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A Problem Child

A Problem Child. Dr Melvyn A Sydney-Smith. KGSJ. MBBS, PhD, Dip Clin Nutrit, Mast Prac NLP, Dip Clin Hypnosis, FACNEM. Adjunct Professor (Nutrition Medicine). RMIT University. Australian College of Holistic Medicine. The Presenting Problem.

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A Problem Child

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  1. A Problem Child Dr Melvyn A Sydney-Smith. KGSJ. MBBS, PhD, Dip Clin Nutrit, Mast Prac NLP, Dip Clin Hypnosis, FACNEM. Adjunct Professor (Nutrition Medicine). RMIT University. Australian College of Holistic Medicine

  2. The Presenting Problem • Daniel ~ aged 10 yrs ~ was brought to the clinic in a wheelchair because of: Present in both legsin all muscles PAINSevere & disabling Unable to walkor weight bear Exacerbated markedlywith both active and passive movement Confined to a wheelchairfor previous six months Unable to attend school~ has been asked to leave www.nutritionmedicine.org

  3. July 2005 ~ illness commenced No actual vomitingdiarrhoea or vertigo No URTI symptoms First became ill 1 weekafter visit to farm ~handled chickens Acute onset of nausea, dizziness, abdominal pains & flatulence S/B GPno specific diagnosisRx: Metoclopramide H pylori serology ~ Neg Antigliadin Abs ~ <5 Anti-TTG Abs ~ <2 S/B PaediatricianFBE, MBA, ESR, CRP  NAD Barium swallow  NADU/S abdomen  NAD Nausea, flatulence & dizziness,persisted unabatedonset lethargy & fatigue Dx: Helicobacter gastritisRx: Clarithromycin OmeprazoleNB: H pylori serology ~ negative Abdominal pains easedbut nausea, flatulence& fatigue exacerbated Referred to Dietitian& Gastroenterologist MRI performed  NAD www.nutritionmedicine.org

  4. Advised a Gluten & dairy-freediet for 3 weeks NB: Coeliac serolgy negative S/B Dietitian Abdominal pains & flatulenceimproved markedly ~BUT~ not totally Nausea, lethargy &fatigue persisted Recommenced onlactose-free milk, hard cheese & Rye bread Continued lactose-free milk, cheese & rye bread No overt deterioration Gastroscopy performedno endoscopy S/B Gastroenterologist Macroscopically was normal Dx: none given Rx: Zoton Microscopically showedinflammatory cells in theupper oesophagus Nausea & dizziness increasedabdominal pain & lethargymarkedly exacerbated Zoton ceased www.nutritionmedicine.org

  5. Sept 2005 ~ attended nutritional GP ~ FULL BLOOD EXAMINATION ~ mild microcytosis (MCV 78) ~ mild eosinophilia ~ low ESR & CRP Marked & persistent nausea, dizziness intermittent vomitingabdominal pains & flatulencelethargy & physical fatigue Faecal test: Appearance Unformed stool Parasites Blastocystis hominis + Antigen test No Giardia or Cryptosporidia detected Culture No pathogens isolated (Ref 1) Dx: Intestinal Parasitesuggested Rx: Metronidazoleand Probiotics Taken to see Naturopath instead www.nutritionmedicine.org

  6. Oct~Dec 2005: attended Naturopath ~ Bioenergy testing performedDx: intestinal mucosal cell energy imbalance fermented soy protein,zinc carnosine,liquorice extract Rx: Herbal therapyGastroAid ArabinoGuard Zeolite drops Molybdenum Arabinogalactanglycoprotein Mineral ~ Clinoptilitecrystalline aluminosilicatesCa, Mg, K, Na 70% improved appetite energy Persistent nausea, dizzinessabdominal pains CDSA performed ~No abnormality apartfrom Blastocystis hominis Missed a lot of schooland social/sport activities No specific therapy offered www.nutritionmedicine.org

  7. Jan~April 2006: Naturopathic therapy continued Kinesiology testing continuedto show parasite presence Multiple remedies utilised ~herbal anti-parasitic agentsartemisia, barberryblack walnut, grapefruit seed ~Digestive aids Betaine HCl/Pepsin, Pancreatic enzymeProbiotics, Prebiotics, Colostrum ~Vitamins & minerals Remedies changed according to symptom history andkinesiology testing Health status reasonable Jan-April’06despite low-grade nausea andill-defined abdominal pains Attended school most days& played sport regularly www.nutritionmedicine.org

