Immune/Allergy

Group 7December 6, 2010

Case Presentation

• It’s the end of the day on a Friday evening. You the chiropractor are about to close up shop when a woman with her small child walks in the office. Her name is Mary and her child is a six-year-old boy named Chad.

• After initial paperwork, you get down to business by asking Mary why she and Chad have come to the office.

Case Presentation

• “Chad’s been diagnosed with autism recently by the doctor and my husband Frank and I have tried everything to help him. He’s been on medications and has been given antibiotics since he was younger, which at first seemed to help but lately it seems like they have really made him sick.”

• You notice Chad has a runny nose and his ears are red.

Case History Question #1A

• 1. A. “When did you first notice his overall change in behavior?”

• “He has had a hard time with this since he was about two years old. It just seemed to gradually come during that time. Before that time he was a perfectly normal and happy kid.”

Case History Question #1B

• 1. B. “What happened?”• “Chad did receive his shots when he was about

two years old, but just the routine ones for measles, mumps and rubella. Shortly after this, another round of antibiotics for yet another ear infection seemed to be the last straw. He hasn’t been the same since. He has had recurrent ear infections and his doctor has prescribed antibiotics multiple times over the past four years.”

Case History Question #2

• 2. “Can you explain the specific changes in behavior and health that are most noticeable to you?”

• “Well at school we had to put him back in pre-school because the teachers were having a hard time successfully communicating with him when he was in kindergarten. It’s frustrating. Even at home there are times when we just can’t seem to understand what he wants.”

Case History Question #3

• 3. “Does your child interact with other children his age?”

• “At school, the teachers have noticed, along with his communication problems, that Chad appears lethargic compared to the other kids his age. When we’ve watched him at the park with a lot of kids around him, he seems to get in his own little world and doesn’t respond very much when other kids want to play with him.”

Case History Question #4

• 4. “Would you consider your child to be a picky eater?”

• “It’s nearly impossible to get him to eat anything. Sometimes it’s just Cherrios. Other times it is macaroni and cheese.”

Case History Question #5

• 5. “Does your child have any allergies?”• “Yes. He’s definitely allergic to peanuts, and

I’m beginning to think he’s allergic to other foods because sometimes he breaks out in a horrible rash on his lips together with a runny nose and red ears like he has now.”

Overall Case History Findings• Poor language development• Poor social skills • Anxiety• Stimming• Poor motor skills• Poor coordination• Hyperactivity and distractibility• Low weight for age• History of chronic illness: recurrent otitis media and rhinitis• Persistent rash on lips• Redness on ears • Gastrointestinal disturbances (diarrhea and constipation)• Known allergy to peanuts

DDXPostural alterations (781.92)

-Causing insufficient afferent input to his developing NS, resulting in Sensory Ataxia (781.3)

Spinal subluxations (739.1, 739.2, 739.4)-Resulting in aberrant nerve function

Nutritional Deficiency (V12.1)- Caused by: Intestinal Candidiasis

Intestinal HyperpermeabilityGluten sensitivityCasein sensitivityImpaired methylationMercury toxicity

Lab Tests• Great Plains Laboratory:

– Amino Acid Plasma – Comprehensive Stool

Analysis– Essential Fatty Acids– Glutathione– Organic Acids Test– Gluten-Casein Peptide Test– Metals Urine Test (24hr)

• ImmunoLabs:– Immuno Bloodprint- IgG

ELISA Food Sensitivity Assay

– IgE Airborne & Food Allergy Assays- Standard Food and Mold

Lab Testing (cont.)

