Spondyloarthritis comprises a group of inflammatory diseases of the joints and spine, with the main clinical manifestations of inflammatory pain, stiffness, and swelling. The HLA-B27 antigen is present in 90% of spondyloarthritis patients, and there is a hypothesis that this antigen plays a role in shaping the gut microbiome and inflammatory responses in the gut lining. Changes in gut microbiome composition correlate with autoimmune diseases through mechanisms such as activation of the immune response, molecular mimicry, and increased intestinal permeability. ¹ This case discusses a client presenting with undifferentiated spondyloarthritis and rheumatoid arthritis.

Initial presentation

A 41-year-old male presented with chronic joint pain spanning back 20 years, worsening since contracting COVID seven months prior.  His main symptoms were chronic pain (8/10) and inflammation in his joints, specifically his shoulders, back, arms, hands, ankles, and knees; fatigue requiring daily 2-hour naps; and gut dysfunction, specifically loose stools five times daily and excessive gas. He was sleeping 4 hours a night, and owns his own business with high stress, and no exercise. His father suffers ankylosing spondylitis, and both his brother and father are HLA-B27 positive. His current blood tests show high antinuclear antibodies (ANA) speckled; Vitamin D3 72 nmol/L; ESR 10 mm/hr (ref 1-15); elevated CRP 8 mg/L (ref 0-6) as well as values sitting outside the optimal reference ranges on most bloods, showing high cholesterol, slight kidney dysfunction, higher than optimal thyroid stimulating hormone (TSH), and low white cell count (WCC).

The case history found that 20 years ago, after a number of personally stressful life events, he suffered six months of high fevers followed by full body alopecia, fatigue prohibiting walking, joint pain, high CRP (>300), and high speckled-ANA antibodies. He was prescribed long term, high-dose anti-inflammatory and antidepressant medications by his doctor. The doctors at the time could not confirm a diagnosis.

Prescription:

The key drivers of his pain and systemic inflammation are HPA axis dysfunction driven by poor sleep, stress and emotional trauma; and GIT inflammation.

Goals:

• Reduce gut inflammation to reduce systemic inflammation
• Balance immune function through herbal therapy and key nutrients
• Promote a diet and lifestyle that supports the HPA axis
• Improve functional capacity and ability to carry out daily activities of living 

Recommendations:

• Bring bedtime forward to 11:00pm, early morning sunlight, grounding, daily gentle exercise
• Wholefoods, gluten free, anti-inflammatory diet. 
• Referral for testing of HLA-B27 antigen, back to doctor for further investigation into pathology of joints
• Calcifediol Tablets: 1 tablet daily, containing calcifediol 10 ug
• Concentrated Fish Oil Capsules: 2 capsules 3 times daily, each containing 400 mg of EPA and 200 mg of DHA per capsule
• Quercetin: 2 capsules, 2 times a day, each containing liposomal quercetin 250 mg
• Magnesium and B Vitamin Powder: 1 scoop daily, containing magnesium 310 mg plus B vitamins and cofactors
• Bioavailable curcumin Tablets: 1 capsule twice daily, each containing Turmeric (Curcuma longa) phospholipid complex 500 mg
• Liquid herbal blend: 5 mL, 3 times daily, containing Ginger (Zingiber officinale) 1:2, 50 mL, Devil’s Claw (Harpogophytum procumbens) 1:2, 125 mL, Echinacea (Echinacea purpurea and Echinacea angustifolia blend) 1:2, 100 mL, Siberian Ginseng (Eleutherococcus senticosus) 1:1, 75 mL, and Hemidesmus (Hemidesmus indicus) 1:2, 150 mL 

With the high speckled ANA I was querying an organ specific autoimmune condition on top of his joint pain, due to his severe gut symptoms and lack of initial diagnosis. Many of this patients’ drivers were due to his lifestyle, so a focus on making these changes while supporting his body to come back to immune homeostasis is the first line of treatment. I also wanted to give him some symptomatic relief while we worked on the root cause.

