There are many potential causes of fatigue. A naturopathic differential diagnosis might include nutritional causes, stress, chronic infections, mitochondrial dysfunction, adrenal fatigue, chronic fatigue syndrome, depression and sleep issues, including sleep apnoea. 

Often, more than one factor is driving the fatigue and treatment requires changes as issues resolve. This case is an example of ‘peeling the onion’ to find resolution.   

Initial Consultation

A 48-year old male presented with a history of fatigue for the last six years. His energy fluctuated between 3/10-8/10 with a need for an afternoon nap most days. He felt generally unwell and reported other symptoms including:

• Brain fog and poor memory
• Frontal headaches 2-3 times weekly treated with paracetamol or ibuprofen
• Hot and cold flushes
• Achy body
• Sore feet – balls and heel
• Restless legs and twitching in muscles
• Sore testicles
• Food cravings – chocolate and chips
• Inability to quench thirst
• Abdominal bloating
• Reflux and heartburn – treated with metoclopramide twice weekly
• Morning nausea
• Poor immunity – many respiratory and ear infections in the past two years
• Eczema on face – treated with hydrocortisone cream as needed
• Snoring
• Waking due to shoulder pain and for bowel movement during the night

Other relevant history included:

• Diet high in sugar, wheat and dairy
• Works in weed control – exposure to glyphosate and other chemicals
• Previous testing revealed negative Helicobacter pylori antibodies, negative coeliac serology, negative faecal multiplex PCR, positive Candida albicans culture from ear swab

Initial Prescription

The initial prescription was aimed at supporting immune function, reducing viral load and replenishing depleted nutrients:

• A herbal tablet containing Licorice (Glycyrrhiza glabra) 2.9 g, St. John’s wort (Hypericum perforatum) 1.4 g and Thuja (Thuja occidentalis) 200 mg to be taken 1 tablet 3 times daily;
• A herbal tablet containing Astragalus (Astragalus membranceus) 850 mg, Siberian ginseng (Eleuthrococcus senticosus) 750 mg and Echinacea (Echinacea purpurea) 650 mg to be taken 2 at breakfast and 1 at lunch;
• A magnesium, taurine and B vitamin powder providing magnesium 350 mg (as glycinate, citrate, orotate and ascorbate), taurine 3g, zinc 15.1 mg (as citrate) and B vitamins to be taken once daily.

He was referred to his GP for further testing and asked to make the following dietary changes:

• Reduce intake of wheat and dairy
• Switch sugary snacks for vegetable sticks and hummus or avocado and cashew cheese on rice crackers. 

3-Week Follow-Up

The patient reported no improvement in his energy levels and continued to experience respiratory infections. His gut health improved with less reflux and heartburn, no morning nausea and there was no need to pass bowel movements at night. His snoring had also reduced. Other symptoms remained stable from his initial consultation. 

Blood results revealed:

• Cortisol: 330 nmol/L (9 am) (220-660)
• Serum zinc: 8 μmol/L (10-25)
• Serum copper: 16 μmol/L (10-30)
• Active B12: > 128 pmol/L (>35)
• Iron studies: within healthy range
• Negative dengue fever, Ross River virus, cytomegalovirus, Barmah Forrest virus.
• Past exposure to Epstein-Barr virus
• Negative ENA and ANA
• TSH: 0.77 mIU/L (0.50-4.0), negative thyroid antibodies

His prescription was changed to focus on adrenal health, restoring gastrointestinal epithelial integrity and optimising gut microbiome with special focus on reducing yeast such as Candida spp. and included:

• A herbal tablet containing Rhodiola (Rhodiola rosea) 720 mg and Korean ginseng (Panax ginseng) 500 mg to be taken 2 at breakfast and 1 at lunch;
• A herbal antimicrobial tablet containing Phellodendron (Phelloendron amurense) 1.6 g, Andrographis (Andrographis paniculata) 1.0 g, Anise (Pimpinella anisum) oil 125 mg, Oregano (Origanum vulgare) oil 75 mg to be taken 2 tablets twice daily for 3 days per week;
• A multistrain probiotic containing Bifidobacterium longum, breve, B. infantis, B. lactis, Lactobacillus rhamnosus, L. paracasei, L. salivarius, L. casei to be taken 1 capsule daily with food for 4 days per week (non-antimicrobial tablet days)
• A gut healing powder containing glutamine 2 g, Slippery elm (Ulmus rubra) 500 mg, pectin 100 mg and Saccaromyces cervesiae to be taken 1.5 teaspoons twice daily

This protocol along with a low sugar diet was to be followed for 6 weeks.  

9-Week Follow-Up

The patient had noticed a small, but noticeable improvement in energy levels with more stability throughout the day (less napping). He also reported improved brain fog, reduced eczema, less food cravings and normal thirst.

The patient was referred for testing for environmental chemicals and Lyme’s disease and prescribed a gentle detoxification protocol whilst awaiting results which included:

• A herbal and nutritional powder to support liver detoxification containing Broccoli (Brassica oleracea) 7g, Turmeric (Curcuma longa) 2.13g, and cofactors for detoxification to be taken once daily;
• An alkalising mineral powder containing calcium 400 mg, magnesium 187 mg, potassium 300 mg and cofactors to be taken 10 g twice daily

He was instructed to drink 2.5 L of water daily, increase fibre with 1 teaspoon of psyllium husks in water at night time, to practice dry skin brushing daily and use a sauna weekly.  

11-Week Follow-up - Phone Check-in

The patient reported further small improvements in energy levels (now 6/10 most days) and a reduction in headache frequency. He booked the phone check in as he was moving out of the country and was discontinuing consultations. He had not completed the environmental toxins or Lyme’s tests.

Conclusion

This case demonstrated that there are many roads to fatigue and patients have often traversed several of them before they reach our clinic rooms. Getting to the bottom of cases such as these often requires some trial and error, and persistence, especially when treatment does not seem to be achieving the desired results. Pathology testing assists the process by revealing, or ruling out, underlying causes. This patient’s road to recovery had only just begun, but was hopefully continued with another practitioner elsewhere.