  8. MAY 2006 ~ Health statusdeteriorated markedly decreased energyfluctuating appetiteincreased nausea S/B GPFBE, ESR & CRP  normalBiochemistry  normalFaecal sample showed Blastocystis hominis Returned to naturopathfor ongoing treatment Prescribed metronidazole~ declined treatment Multiple herbal treatmentutilised on an ad hoc basis Has been unwell ever since then www.nutritionmedicine.org

  9. FEB 2007 ~ remains unwell Cytotoxic testingPositive reactions to: Cows’ milk 4+ Oats 4+ Metabisulphite 4+ Soybean 2+ Honey 2+, Persistent Low energydizzinessnausea & anorexia malodorous flatulenceNo diarrhoea S/B nutritional GPFBE Neutropenia, mild Eosinophiliamild Monocytosisnormal CRP, high ESR Dx: Intestinal parasitosisFood sensitivityImmune deficiencyIron deficiency Iron study: Iron 3 umol/L (10-33) TIBC 73 umol/L (45-70) Saturation 4 % (16-50) Ferritin 21 ug/L (10-140) TreatmentAdvised to stop milk & oats Herbal anti-parasite agents Iron supplementsCarnivora ~ immune stimulant www.nutritionmedicine.org

  10. May 2007 ~ remained unwell Chronic symptoms persist ~AND NOW~ Acute onset severe R heel pain ~ unable to weight bear ~ on crutches for 10 weeks S/B Integrative Medicine GP ~ Sever’s Disease (Ref 2) calcaneal apophysitis microtrauma related inflammation Multimodal Therapy ~ crutches for 10 weeks ~ physiotherapy ~ acupuncture ~ Chinese herbal therapy Settled after several months~BUT~ nausea, dizziness, abdominal pains low energy state persisted www.nutritionmedicine.org

  11. Aug 2007 ~ remains unwell Chronic symptoms persist S/B GPDx: vitiligoNo treatment ~and~ told not to worry Developed small white patches on forehead ~ non-pruritic~ not raised above skin surface Reacted to Slippery Elm~ increased nausea & abdominal pain S/B nutritional GPPrescribed Golden SealLemon Juice & Slippery Elm Continued all other~ herbal medicines~ digestive aids~ probiotics & prebiotics Vitiligo: ~ ill-defined pathophysiologyautoimmune, neurohormonal & apoptotic factors Ref: 5-6 www.nutritionmedicine.org

  12. Oct 2007 ~ still unwell S/B GP ~ Eye swab grewStreptococcus pneumoniae Acute conjunctivitisin L eyeerythemaswellingpustular discharge Nausea, dizzinesslack of energy physical tirednessabdominal painsflatulence Prescribed ~ Chloromycetin eye ointmentAmoxicillin caps Tolerated this well ~ mild (20%) increase in nauseano diarrhoea or increasein other symptoms www.nutritionmedicine.org

  13. early-Jan 2008 ~ chronic symptoms persist Developed pain in R hip and R wrist very painful wrist, couldn't write associated muscle weakness in both legs S/B nutritional GP: ~ X-rays showed NAD ~ FBE, ESR, CRP normal~ Viral serology negative No specific diagnosis Symptomatic treatment:with paracetamol/codeine and Hops/Curcumin herbal mix ~ slow recovery over 10 days www.nutritionmedicine.org

  14. Feb 2008 ~ chronic symptoms persist Woke early with myalgia/arthralgia:~ severe R calf & thigh muscle painwith soreness in hip, knee & ankle ~ less pain in L calf & thigh muscle pain more pain in L hip, knee & ankle ~ unable to walk or weight-bear ~ NO muscle weakness just pain on movement S/B various doctors ~ GPs,physician, rheumatologistPathology tests said to be normal ~ FBE, ESR & CRP ~ Blood biochemistry~ Rheumatoid serology~ Lupus serology~ arthrogenic virus serology Psychiatrist Dx:Functional disorder Symptom conversion Treatment:Amitriptyline No specific diagnosistold it was nothing serious Advised to stay active ~ only able to go swimming Chiropractor Dx:Fibromyalgia Due to virus infection ~ would slowly recover www.nutritionmedicine.org

