April 11, 2019 at 7:42 am #3828Archived PostsModerator
As an NHS GP new to Functional Medicine I would very much appreciate your thoughts re a 53 year old gentleman with an unusual presentation.
In February 2017 he had 2 weeks of a flu-like illness which went on for 2 weeks and culminated in 2 days of a severe headache and nausea. He was taking ibuprofen throughout the 2 weeks with omeprazole as gastric protection.
After this illness, he has been left with 3 enduring symptoms for the past 6 months with no improvement over time;
• Cognitive impairment
• General slowness of movement
• Intermittent acidity and early satiety.
Physical movement [not over exertion] exacerbates his symptoms and he can take at least a week to get back to his “new normal” level of poor function. For example, a day travelling to Spain for his summer holiday resulted in worsened symptoms for 8 days, and the trip back resulted in a 15 day exacerbation.
He has only been able to work from home in a much reduced capacity since his illness. He has also stopped driving.
Prior to this illness he had been suffering with a 24 month history of an odd smell in his nose. He saw an ENT surgeon re this and had an MRI brain and sinuses in 11/2016 which showed mild right maxillary sinus inflammation only. On the 3rd day of his flu he was reviewed by ENT and prescribed an antifungal [fluconazole] and a steroid nasal spray [mometasone].The smell resolved within 5 weeks of taking this medication.
He had also been experiencing neck pain in December 2016 and had been taking regular diclofenac at this time. He saw an osteopath and his neck issues settled.
He also mentions a degree of cold intolerance, and cold hands and feet in the past few months.
He had been under significant stress the previous year, but these stresses have completely resolved.
Past Medical History;
He has no significant past medical history and has previously been very fit and well. He does not smoke and rarely drinks alcohol.
Ranitidine-this was started in February instead of the omeprazole as the patient was concerned about the possible association of cognitive decline with PPIs
Vitamin D and Bio-kult probiotics-taking for several months.
To elaborate on the symptoms;
This gentleman is the CEO of a large IT company based in Poland, and has been writing computer programmes for 40 years. He is able to quantify the degree of cognitive impairment in that he can code/write programmes at between a third and a tenth of his usual speed when he is at his best. At his worst it is between a tenth and a fiftieth. Of note is that he was flying to Poland several times a month previously. Other foreign travel includes China two and a half years ago.
If he is talking to more than one person he struggles to listen, synthesise and contribute to that conversation. He feels words slipping away and stops mid-sentence.
He has seen a neurologist who queried some viral related vestibular ocular imbalance with a background of previous stress. The patient does not feel the symptoms are psychological.
He has seen a psychologist who has concluded that he is neither stressed nor depressed.
A further MRI brain is planned.
Slowness of movement
He describes his head as “feeling wrong” as if he is slightly drunk. This feeling of disequilibrium is exacerbated with motion, but is not an instantaneous deleterious response to movement. Instead it is a build-up in the sense of disequilibrium as per with the exacerbation with travelling. He has seen a vestibular physio who did not think it was a balance or middle ear problem. The ENT consultant also felt it was not ENT related.
He has always been a fast walker [3-4 miles per hour] but now at best, it is half that.
At worst it is a slow shuffle. If he becomes aware of the slowness, he can speed up by consciously planning and executing movement of his limbs, but as soon as he stops concentrating he slows down. His limbs can feel heavy.
Of note is that he does not have any perception of feeling tired or having lack of energy. Everything is just “slow”.
Intermittent acidity and early satiety
Reflux/”feeling of gullet being full and inability to swallow combined with severe drooling”.
This has mainly settled with ranitidine, stopping the ibuprofen/diclofenac and eating smaller low carb meals. He is taking Bio-kult probiotics.
He lost a stone in weight over the first 4 weeks as he was eating little, but this has now stabilised.
He does get a degree of burping, and pasta and pizza can exacerbate symptoms.
He has an exacerbation approximately every 4 weeks and can last 12-24 hours. It always coincides with exacerbation of the movement and cognitive issues.