• Metametrix:– Elements Analysis-

Erythrocyte and Whole Blood

– Fat Soluble Vitamins– Lipid Peroxidase

• Total Costs=– $1237– $1414– $788

$3439

Lab Results: Great Plains Laboratory

• Amino Acid Plasma– Low methionine- a sulfer

AA, a key element in methylation process

– Low phenylalanine-NT/precursor

– Low tyrosine-NT/precursor

– Low cysteine-Detoxification

• Comprehensive Stool Analysis– Positive for yeast,

carbohydrates, and decreased beneficial flora

Lab Results: Great Plains Laboratory

• Essential Fatty Acids– Low EPA- Pro-

inflammatory status– Low DHA- Pro-

inflammatory status– Low GLA-

neuropathology or behavior disorder

• Glutathione– Low– Used in the methylation

process for detoxification

Lab Results: Great Plains Laboratory

• Gluten-Casein Peptide Test– High relative ratio P/C-

Casomorphin– High relative ratio P/C-

Gliadorphin

• Organic Acids Test– High arbinose- indicates

yeast overgrowth

• Heavy Metal Urine (24 hr)– High levels of Mercury

Lab Results: Immunolaboratories

• IgG ELISA Food Sensitivity Assays– Sensitive to cheese,

cow’s milk, wheat, barley, malt, oat, quinoa, rye

• IgE Food Allergy Assay– Allergic to peanuts

Lab Results: Metametrix• Elements Analysis-

Erythrocyte and Whole Blood– Low Zinc- impairs digestion,

methylation, immune response. A vital component for cognitive function

– Low Magnesium- decreased methylation, sulfation and enzyme activation

– Low Selenium– High Copper- Inverse related

to zinc– High Mercury

• Fat Soluble Vitamins– Low vitamin A– Low vitamin E– Low vitamin D

Deficiency of these vitamins indicate low intake and GI abnormalities that hinder absorption

Lab Results: Metametrix

• Lipid Peroxidase– High – Indicates an inability

to control free radical formation

– Antioxidant supplementation is needed.

• www.greatplainslaboratory.com

• www.immunolabs.com• www.metametrix.com

Physical Exam

• Posture Assessment• Romberg’s and Mittlemeyer’s• Cranial Nerves• Hopscotch• One leg stand

Test results

• Posture Assessment with PosturePrint demonstrates:– Right head tilt– Anterior head carriage– Bilateral internally rotated shoulders

• Dramatic left sway with Romberg’s• 45 degree left turn with Mittlemeyer’s– Indicating left cerebellum deficit

Test Results• Bilateral dilated pupils- indicating anterior canal

activation and anterior head carriage• Problems with left lateral gaze due to left

cerebellum deficiency• Scent detection was negative on the right and

identification was negative on the left

• Hopscotch and standing on one leg while throwing and catching a ball showed marked incoordination- indicating aberrant nerve function and inadequate afferent input

DX

• Sensory Ataxia (781.3)• Nutritional Deficiencies (V12.1)• Somatic dysfunction

-cervicothoracic 739.1-thoracolumbar 739.2-sacroiliac 739.4

Treatment OutlineFirst Day– Consultation and Physical

Exam– Order Necessary lab test

2 weeks after consultationStage II Nutritional Treatment -Specific food reaction diet based on testing (eliminate allergies- IgE, and insensitivities- IgG)-The Sensitive Six Elimination Challenge to determine intolerances-Additional supplementation based on testing

Second DayStage I Nutritional Treatment • -GF/CF Diet

-Dig. Enzymes, Probiotics, Supplementation for support of the GUT- Anti-yeast diet-Feingold Diet to reduce phenols and toxins

-ROF: Chiropractic Treatment plan- 1st Adjustment and Active Care

• Phase 1: 5x/wk for 4 weeks• Phase 2: 3x/wk for 12 weeks• Phase 3: 2x/wk for 6 months

Treatment Description

• A trial of chiropractic adjustments and therapeutic activities to increase afferent input into the nervous system

• Improve coordination with repetitive actions. • Strengthening inhibited muscles and moving in the

sagittal plane will allow changes in posture to take placeincreased facet loading and subsequent increased sensory input to the brain.

• A trial of nutritional supplementation and remodel the diet to overcome nutritional deficiencies, gut dysbiosis and impaired methylation.

3 Pillars of Treatment

Based on our physical exam findings and lab results, our goals are based on:

• Eliminating spinal subluxations• Correcting alterations in posture• Remediating nutritional deficiencies

Nutritional TreatmentStage I

• Probiotic: Lactobacillus acidophilus GG $25/1 month supplyDose: 10 billion cells/day

• Houston’s HN-Zyme Prime $25/ 3 month supplyDose: 1 capsule w/ meals (gradual approach)

• Houston’s AFP Peptizyde (protease) $30/3 month supplyDose: 1 capsule w/ meals (Begin after Zyme Prime is well tolerated. Start at ¼ capsule at meals and increase to 1 capsule per meal after 1 month)Includes DPP4 and protease to digest gluten, casein and soy without fruit extracts.

• Candex $45/1 month supplyDose: 2 capsules 1x/day 1 hr

• Candida Defense Formula $30/ 45 day supply ***Dose: 2 capsules/day

• Houston’s No-Fenol $30/ 90 capsulesDose: PRN

GFCF Diet• Gluten– Found in all wheat, rye, barley, and most oat products

• Casein– Found in all dairy products

Both are proteins that leak into the gut, undigested, and attach to morphine receptors of the autistic child’s brain. Essentially, many autistic children are “drugged” on wheat and milk products, as if they were on a morphine drip.

They also inhibit digestive function which leads to a decrease in nutrient absorption.

