Presenting Symptoms

A 56-year-old woman presented to clinic with chronic digestive and respiratory dysfunction. Since childhood she had suffered from flatus[*] and irritable bowel syndrome (IBS). As an adult, she experienced chronic abdominal upset, distention and sharp, stabbing-like pains with several foods. She suffered from long-term constipation, often going up to a week without passing a stool. However, when she did pass a stool, they were loose, passing 1 to 2 per day (type 5 and 6 on the Bristol Stool Chart), varying in colour between light, clay and yellow brown. Her stools were worse for saturated fatty foods and fibre-rich foods.

Irrespective of this, the patient’s main reason for seeking treatment was her chronic lung infections due to bronchiolitis[†]. She had been diagnosed with asthma and episodes of bronchitis, which first presented at two years of age and continued into adulthood, with a serious episode in 2010. In 2017 she developed pneumonia, which took six months to resolve. Since then she has suffered 16 subsequent episodes (10 within the last 12 months), all of which have required antibiotic treatment. Acute symptoms include fever, chest pain, productive cough, occasional wheeze, and residual phlegm between episodes. She also suffered from sinusitis. Tonsils and adenoids were removed at 7 years of age.

The patient also presented with several other symptoms including migraines, began at 10 years of age prior to menarche, which worsened with oestrogen containing oral contraceptive pills (OCP), pregnancies and IVF cycles. Although post-menopausal, she still suffers recurrent migraines, significant episodes of dizziness and travel sickness.

Current medications

• Breo-Ellipta inhaler (fluticasone furoate and vilanterol) - daily
• Salbutamol inhaler - daily and as needed
• Telfast 180 mg/day
• Roxithromycin 300 mg on hand for lower respiratory tract infection

Current supplements

• Pancreatic enzymes with Fennel (Foeniculum vulgare) and Gentian (Gentiana lutea)
• Magnesium chelate plus B vitamins powder
• Over the counter (OTC) women’s 50+ multivitamin
• OTC gut relief powder - glutamine, Acacia (Acacia Senegal), quercetin, Globe Artichoke (Cynara scolymus), Marshmallow (Althaea officinalis), zinc
• OTC menopause relief - Dong Quai (Angelica sinensis), Kudzu (Pueraria lobata), Chaste Tree (Vitex agnus-castus)
• OTC multi-strain probiotic
• OTC kelp

Diet

• Previously advised to follow low FODMAPs and low salicylate diet
• Overnight fasting (14 to 16 hours)
• As a result, limited diet, eating the same foods each day, few vegetables or fruits,  no pulses from previous advice and associated gut symptoms
• Usually late breakfast - egg white and oat flour/fibre pancake
• Afternoon snack - rice cakes with cream cheese, apple (no skin)
• Dinner - seafood, green beans, cooked oats with natural yoghurt
• Occasional milk chocolate (caused bloating, gastrointestinal pain and loose stools)
• Good water intake, no coffee
• Regular added salt

Key pathology findings

Microbiome

• Low resistant starch

WBC count

• Raised neutrophil to lymphocyte ratio (4-9:1), consistently low lymphocytes (<1x109/L), raised monocytes (>0.5x109/L), cluster differentiation 3 (CD3), CD8+/CD3+, immunoglobulin E (IgE) [>100]
• Low natural kill (NK) cells

Tissue damage

• Raised lactate dehydrogenase (LDH), variable but often 280+ U/L

Thyroid profile

• Thyroid stimulating hormone (TSH) – 0.99 mIU/L (range 0.4 to 4.0 mIU/L) – normal
• Thyroxine (T4) - 9.9 pmol/L (range 9.1-19.6 pmol/L)
• Triiodothyronine (T3) - 3 pmol/L (range 2.4-5.9 pmol/L)
• No thyroid antibodies (thyroid peroxidase (TPO), thyroglobulin [TG])