  15. Feb~July 2008 ~ chronic pain persists Chronic leg pain:~ confined to wheelchair ~ unable to attend school ~ nausea, dizziness, fatigue abdominal pains persist Dx: Functional DisorderTreatment: ~ Amitriptyline ~ herbal anti-parasites ~ Chinese herbs~ Chiropractic Pain present most days ~ does wax and wane ~ but never goes away Nausea & dizzinessalso present most days ~ also waxes and wanes ~ but never goes away No obvious precipitating factors~ occasionally is able to walk around house swim in pool ~ always feels worse afterwards www.nutritionmedicine.org

  16. Mid-April 2008 ~ chronic pain persists Episode of tachycardia whilst on school excursion: ~ pulse measured on electronic machine was 200bpm ~ S/B nutrition GP & pediatrician shortly thereafter ECG study showed NAD No treatment offered ~ then S/B naturopath asked him to stop all herbs continue with only: Kinex, Echinacea, Arnica homeopathic, Caltrate, Panadeine NB: amitriptyline was also continued (ref: 7-8) ~ has had no further cardiac problem since ?? Amitriptylinecardiotoxicity www.nutritionmedicine.org

  17. Herbal / Nutritional Treatments Prescribed www.nutritionmedicine.org

  18. Past history: Normal pregnancy & delivery ~ mother had no problems during pregnancy ~ Long labour: OP position and 12 hour labour Breast fed for 3 years ~ commenced on rice cereal, veges and fruit puree at 4/12 NB: dairy foods & wheat products introduced about 12-18/12 age ~ thereafter ate quite a bit of cheese ~ egg & chicken introduced about 6/12 age www.nutritionmedicine.org

  19. Past History Sleep disturbance since infancy ~ ~ restless sleep ~ Mum says he gets to sleep OK ~BUT~ Daniel says he has difficulty getting to sleep ~ waking & thrashing around during night & also sleep talking NB: Chinese herbs in about Sept/Oct 2007 ==> ceased about 3-4 weeks ago ~ Mum has noted slight recurrence of sleep disturbance since then ~ on wakening does feel OK ~ sometimes feels tired on wakening * mostly wakes without any dream recall ~ No nitemares ~ Flatulence: ~ has had frequent malodorous flatulence and abdominal discomfort since age 2-3 yrs ~ tried exlcuding gluten grain  no effect Tonsillitis ~ several bouts ~ only after eating junk food Rx: amoxycillin or clarithromycin ~ perhaps x2-3 Suggests problems withserotonin/dopaminemetabolism Suggests digestive disturbance& enteric dysbiosis Suggests food sensitivity www.nutritionmedicine.org

  20. Family History Family History: ~ parents divorced when he was 3 years old • mother has hayfever & eczemaNB: Daniel gets eczema if uses normal soap • maternal grandmother has hayfever & sinus problems • maternal uncle had asthma ~ • Maternal grandfather: rheumatoid arthritis • Father has no medical problems • Paternal uncle has asthma • NO thyroid disease or other autoimmune disease in family www.nutritionmedicine.org

  21. CURRENT DIET • Diet: usually eats wholegrain bread & uses lactose-free milk B’fast: Rice bubbles or Corn-flakes + Lactose-free milk or soy-milk ~OR~ scrambled egg & toast ~ occasionally has Cheese on Toast Mid-am: Fruit or Muesli bar Lunch: S’wich with egg/lettuce ~or~ chicken/salad ~or~ ham/tomato + Fruit-juice Mid-pm: Muesli bar &/or Fruit Dinner: Meat (chicken, beef, lamb) ~ with steamed/stir-fried Veges Dessert: ice-cream (low lactose) & fruit ~ occasional custard Drinks: mainly water ~ 1 bottle fruit-juice a day www.nutritionmedicine.org

  22. Patient Assessment & Pathology Investigations: Nutrient status ~ Blood chemistry (MBA) Vitamin & Mineral status We want to direct Patient assessmentinto 4 main areas Metabolic status ~ Protein metabolism Carbohydrate metabolism Neurotransmitter balance Bowel Dysfunction ~ Bacterial dysbiosis Parasites Digestive efficiency Immune activity status ~ Inflammation activity Food sensitivity Bowel flora Hormone status ~ Adrenal hormones Thyroid hormones www.nutritionmedicine.org

  23. Physical Examination Physical Examination: with children always check past growth ~ height & weight • Height: 148.5 cm, Weight: 32.1 kg, BMI: 14.6 ~ • NB: percentiles are OK but show no significant weight increase over past 36 months ~ ? Reflects low anabolic/catabolic balance www.nutritionmedicine.org