Anti-Yeast Diet

• Yeast (candida) overgrowth can lead to yeast infection and leaky gut syndrome. This causes a decrease in nutrient absorption as well.

• It is found in most breads and vinegar. Some vinegar containing foods are mayonnaise, salad dressing, bbq sauce, and pickled foods. Also avoid fermented foods like sauerkraut or cider, and all cheeses.

Feingold DietOriginally developed for people with allergies but now

used for much more.

REMOVE ALL ADDITIVES

Also remove aspirin and foods containing salicylates.

People with autism were found to have very low levels of phenol-sulphotransferase-P (PST). If you have a PST deficiency, it is harder to get rid of natural toxins (like salicylate) or phenolic additives (like food dyes).

Sample Breakfast• 1) Gluten and casein free cereal with coconut

milk. Cut up fruit to sweeten.

• 2) Eggs, nitrate free sausage or bacon, and toast with CF margarine and low sugar jelly.

• 3) GFCF waffles or muffins.

Watered down juices and alternative milks are fine.

Sample Lunch• 1) Almond butter and jelly (Welch’s 100% grape

jelly) on millet bread. Cascadian farm french fries.

• 2) Boars head lunch meat (GFCF) on Glutino premium bread with carrots, celery, and almond butter.

• 3) Hebrew National Reduced Fat hot dogs on Kinnikinnick buns and apple slices.

Watered down juices and alternative milks are fine.

Sample Dinner• 1) Steak with spinach and potatoes (non-

prepackaged).

• 2) Chicken breast battered in GFCF bread crumbs and rice spaghetti noodles over tomato sauce, and a salad.

• 3) Baked salmon with sweet potatoes, steamed broccoli, and corn.

Watered down juices and alternative milks are fine.

Nutritional TreatmentStage II

• Specific Food Reaction Diet- Remove the following foods indefinitely:Sensitive to : Cheese, cow’s milk, wheat, barley, malt, oat, quinoa, ryeAllergic to: Peanuts

• The Sensitive Six Elimination Challenge:

• Eliminate the following-1. Wheat2. Dairy3. Corn4. Eggs5. Soy6. PeanutsAny other food the child craves

• Note any changes in behavior and symptoms for 10 days

• Add corn, eggs, soy and craved foods back to the diet one at a time every two days, and observe for reactions. (ie. Bloating, swelling, HA, behavior problems)

Nutritional TreatmentStage II

• Vitamin C 250-2000mg **New beginnings Buffered Vitamin C. 2 capsules ( 700mg) $25/3 month supply

• Vitamin E 100-400i.u. New beginnings Vitamin E $20/ 3 month supply(400 i.u.)

• Zinc 20-60 mg New beginnings Chelated Zinc 1 capsule (54 mg) $15/2 month supply

• Calcium 400-1000 mg **100 mg from Buffered Vitamin C

• Magnesium 100-500 mg **100 mg from Buffered Vitamin C

• Cod Liver Oil (Vitamin A and D, DHA) 1-3 tsp Carlson’s Cod Liver Oil 1 tsp. $35/3 month supply

• Vitamin D 400-800 i.u. *** 400 i.u. in Cod liver oil

Nutritional Treatment Stage II

• EFAs 2-6 capsules EPA/DHA;GLA 80-240 mg -New beginnings Ultra Omega-3. 4 capsules (4000 mg) $40/1 month supply.-(1200 mg) in cod liver oil-Evening primrose oil 1 capsule (120mg) $20/3 month supply.

• Curcumin 500-1500 mg New beginnings Curcumin. 6 capsules (850mg) $15/4 month supply

• Transfer factor 200-1800 mg 4Life Transfer Facto-Tri Factor. 2 capsules (600 mg) $45/2 month supply

• Folinic Acid 800-1600 mg New beginnings Folinic Acid 1 capsule (400mcg) $15/ 4 month supply

• Methylcobalamin1250-2500 mcg nasal spray Available by prescription only. 1250 mcg MB12 and 300 mcg Folinic acid per spray.