Nutrients

• Adequate vitamin A, B1, B2, C and D, iron, zinc, copper, selenium
• Marked elevation of urinary iodine (349 µg/L)

Respiratory

• Multiple lung sputum tests varied between Haemophilus influenzae or  no finding
• Respiratory testing of forced expiratory flow (FEF) at 40% to 80%, responded to inhaled bronchodilators. Assessment taken in between acute infections

Initial Consultation

During the initial consultation the following underlying/exacerbating factors were identified:

• Bowel dysbiosis, lack of microbiome diversity and small intestinal bacterial overgrowth (SIBO) secondary to antibiotic treatment, leading to gut-lung axis dysfunction.  
• Allergic lung sensitisation secondary to chronic lung infections and suppressed lung immunity, leading to increased pneumonia risk secondary to inhaled corticosteroid, possible fungal lung overgrowth and increased airborne reactivity
• Potential mast cell activation
• Subclinical underactive thyroid function (subsequent basal temperature readings of 35.5 - 36 degrees C)

As a dysfunctional microbiome has significant systemic impact, the initial treatment focus was to decrease gastrointestinal sensitisation. The patient was advised to avoid cream cheese (reactive food) and kelp (excess iodine) and decrease her salt intake by half.

Further testing was also advised and included antinuclear antibodies (ANA), immunoglobulin panel, histamine, tryptase, and reverse (rT3).

Initial prescription

• Modified activated clinoptilolite (MANC), 400 mg/TDS before meals, for histamine chelation.
• Levagen+™ PEA, 600 mg/BD, to decrease gastrointestinal sensitisation, intestinal permeability and inflammation, possible mast cell activation and histaminergic sensitisation.
• Probiotic, 1 capsule daily, containing Lactobacillus rhamnosus (LGG®) and Lactobacillus paracasei (LP-33®) for allergy reduction and immune modulation.
• Maintain previous supplements including gut relief formula, menopause relief, digestive enzymes, multivitamin, and magnesium.

Second Consultation (3 weeks later)

• Gastrointestinal symptoms started to improve
• Regular, singular daily stool, firmer and less yellow. Much less flatus.
• Able to reintroduce Brussel sprouts, peas, pumpkin, sweet potato, carrot, and swede
• Headaches and hot flushes had begun to diminish, as such, she was advised to reduce the menopause formula
• Energy improved despite less sleep (lifestyle related)
• No lung exacerbation or asthma episodes
• Sinuses/catarrh remained unchanged

Third Consultation (2 weeks later)

• No bloating or stabbing pains
• Daily, firm stool
• Two episodes of nausea and headache with cheese platter and preserved meat
• Continued tolerance of previously added vegetable
• No acute lung exacerbations, minor nocturnal asthmatic cough
• No change in sinus congestion

At this stage, the patient’s prescription was adjusted to:

• Include saline nasal spray/TDS
• Include lecithin 1200 mg/meal
• Include thyroid support (inositol, selenium, Withania (Withania sominera), activated B vitamins)
• Reduce digestive enzymes to BD
• Reduce MANC to BD
• Discontinue previous OTC multivitamin

Fourth Consultation (4 weeks later)

• Stools now darker, firmer and daily
• No nausea, bloating or pain, even with fatty food
• One night of fever and chills, no lung pain and no antibiotics needed

The patient’s prescription was adjusted to include:

• Broad spectrum antimicrobial – Oregano (Origanum vulgare), Thyme (Thymus vulgaris), Myrrh (Commiphora myrrha), Phellodendron (Phellodendron amurense) and Garlic (Allium Sativum), 1 capsule/TDS (3 days on, 4 days off) increasing to 2 caps TDS
• NAC Powder, 1 g TDS, for biofilm eradication and to modulate lung inflammation/immunity

