Bretherick, Andrew D, McGrath, Simon J, Devereux-Cooke, Andy et al. · NIHR open research · 2023 · DOI
This large study asked over 17,000 people with ME/CFS about their symptoms, when their illness started, and what health conditions they experience. The researchers found that ME/CFS is not one-size-fits-all: people whose ME/CFS began after an infection (like COVID-19 or glandular fever) reported different patterns of symptoms and other health problems compared to those whose illness started without a clear infection. The study also confirmed that women are more affected by ME/CFS than men, and discovered that women tend to have more additional health conditions alongside ME/CFS.
This study provides the largest systematic characterization of ME/CFS heterogeneity to date, suggesting that future research treating ME/CFS as distinct subtypes (rather than a single condition) may improve our ability to identify underlying biological mechanisms and develop targeted therapies. By demonstrating that infection-type at onset correlates with different symptom patterns and comorbidities, the study supports a more nuanced approach to understanding ME/CFS pathogenesis and potentially identifying subgroup-specific interventions.
This study does not prove that infection causes ME/CFS or that different onset types have different biological mechanisms—it only shows associations in self-reported data. The cross-sectional design cannot establish causation, temporal relationships, or whether observed differences reflect true disease subtypes or variation in symptom reporting and comorbidity recognition. Results are limited to UK participants and may not generalize to other populations.
About the PEM badge: “PEM required” means post-exertional malaise was an explicit required diagnostic criterion for participant inclusion in this study — not that PEM was studied, observed, or discussed. Studies using criteria that do not require PEM (e.g. Fukuda, Oxford) are tagged “PEM not required”. How the atlas works →
The first block is for the primary paper and is the citation you should use in research work. The atlas-snapshot line only applies if you are specifically referring to this atlas’s reading of the paper on the date shown.
Primary citation
Bretherick, Andrew D, McGrath, Simon J, Devereux-Cooke, Andy, Leary, Sian, Northwood, Emma, Redshaw, Anna, et al. (2023). Typing myalgic encephalomyelitis by infection at onset: A DecodeME study.. NIHR open research. https://doi.org/10.3310/nihropenres.13421.4
BibTeX
@article{mecfsatlas-bretherick-2023-typing-myalgic,
author = {Bretherick, Andrew D and McGrath, Simon J and Devereux-Cooke, Andy and Leary, Sian and Northwood, Emma and Redshaw, Anna and Stacey, Pippa and Tripp, Claire and Wilson, Jim and Chowdhury, Sonya and Lewis, Isabel and Almelid, Øyvind and Baby, Sumy V and Baker, Tom and Becher, Hannes and Boutin, Thibaud and Clyde, Malgorzata and Garcia, Diana and Ireland, John and Kerr, Shona M and McDowall, Ewan and Perry, David and Samms, Gemma L and Vitart, Veronique and Wolfe, Jareth C and Ponting, Chris P},
title = {Typing myalgic encephalomyelitis by infection at onset: A DecodeME study.},
journal = {NIHR open research},
year = {2023},
doi = {10.3310/nihropenres.13421.4},
note = {PubMed: 37881452},
url = {https://www.mecfsatlas.com/evidence/bretherick-2023-typing-myalgic},
}Atlas snapshot reference
ME/CFS Atlas. Generator v1 / Scanner v1.4 / policy v0.1. Accessed 2026-05-30. https://www.mecfsatlas.com/evidence/bretherick-2023-typing-myalgic
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