Patient case history
A 20 year old, Asian male patient (BRR) complained of sudden onset of depression and suicidal thoughts almost all the time. He had shifted from India to New Zealand 6 months back to pursue further studies. He took part time job of cleaning utensils and kitchen in a restaurant and within 2 weeks his depression had started. He would describe himself going into a state in which his mind would go blank and he would struggle to even remember his name. He started struggling in his studies and his grades started falling.
Patient suffers from stammering issues since childhood suggesting an underlying psychological stress. But he never had suffered from anxiety or depression before and there was no family history of depression either. Shifting to another country, with new college and job, new culture etc. could have been stress triggers. Both physical and mental stress was likely to be underlying cause of his conditions.
Apart from depression, he was suffering from skin infection – periorbital (under both eyes) and on the lateral side of left cubital fossa along with nasal sinusitis since past 2 months. Clinical signs and symptoms of his skin infection included red itchy lesions with classical ringworm pattern, red bordered lesions with oozing with crustation, constant itching and flaking of the skin which would bleed a bit after scratching. His complaints of sinusitis included runny nose and headache which he thought was probably due to pollen allergy.
No investigations were done and both conditions were being treated: topical steroid cream for skin infection and oxymetazoline nasal spray, with no change in clinical signs and symptoms. He didn’t have past history of chronic or allergic sinusitis or other allergies, although his brother and father suffer from allergic sinusitis. Since there was no change/improvement in his condition after 2 months of topical treatment, he was prescribed an antibiotic course for a week. After the antibiotic course, all his signs and symptoms worsened and then he contacted me for solution.
Because of geographical separation, doing any physical examination or prescribing any investigations and medications was not possible. Based on his description and examination of the photographs, the skin infection was suspected to be fungal in nature. He was living with his uncle (who was suffering from drug resistant fungal infection since 20 years) and an aunt (who was suffering from depressive bouts once every few months since 20-30 years) – suggesting he contracted infection from them.
He was advised to start with Phosphatidylserine (300 mg PO BD for 3 months) to lower his cortisol levels. The rationale being: his physical and mental stress must have elevated cortisol and thereby lowered IgA levels; allowing fungal infection to grow. Fungal infections are known to alter the mood of a patient. Within 3 days of serine, the periorbital skin infection completely cleared off and his sinusitis symptoms had improved by 50%. His depression and skin infection of cubital fossa persisted although there was an improvement in both conditions. Within a month the patient flew down to India and then a proper treatment plan was devised.
Past medical history
- No other significant medical history.
- No immediate family history of mental disorders or depression or suicide.
Concomitant medications – None, all his medications were stopped
|Tests||Findings (only the significant findings are given)|
|Genova’s 20 amino acids blood spot test
|Complete blood count with and serum iron||· Increased RBC count with a slightly elevated red cell distribution width – indicating infection, hypoxia and low iron
· High lymphocyte percentage (with a normal lymphocyte count) – indication infection
· Elevated IgE – indicating parasitic infection or allergy
· Low vitamin D3
|Liver and kidney function tests||Elevated total bilirubin (including direct and indirect bilirubin) – indicating RBC destruction due to infection|
|Urine examination||Presence of pus cells (15-18/hpf)|
|Stool examination||Presence of E. Histolytica (0-1) and mucous|
|Stool culture||E. Coli sensitive to IV Cefoperazone/Sulbactam|
Treatment approach from Functional Medicine point of view
- Supplemental amino acids – (PO for 3 months)
Arginine (3gm BD), Taurine (3gm BD), Glycine (5gm BD), Glutamine (5gm BD) and Tryptophan (500 mg BD) along with Phosphatidylserine (300mg BD)
|Typtophan||Low tryptophan indicates that levels of serotonin might be low along with high utilization of interferon gamma quinolinate (a precursor of interferon gamma: hence IFG was given)|
|Histidine||High histidine indicates presence of allergy|
|Phenyl alanine||Decreased phenylalanine indicated need to form excessive stress hormones|
|Glycine||Low glycine indicated that probably it was being used to conjugate xylene (probably present in the cleaning supplies used by him for cleaning utensils at his part time job). Low glycine with normal theonine indicated lack of vitamin B6 required for conversion of theonine to glycine.|