He has no other g.i issues. He has seen a gastroenterologist who has listed him for a gastroscopy and an abdominal ultrasound scan.
Full blood Count,LFT,renal,TFT,CRP,amylase,HbA1c,amylase, HP serology,PTH,B12,folate,coeliac, [IgAtTG] and prolactin; ALL NORMAL
Cortisol-taken at 9am which was approx 2.5 hours after getting up, was low at 304 [>400 considered normal]
I would be most grateful for any advice or thoughts re this gentleman. The conventional medical approach has as yet been unsuccessful in helping him.
Posted By: Harriet Campbell
April 11, 2019 at 7:45 am #3836Carrie Decker, NDParticipant
Thank you for posting this complicated case here for feedback. I am sorry to hear of this man’s sudden onset of such a severe undiagnosed health condition and glad you are working to support him.
In addition to your support, I would look to having this man see additional specialists for further screening. Many of his symptoms have features similar autoimmune-related conditions including Guillain-Barré syndrome, polymyositis, and Raynaud’s. Also, seeking a second opinion of a neurologist is in order, as there also are features which resemble motor neuron diseases such as amyotrophic lateral sclerosis (ALS), which often take some time to diagnose. Finally, a consult with an infectious disease specialist may be in order to rule out potential more rare infections which could be underlying his motor and cognitive symptoms.
Sometimes, a trigger such as an infection overwhelms the system and is the switch that flips a state of health to one of autoimmunity or rapid decline. This may be related to immune system activation, immune dysfunction, toxins related to the infection, and even the impact on genetic transcription among many other things. We often are not able to determine exactly what went wrong. In these settings, the approach to supporting patients often will be similar and will include aspects of supporting the body to have a normal immune system response, supporting the body with nutrients, supporting digestion, gastrointestinal health, and elimination, reducing inflammation, and eliminating possible contributing factors (cleaning up the diet, resolving infections, detox from heavy metals, mould toxins). Without an absolute diagnosis of this man’s condition, it is likely your support will include these things.
If this man does not receive further work-up by an infectious disease specialist, the possibility of a latent viral infection contributing to symptoms would also be high on the list to rule out. Regenerus Labs and Infectolab offer a chronic viral panel for many items which may be an issue (CMV, HHV-6, EBV, HSV-1 & HSV-2) in their test ‘Advanced Chronic Viral Profile’. Anti-viral and immune supportive agents also may be useful if there is a viral or infectious aetiology suspected. Even if your client is not able to perform the chronic viral panel, you still may want to consider a trial of antiviral agents.
Humic acid supports the body in responding against viral agents by binding to viral agents as well as acting like a chelator and displacing them from the cells. Do also read the 3 articles on the Clinical Education web page on the subject of humic acid: http://tinyurl.com/p2h6dky. At times, there may be an increase of symptoms due to the virus as it seeks a means of surviving, but with the continuation of treatment symptoms diminish as the viral load is decreased over time. A pdf with listings and dosages of humic acid and other anti-viral agents available can be found at: http://tinyurl.com/bgvyl6h. My suggestion would be to first initiate neural-supportive supplements prior to gradually increasing the dosage of humic acid or other anti-viral agents.
Coenzyme Q10 (CoQ10) has been investigated as a supportive treatment in several studies for individuals with conditions related to neuroinflammation such as Parkinson’s disease, multiple sclerosis, and Alzheimer’s. Dosages studied and found to be safe range from 300mg – 1200mg/day, and the highest dosages were found to be most beneficial. CoQ10 appears to slow the progressive deterioration of function in Parkinson’s disease.