Test results from the previous recommendations revealed

• High histamine - 0.7 nm/mL
• High rT3 – 214 pmol/L (range 230.0 - 540.0 pmol/L)
• Low-normal serum calcium 2.20 nmol/L  (range 2.15-2.60 mmol/L)
• Improved basal body temp (36o to 36.3o)
• Negative ANA
• Low tryptase
• Low-normal IgA, IgG and IgM

As such, the patient’s prescription was adjusted to include:

• Magnesium citrate 150 mg/BD
• Herbal tonic – 7.5 ml/BD, for thyroid and immune enhancement, and to reduce allergic sensitization:
  • Tinospora (Tinospora cordifolia)                                                                         40 mL
  • Echinacea Premium (Echinacea purpurea root + Echinacea angustifolia)       50 mL
  • Astragalus (Astragalus membranaceus)                                                            50 mL
  • Korean Panax Ginseng (Panax ginseng)                                                            30 mL
  • Baical Skullcap (Scutellaria baicalensis)                                                            45 mL
• Increase the broad-spectrum antimicrobial to 2 capsules/TDS (10 days on, 4 days off)
• Reduced Levagen+™ PEA to 300 mg/BD
• Discontinue digestive enzymes
• Acute Immune Support, 1 tablet every 3 hours

The patient continued to improve and added green leafy vegetables with no adverse effects.

Other pathology changes:

• T4 (15 pmol/L), T3 (3 pmol/L [still low]
• Normalisation of neutrophil/lymphocyte numbers and ratio, reduction of monocytes to normal (0.29x109/L)
• Histamine reduced to 0.6 nm/mL (from 0.7)[SP1] 
• LDH now below 250 U/L

Current Health Status (9 months after initial consultation)

To this day, the patient only experiences minor lower respiratory tract infections (LRTIs) requiring a five-day course of Roxithromycin (as per her doctor’s instruction), however, she does not experience the previous fever, lung pain, lung expectoration or consolidation. Overall, she has recovered well. She experienced one episode of thick upper tracheal phlegm, with wheeze and some fatigue but no fever or lung pain. Implementing Acute Immune Support (1 tablet every 3 hours) resulted in resolution within 3 days. She now has complete resolution of sinus congestion and postnasal drip. Having just undergone a recent surgery, it was positive to note she experienced no adverse gastrointestinal side-effects from routine antibiotic prescription. Here headaches/migraine returned post-surgery but now resolve quickly. Partially hydrolysed Guar Gum (PHGG) and Acacia Gum powder has been added to her diet and is well tolerated. Further adjustments to her prescription included the addition of chlorella powder (up to 3 g/BD) to improve immune function and reduce allergic reaction, and weekly alternation of the broad-spectrum antimicrobial with conifer green needle complex (antioxidant, immune enhancement and anti-microbial).

Clinical Take-Aways

Chronic infections can present a treatment challenge. We need to address both the underlying susceptibilities, the recurrent infections, promote healing from damage of infection and address the negative consequences from the prescribed treatments.

The importance of correcting Gut health has wide reaching implications ,implications, both to improve its own function, but also in addressing far reaching chronic systemic health problems.

Emerging research in the Gut- Lung axis area is highlighting how antibiotic treatment causes deleterious changes in the gut microbiome and subsequent impaired lung immune response to infection. Whilst most of this research is animal based, findings are likely applicable to humans.

This can set up a negative cycle that further entrenches infection and inflammation and diminished capacity to restore lung health.

Further research has emerged highlighting the use of oral and inhaled (lung and nasal) corticosteroid treatment leading to fungal overgrowth (especially Aspergillus spp.), creating more inflammation and allergic sensitization. This causes a worsening of asthma and reduced lung immune response in clearing infections.

We have to be conscious of these contributors to chronic health conditions, and take this into account when implementing our treatment strategies

[*] Gas in or from the stomach or intestines, produced by swallowing air or by bacterial fermentation.

[†] Bronchiolitis is a common lung infection in young children and infants. It causes inflammation and congestion in the small airways (bronchioles) of the lung.