You don’t often think, that when you’ve had a flu that leaves you feeling fatigued and run down, that your gut microbiome may have had an impact on how your immune system reacted. 

A healthy gut promotes and protects against the risk of pathogenic infection by promoting immune homeostasis.^{1, 2} The naturopathic ethos of, “treat the gut first’’, is being backed up by some serious science. So, before you reach for immune modulating herbs, think about the microbiome and healthful diets that could put your patient back on track.

Medical history and presenting symptoms

A 30-year-old male patient came to see me for his first visit in winter. He was unwell, on and off for the past year with flu like symptoms and severe reflux. The last four weeks he reported feeling like he had a persistent flu, and was complaining of a residual cough post virus, different to his reflux cough, with a fever (38.2 Celsius). He was recently diagnosed with a secondary infection, which he was prescribed antibiotics with no effect, temperature spiked and he was admitted to hospital. X ray results were clear, however blood results showed abnormally high CRP, and liver function. Constantly low iron studies when tested every three months.

As a child he had grommets, gastro-oesophageal reflux possibly for 6 years, worse in the past year, cytomegalovirus infection one year ago, and has never felt well since. A colonoscopy reported nothing and gastroscopy findings, reflux with gastritis. Bioscreen confirmed multiple heightened firmicute bacterial overgrowth and low bacteroides species.

Bowel movements were often loose, soft and not formed, Bristol stool chart #7. He was highly anxious with symptoms of burping, gastric distension, pain, burning reflux, mucous gagging response to reflux and coughing.  Subjective patient pain and discomfort score was rated as 9/10.   He also had a recent flu virus with secondary infection.

Medications to reduce gastric discomfort included

• Proton pump inhibitor (Nexium) 40mg in the morning
• H2-antagonist (Tazac) 150mg morning and night
• Antacid (Gaviscon) after each meal up to six times a day

Initial Treatment 

Reduce pain and discomfort score, improve immune response, decrease food reaction, decrease pathogenic microbes, reduce inflammatory response, reduce pain and support gastric tissue

Prescription

• Extreme Low FODMAP diet with a focus on high vegetable intake
• Turmeric complex, 1 tablet twice a day with food; containing curcumin phospholipid complex 555mg, Acacia catechu stem 1000mg, baical skullcap (Scutellaria baicalensis) root 4000mg, to address mental anxiety and decrease gastric inflammation
• Indigestion & heartburn Relief tablet, 1 tablet five times a day after ingestion of food; containing Deglycyrrhized licorice (Glycyrrhiza glabra) root 3.42g, chamomile (Matricaria recutita) flower 600mg, meadowsweet (Filipendula ulmaria) 500 mg, chamomile flower essential oil 5mg
• Antimicrobial support tablet, 1 tablet three times a day; containing thyme oil 5mg, clove bud oil 5mg, garlic (Allium sativum) bulb 684mg, Phellodendron (Phellodendron amurense) stem bark 5.6g, nigella (Nigella sativa) seed 1g, cinnamon (Cinnamomum verum) stem bark 500mg to address gut pathogen load 

2-Week Follow-Up

Patient reported mild improvements

• Bowel movements were slightly less loose and more formed, Bristol stool chart #6-7
• Highly anxious
• Symptoms of burping, gastric distension, pain, burning reflux
• Mucous gagging response to reflux continue at a milder level
• Pain had subsided somewhat, subjective patient pain and discomfort score 7/10
• No infections
• Fever subsided

Medications

• Continue Nexium 40mg in the morning – with alternate days at 20mg
• Tazac 150mg at night
• Gaviscon after each meal

Follow-Up Treatment

Reduce pain and discomfort score, improve immune response, decrease food reaction, decrease pathogenic microbes, support gastric tissue and digestion and improve microbe balance.

Prescription

• Continued extreme low FODMAP diet
• Multi strain probiotic, 1.5 grams twice a day in water before food; containing Lactobacillus acidophilus R0418 1.65 billion CFU, Bifidobacterium infantis R0033 900 million CFU, Lactobacillus delbrueckii ssp. Bulgaricus R9001 150 million CFU, Lactobacillus plantarum R1012 1.2 billion CFU, Bifidobacterium breve R0070 900 million CFU, Bifidobacterium longum R0175 900 million CFU, Lactobacillus helveticus R0052 1.5 billion CFU, Lactobacillus casei R0215 1.2 billion CFU, Streptococcus thermophilus R0083 600 million CFU, Lactobacillus rhamnosus R1039 9 billion CFU, Lactobacillus rhamnosus R0011 12 billion CFU
• Antimicrobial support tablet, 1 tablet a day after food;
• Indigestion & heartburn relief tablet, 1 tablet 5 times a day after ingestion of any food;
• Vegetable digestive enzyme support, 1 capsule three times a day after meals; with Amylase 15000 DU, Protease 50 000 HUT, Lipase 1200 LipU, Tilactase 1500 ALU, Cellulase 300 CU, Bromelains 80mg, dandelion (Taraxacum officinale) root 665mg, ginger (Zingiber officinale) root 333mg 