Shults CW, et al. Effects of coenzyme Q10 in early Parkinson disease: evidence of slowing of the functional decline. Arch Neurol. 2002 Oct;59(10):1541-50. http://tinyurl.com/pbbhurw
Ebadi M, et al. Ubiquinone (coenzyme q10) and mitochondria in oxidative stress of parkinson’s disease. Biol Signals Recept. 2001 May-Aug;10(3-4):224-53. http://tinyurl.com/o7yszlm
Beal MF. Mitochondrial dysfunction and oxidative damage in Alzheimer’s and Parkinson’s diseases and coenzyme Q10 as a potential treatment. J BioenergBiomembr. 2004 Aug;36(4):381-6. http://tinyurl.com/p6874kj
Sanoobar M, et al. Coenzyme Q10 supplementation reduces oxidative stress and increases antioxidant enzyme activity in patients with relapsing-remitting multiple sclerosis. Int J Neurosci. 2013 Nov;123(11):776-82. https://tinyurl.com/yaxjbna6
Omega 3 fatty acids are also anti-inflammatory and may have a protective effect in conditions associated with neurodegeneration or nerve damage. Other mitochondrial and neural supportive nutrients include phospholipids, lipoic acid, and acetyl-l-carnitine.
Bousquet M, et al. Beneficial effects of dietary omega-3 polyunsaturated fatty acid on toxin-induced neuronal degeneration in an animal model of Parkinson’s disease. FASEB J. 2008 Apr;22(4):1213-25. http://tinyurl.com/kzcqpdt
Ward RE, et al. Docosahexaenoic acid prevents white matter damage after spinal cord injury. J Neurotrauma. 2010 Oct;27(10):1769-80. http://tinyurl.com/mgu49od
Salinthone S, et al. Lipoic acid: a novel therapeutic approach for multiple sclerosis and other chronic inflammatory diseases of the CNS. EndocrMetab Immune Disord Drug Targets. 2008 Jun;8(2):132-42. https://tinyurl.com/ychtgvy5
Zhang H, et al. Combined R-alpha-lipoic acid and acetyl-L-carnitine exerts efficient preventative effects in a cellular model of Parkinson’s disease. J Cell Mol Med. 2010 Jan;14(1-2):215-25. http://tinyurl.com/mamhbp4
Given the state of deficiency, you may wish to consider glandular combinations in supporting his recovery. With the potential chronic infection, adrenal insufficiency, and gastrointestinal symptoms, a glandular including thymus, adrenal, spleen, and pancreas may be helpful. Each of these glandulars is available individually as well, and you may just want to start with adrenal cortex to support the body in production of cortisol. I often see some improvement in energy with this.
An acronym we were taught to remember when considering what might promote reflux is C.R.A.P. The letter C refers to Coffee, Cigarettes, Chocolate, Corticosteroids; R refers to Refined carbohydrates and Rx (prescriptions) that relax LES (anticholinergics, calcium channel blockers, beta-agonists for asthma); A refers to Acidic foods, Alcohol, Allergic foods, Aspirin (NSAIDS); and finally, the letter P refers to Pop (soda), Peppermint, Packing in food at bedtime, and Progesterone (pregnant women). Do run through this list to consider if there are any which stand out as items which may be an issue for him.
Breaking food down to amino acid constituents, thereby decreasing antigenicity, via digestive enzymes and other digestive support will help to decrease reactivity and promote appropriate mechanisms to restore barriers and functionality in the gut. I have seen the use of supplements including digestive enzymes help to resolve reflux at times as well. As the mucosal boundary is where many of the pancreatic enzymes are activated, when it is damaged it can lead to poor breakdown of food substances, further contributing to symptoms and inflammation.
Epithelial Growth Factor (EGF) is a polypeptide that stimulates growth and repair of epithelial tissue such as the oral mucosa and gastrointestinal epithelium. EGF is a normal constituent of saliva production during the act of eating, is also secreted into the gut lumen and found in colostrum and milk. Salivary EGF also upregulates small intestinal absorption of electrolytes and nutrients. Michael Ash has written more about the use of epithelial growth factor in the resource “Epithelial Growth Factor for Reduced Gut Permeability / Pathogen Attachment and Nutrient Uptake” which can be found here – http://tinyurl.com/qf2qbr6. Glutamine has been shown to support integrity of intestinal permeability, as well as slippery elm powder, and N-Acetyl-D-Glucosamine.
