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AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS this can result in the acquired immune system producing antibody against gliadin and tissue transglutaminase (TTG; TTG binds gliadin and presents it to the immune cells) which may lead to damaged enterocytes. A key feature of celiac disease is the blunting of intestinal villa due to autoimmune destruction. What is gluten sensitivity? Gluten sensitivity is considered distinct from Celiac Disease because gluten sensitivity is not accompanied by the development of anti-tissue transglutaminase nor does it appear to be an autoimmune phenomena.(32) Gluten sensitive individuals can test positive for antigliadin antibodies. They do not have the characteristic autoimmune damage to the intestinal villa. Both GS and CD can present with similar clinical features. GS is thought to be under-recognized and therefore under-treated. Gluten sensitive individuals will respond to a gluten-free diet and may experience improvements in a wide variety of symptoms. Tying it all together The following is an very complicated clinical case involving a patient struggling with the development and management of autoimmune disease. Complicated problems require the management of multiple systems, particularly the gastrointestinal tract. It further illustrates the utility of addressing food sensitivity, and the often dramatic clinical improvement seen when inflammatory foods are identified and removed. Clinical Vignette TT is a 33 year old white female G4P4 who presented with worsening fatigue since the delivery of her fourth child three years ago. She had a 12 year long history of peculiar medical problems including flank pain, abdominal pain, pelvic pain, urinary urgency and frequency. Relevant past medical history was positive for atopic dermatitis and asthma for which she used a leukotriene inhibitor. Her pregnancies were complicated by preterm labor symptoms, allergic reactions, hives, and she was admitted to the intensive care unit during two of the four pregnancies due to these reactions. All deliveries occurred after 37 weeks gestation. 78 2012 After the delivery of her fourth child, her health began a rapid decline, and over the next 2 years she experienced symptoms including fatigue, low grade fever and chills, low body temperature, lower extremity arthritis, nocturia of 4-6 times per night, and frequent urinary tract infection symptoms. Periodic documented positive urine cultures showing E. coli and P. mirabilus. TT sought care from specialists in gynecology, nephrology, general surgery and urology during a 6 year period. She received diagnosis, such as kidney stone, cysteinuria and appendicitis. Multiple CT scans during this time period were normal with the exception of a small
AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS However, her arthritis worsened and she periodically needed assistance with crutches, especially during her menstrual periods. Her fatigue and mental sluggishness persisted and she continued to need narcotic painmedication at least once daily. She sought care from a physiatrist specializing in acupuncture and manual medicine and began neuroleptic and antidepressant medications (Neurontin, Lyrica, Cymbalta, and Celexa). The side effect profile of these medications were not well tolerated. Approximately one year after the diagnosis of Bladder Pain Syndrome (IC), she return to her gynecologist who recommended a 4 point saliva test and comprehensive thyroid testing. Thyroid labs were suboptimal with a TSH of 3.2, free T4 of 0.8 and free T3 of 1.1 with positive thyroid peroxidase antibodies. Low basal body temperature testing showing follicular phase axillary temperatures below 97F was consistent with subclinical hypothyroidism.(3) Salivary cortisol testing was very low across all four points with a low DHEA and low 17-hydroxyprogesterone, consistent with adrenal insufficiency. The patient began a nutritional regimen including zinc, copper, and selenium to support thyroid function, herbal adaptogens (Ashwaganda and licorice), multivitamins, Lcarnitine, vitamin D3, and adrenal extracts. She started Armour thyroid 30mg daily. She saw dramatic improvements in sleep, energy, and mood within a few days. She gradually withdrew neuroleptic medication and reduced her use of narcotic pain medication over the course of a six month time period and was able to begin a modest exercise regimen. Bladder pain improved approximately 50-60% and she reported once per night nocturia. Follow-up testing revealed a TSH of 1.8, free T3 2.0 and free T4 1.2 with persistently positive thyroid antibody titers. Over the course of the following 6 months she continued to improve in all aspects of her health and wellbeing, however suffered with moderate bladder pain and arthritis. An ALCAT food sensitivity panel was then ordered. Within 2 weeks of implementation of the diet, she experienced near complete resolution of bladder pain 79 2012 and arthritis. She continued to improve in all measures and needed pain medication only periodically. Two to three months after this marked improvement, she began to experience facial swelling which she attributed to accidental exposure to pork, a severe intolerance food.This swelling persisted and was followed by increased energy, sweating, insomnia, and a general shift in her mood toward anxiety. She was seen by an integrative medicine specialist during this time who placed her on a variety of supplements but did not address the facial swelling. Her anxiety continued to worsen and she developed more profuse sweating and a rapid heart rate; subsequent thyroid testing showed her TSH to be nondetectable with free thyroid hormones in the thirties and by this time she appeared to be in a state of thyroid storm with an exam revealing a resting pulse in the 130s, exopthalmos, and a goiter. Radioactive iodine uptake scan revealed a diffusely active thyroid gland and she was started on methimazole and propranolol by her endocrinologist. One year later she has continued on this medication regimen to suppress thyroid hormone production and has had persistent thyroid antibodies despite broad nutrient and mineral supplemenation, avoidance of inflammatory foods, oral IgG powder, antioxidant treatment, herbal therapy with Moducare, and 10 courses of hyperbaric oxygen therapy. Considerations have been made for radioactive iodine ablation of the thyroid as well as treatment with a disease modifying agent for rheumatoid arthritis which has shown some benefit in Graves’ eye disease. Lessons Learned In retrospect, this patient has had signs of immune system imbalance since childhood, becoming more overt as she aged with the development of asthma, atopy, and hives. From this case we may learn that patients with a baseline of immune hyperactivity or imbalance may be at risk for autoimmune disease, especially when they experience multiple stressors to the immune system. Longstanding inflammation, chronic pain, and physiologic stress may have worked to further imbalance her immune system.
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