6-Week Follow-Up

Patient was unwell again with mild flu like symptoms for one week after the last appointment.  He reported the following at this consultation:

• Five weeks of no reflux cough
• Still has mucous before and after eating
• Irritation in oesophagus and throat is the same, pain rated as 5/10
• No illness in the past four weeks
• Slightly less anxious
• Bowel motions still a little loose Bristol stool chart #6

Medications

• Reduced Nexium to 20mg in the morning
• Tazac 150mg at night
• Gaviscon three times a day

Follow-Up Treatment

Reduce patient pain and discomfort score, improve immune response, moderate dietary support, digestive support, gut tissue healing support and gut microbiome normalisation.

Prescription

• Continue low FODMAP diet however try to include some foods listed as ‘occasional’ and diarise any reactions
• Multi-strain probiotic, 1.5 grams twice a day in water before food;
• Indigestion & heartburn relief tablet, 1 tablet 5 times a day after ingestion of any food;
• Vegetable digestive enzyme support, 1 capsule three times a day after meals
• Gut repair powder, 5 grams in water after breakfast and before bed; containing Vitamin A (as retinyl acetate) 900mcg, cholecalciferol 5mcg (equiv. vitamin D3 200IU), glutamine 2g, zinc citrate 10mg, pectin (apple) 100mg, arabinogalactan-larix 750mg, deglycyrrhized licorice root 2g, turmeric rhizome 1.5g; Aloe vera inner juice 5g; broccoli (Brassica oleracea var. italica) sprout 1.5g, kiwifruit (Actinidia deliciosa) flesh 625mg; kiwifruit skin 25g

10-Week Follow-Up

Symptoms 

• Throat clearing less at breakfast and at dinner is symptom free
• No reflux cough
• Feeling better- sleeping well
• Feeling calm
• No infections or flu like symptoms
• Bowel motions firmer Bristol stool chart #5

Medications

• Reduced Nexium to 20mg in the morning
• Tazac 150mg at night
• Gaviscon after dinner only

Follow-Up Treatment

Reduce patient pain and discomfort score, improve immune response, re-introduce reactive foods and utilise gut repair powder, support digestion. 

Prescription

• Continue low FODMAP diet and include some foods listed as ‘occasional’ and diarise any reactions
• Multi-strain probiotic, 1.5 grams twice a day in water before food;
• Indigestion & heartburn relief tablet, 1 tablet 3 times a day after main meals;
• Vegetable digestive enzyme support, 1 capsule three times a day after meals
• Gut repair powder, 5 grams in water after breakfast and before bed;

14-Week Follow-Up

Symptoms

• Bowel motions sausage like Bristol stool chart #4
• Food triggers less noticeable in the ‘eat sometimes’ low FODMAP foods
• Symptoms of pain so mild hard to notice any at times, rates as 2/10
• Slight irritation in the morning
• Throat clearing, 95% gone
• No illness in past weeks

Medications

• Nexium 20mg alternating with 10 mg daily
• Tazac 150mg at night
• Gaviscon only if required (once a week if dining out)

Follow-Up Treatment

Continue reduction of patient pain and discomfort score, protect gut immune response, re-introduce some foods and utilise gut repair powder and continue with assisting digestion.

Prescription

• Vegetable digestive enzyme support, 1 capsule three times a day after meals
• Gut repair powder, 5 grams in water after breakfast and before bed;

 

Conclusion

This single case study highlights that the naturopathic ethos of treat the gut first is applicable in immune response for this patient, who continues with supplementation. It additionally highlights that naturopathic prescriptions can be used effectively, concomitantly with prescribed medication with good results in reducing patient subjective pain and symptom score and immune system recovery and reducing medication in collaboration with the prescribing doctor.

 

References

1. Charité - Universitätsmedizin Berlin (2019). How the immune system maintains a healthy gut microbiota. Science Daily. Available online: www.sciencedaily.com/releases/2019/02/190226112241.htm
2. Neumann, C. Blume, J. Roy, U. P, P. Ajithkumar Vasanthakumar, T. Beller, A. Liao, Y. Heinrich, F. et al. (2019). c-Maf-dependent Treg cell control of intestinal TH17 cells and IgA establishes host–microbiota homeostasis. Nature Immunology, 2019; DOI: 10.1038/s41590-019-0316-2