There are several other questions on the Clinical Education group pertaining to the topic of heartburn, reflux, and GERD which you may find useful. To look for these simply use the Search function at the top right of the page when you are within the group and query any of these topic words. Here are links to a few of those responses for you:
http://tinyurl.com/paux9sk – 68 yr old on PPIs wishing to come off them
http://tinyurl.com/m8yz5v5 – 83 yr old on PPIs & reference to the Tuesday Minute on the subject of GERD.
http://tinyurl.com/puk3z5l – 43 yr old with GERD and on PPIs
The following supplements are suggested for you to consider in light of your relevant expertise and understanding of the needs of your client or patient. In sensitive clients, it is important to introduce things gradually starting with small doses, perhaps even opening capsules and starting with ½ of it. They may be used in isolation or as part of a multi supplement strategy, but at all times the consideration of their use should be tied into the specific needs of the individual you are responsible for.
Support for neural health and reduction of inflammation:
ProOmega™ (NN): 3 – 4 soft gels up to twice daily with meals. http://tinyurl.com/7t9myqe Supports reduction of inflammation.
Arctic Cod Liver Oil (Nordic Naturals): 1- 2 teaspoons twice daily with food. http://tinyurl.com/3jgxael Liquid form of fish oil may lead to increased compliance with high dosages as it may be included in a smoothie and diminished overall pills that must be taken daily.
Coenzyme Q10 with Tocotrienols (ARG): 3 capsules 2-3 times a day with meals. https://tinyurl.com/n6g6ryx
Lipoic Acid Plus (BRC): 2 capsules twice a day. http://tinyurl.com/kyqj75y
NT Factor ATP Lipids (ARG): Gradually increase to ½ teaspoon two times daily. http://tinyurl.com/n7b7sap Phospholipid combination that supports cellular membrane repair.
Consider introducing if chronic viral issues are suspected or found:
Wholly Immune (ARG): 1 scoop daily in 8oz liquid. http://tinyurl.com/33v5um9 Contains nutrients, botanicals, and mushroom extract to support immune function.
Humic-Monolaurin Complex (ARG) – Gradually increase to 3 capsules with each meal. http://tinyurl.com/38cc9wd Combination of humic acid, Russian Choice Immune, and olive leaf extract. Supports healthy response to viruses.
Humic Acid (ARG): Gradually increase to 2 capsules with each meal. http://tinyurl.com/buakdqj. Anti-viral.
Immuno-Gland Plex (ARG): 1 capsule up to twice daily with meals. http://tinyurl.com/kydwcdv Contains thymus, adrenal, spleen, and pancreatic glandular.
Adrenal Cortex Natural Glandular (ARG): 1 capsule (250mg) in morning with food. http://tinyurl.com/mt4z8ne In sensitive individuals a lower dosage may be considered (1/2 capsule) which can be taken by opening capsule and adding ½ capsule to food.
Support for reduction of reflux. Introduce prior to gradually decreasing anti-reflux medications:
Intenzyme Forte™ (BRC): 1 with breakfast & 1-2 with lunch & dinner. http://tinyurl.com/ndqfvak Digestive enzymes without additional HCl.
Perm A Vite® (ARG): Gradually increase to 1 Tbsp daily mixed in liquid 1h away from meals. Contains L-glutamine and epithelial growth factor. http://tinyurl.com/37dv2cl Support for gastrointestinal healing.
Sano-Gastril® (ARG): 1 to 3 tablets chewed or sucked, between meals, or as needed. http://tinyurl.com/37deycf Helps to neutralise excess acid without raising the stomach pH excessively and stimulates gastric mucus secretion.
Please consider these suggestions in light of the other clinical information pertaining to this individual. If you have any more information about the specific problems this individual is experiencing, further refinement of these suggestions may be considered. I hope this information is helpful, and if you have any further questions or information specific to the problems this individual is experiencing, please do provide feedback.
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