|Taurine||Decreased taurine indicates lack of vitamin B6 and presence of allergy|
|Low citrulline indicates lack of arginine
Normal ornithine indicates lack of glutamic acid, thus low conversion of ornithine to citrulline
|Increased aspargine with low aspartic acid indicates removal of ammonia from body to compensate low arginine|
- Supplementation of vitamins – (PO for 3 months)
Vitamin B complex (2 per day)
Vitamin B6 (40 mg, 2 per day) – for theonine to glycine conversion
Vitamin B5 (1gm per day) – for glycine conjugation to xylene
Vitamin D3 – 60000 IU once a week
Zinc (20 mg, 1 per day) –strong anti fungal
Tab Fersolate CM OD (ferrous sulphate 0.195 g, copper sulphate 2.6 mg, manganese sulphate monohydrate 2 mg) – to balance out zinc and correct low iron
Chelated magnesium 200mg OD
S-Adenosylmethionine (SAMe) – 200mg OD
- Guna’s Interferon gamma and Interleukin 12 (20 drops of each twice a day for 3 months)
- For fungal infection
Oral fluconazole (100 mg QID for 1 month)
Homeopathy Berberis vulgaris Q (20 drops twice a day for 3 months)
Hemoclean syrup (10 ml BD) and tab Radona (2 per day) – both are herbal supplements used as an antifungal, a treatment modality popular in India)
- Saccharomyces boulardii (500 mg PO BD) and lactobacillus acidophilus (1 billion spores PO BD) for 3 months
- For parasitic infection – following course was given in a sequence (total 10 days)
Tab Ivermectin 12 mg PO single dose on first day
Tab Praziquontol 600mg PO (21/2 tabs TID) on second day
Tab Albendazole 400mg PO (2 per day) for next 3 days
Tab Metrogyl 400mg PO BD for next 5 days
- UGI clean (D-mannose) – 2 PO sachets/day for 1 month
- After completion of 3 months treatment plan, fungal infection had completely healed; and then IV Cefoperazone (1gm) and Sulbactam (0.5gm) BD for 5 days was initiated to remove E. Coli infection. Antibiotics were not given before as it could have aggravated fungal infection.
Outcome at follow up visit after 1 month
At one month follow up, fungal infection of cubital fossa had almost healed. There was no itching left, only discolored lesion was present. His mental state had improved; bouts of depression would come once a week lasting for about an hour or so.
Outcome at follow up visit after 3 months
After 3 months of completion of full treatment course, his depression had almost gone. The bouts of depression would rarely come and whenever he had them, he would recover on his own within 5 minutes or so. His mood had uplifted, wherein he started socializing, interest in studies renewed, taking part in events etc. He started going to gym and eating right to take care of his health and body. The cubital fossa lesion had completely healed and disappeared and all his sinusitis symptoms were eliminated.
As mentioned above after 3 months of treatment; a 5 day IV antibiotics course was given to eradicate E.Coli infection. A stool culture done prior to the IV antibiotics showed that the E.Coli was gone but Klebsiella was present (perhaps the UGI clean eliminated the E. Coli and Klebsiella overgrew). Post antibiotic course, the patient reported to be completely out of depression and felt that he was being his old self. He was feeling energized and happy to take on the challenges of life. The subsequent stool and urine tests showed no presence of any infections left in his system.
Concurrent fungal, E Coli and parasitic infections produce toxins, stimulating the toxin receptor of the brain. It also produces ammonia overloading and disrupting the urea cycle. Usually the arginine removes it from the body, eventually its levels dropped. This leads to neural disturbances, increasing production of stress hormones like nor-epinephrine, cortisol causing mental disturbances. Anxiety rapidly utilizes magnesium and methionine to aid in removal of nor-epinephrine. This lowers taurine and glutathione leading to a cycle of unmitigated oxidative stress.
The cleaning supplies contained xylene, this exposure depleted glycine levels. Glycine is a precussor to glutathione and also an inhibitor to the NMDA receptor and a precursor of serine. The elevated cortisol and lowered secretory IGA enabled the E.Coli to grow in the biofilm of the intestine, which further lowered serine. Lowered serine levels lead to the severe mental disturbances and also blocks the formation of cystathione a step dependent on serine and vitamin B6.
The lowered tryptophan indicated a possible low serotonin and an elevated quinolinate which is a glutamanergic stimulator. Quinolinate is a precursor of interferon gamma: hence external IFG was given to help kill fungal infection and lower utilization of tryptophan to balance serotonin levels.
Thus the basic plan of action was to eliminate the infections and supplement the body with the required nutrition to restore the balance. Supplementation compensated the amino acid and vitamin deficiencies. The anti-parasitic, anti-fungal and anti-biotic treatment eliminated the infections from the body. Once all systems were restored, the depression reversed out.
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