  24. Body Mass Index Chart The fall in BMI between age 7~10 indicates a decrease in lean mass Protein depletion state ~ ? Cytokine related catabolism www.nutritionmedicine.org

  25. Physical Examination • Temp: 36.9 oral, Resp. rate: 12 • CVS: • BP(Lying): 90/50, Pulse(Lying): 80 and Irregular with marked sinus arrhythmia, HS dual, No cardiac murmur, all pulses palpable & equal, • Peripheries: • cold fingers & toes, impaired capillary perfusion >2s, finger pulp atrophy 2+, NB: significant carotenemia +++ • Nails soft & heavily chewed 4+, horizontal grooves 2+, whitespot 3+ • Chest: • pectus excavatum 2+, good air entry, normal BS, No rales or wheeze ? Magnesium/taurine depletion ? Magnesium depletion Protein depletion Protein/zinc depletion www.nutritionmedicine.org

  26. Physical Examination Impaired digestion • Abdomen: • bloated stomach & small intestine, • Tender over: • stomach 3-4+, intestine 3-4+, caecum 3-4+, descending colon 3+, • No hepatic tenderness or organomegaly, • Nervous System: • No cranial n deficit, normal motor & sensory function, • coordination not impaired, • reflexes R= L and hyperactive, • balance impaired ~ failed visual Tandem Stance test • (? due to leg pain) Enteric inflammation& dysbiosis ? Magnesium depletion ? Neuronal dysfunction www.nutritionmedicine.org

  27. Physical Examination ? Immune activation • Face: • scattered target vitiligo lesions & frontal scalp whitening • No other diagnostic signs • Mouth: • crimson crescents 3+, posterior pharyngeal lymphopid hyperplasia, • Neck: • thyroid impalpable, • several large & tender submandibular & cervical nodes • 7-8mm L S/M apex and 17-18mm just below that ~ scattered lymphodynia in L & R anterior & posterior cervical triangles Immune activation Immune activation? infection www.nutritionmedicine.org

  28. Physical Examination • Trunk: • large ecchymotic bruise on posterior-upper L shoulder • associated muscle tenderness in L shoulder girdle, paracervical & upper arm muscles • MSK: • Tender active TPs over alarm points for Liver, spleen/pancreas, gallbladder meridians • Tender 3-4+ in quadriceps, adductor & calf muscles both legs • Hamstring muscles surprisingly not tender • Scattered tenderness in L forearm & deltoid muscles • No spinal muscle tenderness • No overt joint tenderness on palpation • Marked pain on movement of ankles, knees & hips ~ but not forefoot or toes • Joint crepitus noted in R knee 2+ www.nutritionmedicine.org

  29. Possible Diagnoses ~ • long-standing food sensitivity problem ~ {probably IgG antibody reactions} •  increased intestinal mucosal permeability •  increased absorption of bacterial endotoxin & food fragments •  further immune system activation via intestinal CD4 sentinel T-cells • Acute infection from farm chronic infection • possibly Salmonella or Blastocystis • nausea may be related to impaired liver bile salt conjugation or ? Enterovirus colonisation in stomach • End result is bacterial overgrowth in small intestine affecting: • Intestinal digestive function • Immune system activation www.nutritionmedicine.org

  30. Pathology Results ~ red cells Red cell parameters show no diagnostically helpful features ~ with normal haemoglobin level and red cell count www.nutritionmedicine.org

  31. Pathology Results ~ Platelets, ESR & CRP Platelet count is above optimal ~ this may reflect inadequate Vit E status (ref 10) Normal C-reactive protein & ESR indicate no systemic inflammation present www.nutritionmedicine.org

  32. Pathology Results ~ leukocyte count Low neutrophil count & neutrophil/lymphocyte ratio may reflect protein/zinc depletion High eosinophil count suggests allergy process and/or intestinal parasite infection Zero basophil count may reflect low histamine state ~ suggests lack of niacin  impairs gastric acid production, serotonin balance and energy production www.nutritionmedicine.org

  33. Pathology Results ~ protein status The high Urea/Creatinine ratio suggests high protein catabolism rate ~ whilst the low PMI suggests protein catabolism exceeds synthesis www.nutritionmedicine.org