Follow-Up: 1-5 Months

The patient’s pain reduced to 2-4/10 most days, and he could clench his fists without pain. The pain was now mainly isolated to his wrists, arms, and shoulders. Movement in his shoulders was still limited, with difficulty dressing himself. His energy (6/10) and brain fog had improved, and he was now able to exercise with light weights. However, he found he was withdrawing from social situations and “moving like his 90-year-old grandfather”. Sleep slightly improved with 6-8 hours a night. The herbal mix and supplements were maintained, and he was very compliant with diet changes. The HLA-B27 test came up positive and the client went on a wait list for a specialist for diagnosis. I sent for a stool test, as stool were still three times a day, with some gut symptoms, although now formed with less urgency. This came back with Klebsiella overgrowth. Follow up bloods showed improved ESR at 5mm/hr; vitamin D3 120 nmol/L, improved CRP 2mg/L, as well as improvements in cholesterol, full blood count (FBC) and electrolyte/liver function test (E/LFT) parameters.

Klebsiella specifically is associated with ankylosing spondylitis (AS) due to molecular mimicry.  I would have considered AS, however the pain seemed to be related more to the arms and legs than the spine itself. I am particularly concerned for the patient’s mental health and his withdrawal from social situations.

Prescription:

• Referral to exercise physiologist for strengthening of joints and safe exercises around his pain
• Low carbohydrate diet to starve Klebsiella overgrowth, coupled with a regime of antimicrobials and gut healing nutrients.
• Carminative teas such as chamomile, ginger, fennel into daily routine
• Magnesium glycinate: 2 tablets, twice a day, each containing magnesium glycinate 600mg
• Anti-inflammatory tablet: 1 tablet, 3 times daily, containing Turmeric, Boswellia (Boswellia serrata), Willow Bark (Salix alba), Ginger, Quercetin, Hesperidin, Capsicum
• SPM Capsule: 2 capsules, twice daily, containing Specialised Proresolving Mediators
• High Berberine Phellodendron Tablets: 1 tablet, 3 times daily, each containing Phellodendron aumurense 8.8 g, standardised to berberine 200 mg
• NAC Powder: 2 scoops 2 times daily, containing N-acetylcysteine 1 g
• Antimicrobial Tablet: 1 capsule, 3 times daily containing Black Walnut (Juglans nigra); Sweet Wormwood (Artemisia annua); Barberry (Berberis vulgaris); Garlic (Allium sativum); Pau D’arco (Handroanthus impetiginosus); Thyme oil (Thymus vulgaris); Clove oil (Syzygium aromaticum); Oregano oil (Origanum vulgare)
• Gut Healing Powder: 2 scoops twice daily, containing L-glutamine, Larch, zinc, vitamin A, vitamin D3, Aloe and Boswellia

The antimicrobials were pulsed on and off over a period of 8 weeks.  The N-acetylcysteine was given to break any bacterial biofilms. The fish oil was changed for SPM’s to encourage a faster reduction in pain.

Follow up 6 - 10 months:

The client was diagnosed with spondyloarthritis, rheumatoid arthritis and bursitis in both shoulders by his specialist. A re-test of his gut microbiome showed no Klebsiella overgrowth. He can now get through the day without a nap. In times of stress, he reverts to four hours sleep a night, and this follows with his pain intensifying. Pain sits around 2-6/10, and energy 6/10. Gut issues slowly come back when not maintaining supplement routine or when consuming gluten.

Prescription:

The same prescription is maintained, minus the antimicrobials, and with the addition of collagen powder. All diet and lifestyle recommendations are being maintained.

Take Aways:

One area my treatment thus far has failed to address is the severe psychological distress and isolation that chronic pain has caused for this patient.  Future appointments will widen the referral sphere to include psychologists and pain specialists.

The key to this case was in finding his underlying drivers for his initial switch to an autoimmune state, which I believe was the genetic predisposition for this condition, coupled with severe emotional trauma from 20 years ago. The re-ignition of pain from the more recent COVID infection started an inflammatory cycle that required key herbs and nutrients to address.

The potential for multiple autoimmune conditions in this client is a possibility, but modulating systemic immunity and supporting organ specific needs as they arise will take priority.

References

1. Sharip A, Kunz J. Understanding the Pathogenesis of Spondyloarthritis. Biomolecules. 2020; 10(10):1461. https://doi.org/10.3390/biom10101461