: The lack of anemia does not rule out iron deficiency as a cause of fatigue. Additionally, measuring iron stores as simply the level of iron in the blood is inadequate. The iron stores must be measured as “ferritin” a simple and inexpensive blood test but one not always done when evaluating a person for fatigue.

Occasionally low thyroid causes fatigue despite a normal TSH—the usual screening test for low thyroid. TSH comes from the pituitary and increases in the event of a failing thyroid usually providing the earliest clue that the level of thyroid hormone is inadequate.

Occasionally the pituitary is the problem and although the TSH should be climbing as the thyroid fails, it does not. Checking the actual levels of thyroid hormone (T4 and T3) will pick up a thyroid problem even in the event of pituitary insufficiency.

Sometimes an arthritis disease can cause even in the absence of severe arthritis symptoms. Almost always the severity of the arthritic disease seems quite proportionate to the complaint of fatigue. Occasionally this is not so. A person might have rheumatoid arthritis with minor joint problems but have significant fatigue. Treating the rheumatoid arthritis usually causes substantial reduction of fatigue.

A note of caution: The vast majority of individuals with unexplained fatigue and very minor arthritis symptoms do not have positive blood tests for arthritic diseases. Even when the blood tests turn out positive the blood abnormality is, almost always, at a low level, unrelated to the minor arthritis. In these cases treating the person as if the individual did have a serious arthritis disease does not improve the fatigue. In short, arthritis blood tests in the setting of unexplained fatigue are often a “red herring,” but not always.

Occasionally a person may have unexplained fatigue due to a liver problem in the absence of abnormal screening liver function tests. Usually other screening tests, however, denote inflammation.

As mentioned before, the best screening tests to determine if, what appears to be unexplained fatigue, is actually caused by a medical problem are the erythrocyte sedimentation rate (ESR) and the C-reactive protein. Both of these are elevated by any process that causes inflammation. Usually any medical disease that causes fatigue causes inflammation as well.

The ESR and CRP won’t tell you the cause of the problem but do let you know that there is a problem. The absence of ESR or CRP abnormalities does not mean that the cause of fatigue is not physical. However, when these tests are elevated a physical cause of fatigue becomes much more likely.

Types of Fatigue

Over 100 years ago William Osler, the father of internal medicine, divided fatigue into three types. The first is the lassitude and malaise associated with systemic illness such as tuberculosis, cancer, rheumatoid arthritis, etc. The second is the weakness associated with muscle and nerve disorders resulting from ordinary exertion. The last is a painful weariness – the cause of which often eludes investigation.

These categories provide a useful framework in attempting to diagnose the cause of an individual’s fatigue. Duration further categorizes the symptom. Most patients with prolonged, unexplained fatigue have the third type of fatigue described by Osler, a painful weariness.

Fatigue that is less than one-month in duration is often due to a passing virus, stress, or other causes that are difficult to define. The relatively brief nature of the problem eliminates the need for an intense medical investigation, and, unless the problem becomes recurrent, it can be dismissed as one of life’s minor problems.

Persistent, significant fatigue, however, is not a minor problem. Even a loss of 10% of a person’s vigor removes enthusiasm and joy from the day’s tasks. Fatigue pulls down the mood and makes everything an effort. Approximately 15% of the general population suffers from chronic fatigue, unrelieved by rest, lacking an adequate medical explanation.

Approximately 25% of patients visiting a medical doctor complain of fatigue. Less than half will be explained by a medical illness.

Fatigue caused by medical conditions has certain characteristics. A serious medical problem will occasionally present itself as unexplained fatigue before other symptoms become apparent but, inevitably, other symptoms will appear. For instance, a person with pancreatic cancer may first notice fatigue before the appearance of abdominal pain and the other symptoms of cancer occur. Therefore, the longer fatigue persists without other symptoms, the less likely a serious medical condition will serve as the eventual explanation.

Fatigue caused by a medical problem has other characteristics as well. Usually patients with typical, diagnosable, medical problems note that their energy is highest in the morning and slowly winds down over the course of the day as if the store of vigor slowly depletes. A nap may recharge the person.

Fatigue that remains unexplained usually has different characteristics. Many times, a person has a bimodal curve of energy, worse in the morning, improving with the day, fading in the afternoon, and, finally, getting a second wind at night. A nap can actually worsen things. Additionally, sleeping a long time can produce an overslept sensation.

Patients with less serious medical problems can, in certain circumstances, have fatigue with the absence of other symptoms, as is the case with hypothyroidism. Patients with low thyroid may notice tiredness before the other symptoms appear. These include dry skin, constipation, cold intolerance, etc. Likewise, a patient with anemia can feel tired before noticing other symptoms such as pale skin or obvious blood loss.

Causes of fatigue are often easy to figure out. Usually a visit to the doctor and a standard panel of blood tests provides a definite answer. If, after a thorough exam and appropriate blood tests, no answer is apparent, it is unlikely that a medical explanation will be found.