  34. Pathology Results ~ salt balance Normal blood sodium & potassium levels ~BUT~ the low urinary sodium and serum aldosterone indicate impaired salt regulation with adrenal insufficiency ~ associated with chronic fatigue and fibromyalgia (ref 11) www.nutritionmedicine.org

  35. Pathology Results ~ calcium balance Normal blood calcium & phosphorus levels ~BUT~ the low Ca/Phos ratio, low urinary calcium excretion & low Vit D level indicate low calcium status related to Vit D insufficiency ~ NB: associated with chronic fatigue and fibromyalgia (ref 11) www.nutritionmedicine.org

  36. Pathology Results ~ iron status These results indicate iron deficiency ~ despite taking an iron supplement and eating red meat daily  this implies impaired intestinal absorption www.nutritionmedicine.org

  37. Pathology Results ~ other minerals The low magnesium and zinc excretion indicates high-level renal conservation ~ indicates magnesium & zinc deficiency Low iodine reflects moderate deficiency state ~ according to WHO Standards The high bone telopeptide level indicates a very high rate of bone tissue breakdown www.nutritionmedicine.org

  38. Pathology Results ~ Immune function tests The high IgG immunoglobulin may reflect increased immune system activation Low antigliadin antibodies and negative TTG antibody level excludes Coeliac Disease www.nutritionmedicine.org

  39. Pathology Results ~ Food Reactivity The high IgE immunoglobulin level reflects an allergy process or intestinal parasites ~ whilst the RAST shows positive allergy reaction to Gluten ~ possibly also mould mix High normal IgG immunoglobulin level suggests possible immune cell activation ~ whilst the IgG food antibody tests shows positive reactivity to Cows' milk and nut mix www.nutritionmedicine.org

  40. Immune function tests Serology tests Thyroperoxidase ABs71~ NR: 0 - 60 Antinuclear ABs Negative serology anti-DNA ABs Negative serology anti-ENA ABs Negative serology Anti-myelin ABs Negative serology Anti-neuonal ABs Negative serology H pylori ABs Negative serology Strongyloides ABs Negative serology EBV Abs Negative serology RRV ABs Negative serology Barmah Forest Virus Negative serology www.nutritionmedicine.org

  41. Hormone status ~ thyroid Thyroid function is apparently normal ~ despite iodine deficiency and the production of thyroid autoantibody ~NB: low-grade autoimmune thyroiditis present www.nutritionmedicine.org

  42. Hormone status ~ adrenal These results indicate impaired adrenal steroid production ~ unknown cause www.nutritionmedicine.org

  43. Summary: so far, we have identified multiple nutritional problems ~ • Elevated protein catabolism with associated protein depletion • Chronic salt depletion with low aldosterone production • Vit D deficiency with calcium depletion • Iron, zinc & magnesium deficiency • Food sensitivity ~ gluten, cows’ milk protein, nuts, mould • Impaired adrenal steroid production Still need to define: • Metabolic status • Bowel flora imbalance www.nutritionmedicine.org

  44. Urinary metabolite analysis These metabolite results indicate normal fat and carbohydrate metabolism www.nutritionmedicine.org

  45. Urinary metabolite analysis These metabolite results indicate normal TCA cycle activity ~ the undetectable alpha-ketoglutarate implies inhibited glutamate cycling ~ ? XS ammonia load www.nutritionmedicine.org

  46. Urinary metabolite analysis The high B-hydroxyisovalerate level suggests inadequate Vitamin B2 & Biotin status ~ (ref 12-13) High formiminoglutamate indicates inadequate folate status and impaired methylation capacity ~ this may alter monoamine neurotransmitter balance in the brain. www.nutritionmedicine.org

  47. Urinary metabolite analysis Dopamine metabolite Noradrenalin metabolite Serotonin metabolite The low urinary neurotransmitter metabolite levels ~ suggests low neurotransmitter synthesis ~low serotonin & noradrenalin activity is reportedly associated with fibromyalgia (Ref 14) www.nutritionmedicine.org

  48. Urinary metabolite analysis The elevated urinary indican indicates bacterial breakdown of dietary tryptophan ~ it suggests bacterial overgrowth in the intestine ~ and implies inadequate protein digestive capacity. www.nutritionmedicine.org

  49. Urinary metabolite analysis The D-lactate level is high-normal ~ may be related to many years of Lactobacillus probiotics www.nutritionmedicine.org

  50. Lactulose Breath Hydrogen Test www.nutritionmedicine.org

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