• Dimethylglycine (DMG) 125-1000mg New beginnings DMG-125. 1 tablet (125 mg) $25/3 month supply

• Quercitin 600-1800 mg Nutri-West Quercetin-S. 4 capsules/day (800 mg) Price unknown

Chiropractic Treatment

GOALS• Eliminate Spinal Subluxations

•Correct Posture Alterations•Remediate Nutritional Deficiencies

Phase One

• See patient 5x/wk for 4wks• Adjustments– Restore Cervical curve– Focus on areas of the spine that innervate the gut– Adjust left side– Address ribs to increase chest expansion

Phase One

• Therapeutic Activities• Interactive Metronome• Jumping jacks, one legged stance, basketball,

hopscotch and catch

– Posture:• Shoulder blade squeeze, wall angels, wall angels with

resisted neck extension, cervical lateral flexion to the left and left lateral arm raises

4th Week Assessment

• Posture Assessment revealed improvements in head tilt and anterior head carriage

• One Legged Test the child was able to hold the test position for 10 seconds with falling out of the test position to the left

• Romberg’s test and Mittelmeyer’s march results showed the child deviation to the left side

• Cranial Nerve Assessment revealed a decrease in pupil size, improved lateral gaze, and scent awareness in the right nostril

• Hopscotch showed improvements in coordination

Phase Two

• 3x/week for 12 weeks• Chiropractic care – continue as described in phase one

• Therapeutic Activities– Jumping jacks, one leg stance on left leg with eyes closed while the

doctor counts to ten silently, basketball, hopscotch, catch on two green Thera-band pads, vibe plate for five minutes with left leg balance for ten seconds in one minute intervals.

• Posture – continue as described in phase one

12th Week Assessment• Posture Assessment revealed more improvements in head tilt,

anterior head carriage, and shoulder internal rotation• One Legged Test with throwing a tennis ball into a basket. He was

able to hold the test position for 30 seconds without falling• Romberg’s test and Mittelmeyer’s march showed slight deviation to

the left measuring 25 degrees from the starting position at 0• . Cranial Nerve Assessment revealed a decrease in pupil size,

improved left lateral gaze and scent identification in both nostrils• Hopscotch showed more coordination improvements, and the child

exhibited interest and excitement during the procedure

Phase Three• 2x/week for 6 months• Chiropractic – continue as described in phase one

• Therapeutic Activities - Jumping jacks, one leg stance on left leg with eyes closed for 20 seconds, basketball, hopscotch, catch while standing on left leg on green Thera-band pad and throwing tennis ball into basket, vibe plate for ten minutes with left leg balance for ten seconds in one minute intervals.

• Posture: continue as described in Phase One. Add Pediatric Denneroll for 3 minutes at each visit and everyday at home, increasing to 10 minutes as tolerated.

Total Cost of Treatment$13,616

• Initial Lab Testing=$3439• 10 Month Supplement Plan=$2377• 10 Month Treatment Plan=$7800 – $75 per visit• Adjustment• Neuromuscular Re-education• Nutrition Consultation

Outcome Assessment and Results

• Questions you want to ask his parents to gain an insight into the progress at the end of care

• The 4 areas we focus on:– Skin– Respiration– GI– Behavior/Brain

SKIN

1. Does he still have redness on ear?

2. What about the persistent rash on his lips, Is it reduced significantly or permanently gone?

3. Does he no longer have soreness/cracks/white patches on his tongue?

RESPIRATORY

1. Have his otitis and rhinitis issues shown significant improvement?

2. Does he still live his life with recurring ear infection, stuffy nose, and persistent cough?

GASTROINTESTINAL

1. Is he still having abdominal bloating, gas, and cramps after eating?

2. Is the alternating bouts of constipation and diarrhea still there?

3. Does his low weight issue get resolved?

BEHAVIOR

1. Is lack of concentration no longer a problem?

2. Does he interact better with other children?

3. Has his hyperactivity issue got reduced significantly?

4. Is he still an anxious kid?5. Has his motor control improved?6. Has his language developed?

ATEC

LAB RESULTS

• We run the tests again to be definite that his system in optimal state of health: need to check– Blood – Urine– Stool

Test Results After Therapy

• Amino Acid PlasmaAdequate:

Methionine = 67 micromol/L Phenylalanine = 0.058 (range 0.051-0.081 mmol/L)

Tyrosine = 12 (range 9.4-14.6microgram/mL) Cysteine = 10 (range 7.0-22 micromol/L)

Comprehensive Stool Analysis

• (-) for yeast, • (-) for Carbohydrates, • Adequate Beneficial Flora

• Essential Fatty Acids

Adequate Omega-3 FA (EPA + DHA = 1000mg/day) EPA (Eicosapentaenoic acid) DHA (Docosaheaenoic acid)

Adequate Omega-6 FA (Gamma linoleic acid = 0.5g/ kg body

weight)

• Glutathione Adequate glutathione ( 850 umol/l)

• Gluten-Casein Peptide TestLow ratio Peptide fragments/Complete

protein ( in both cases of Gluten and Casein)

• Organic Acids TestArbinose level = 100 (normal 0-115),

previously 4000 or 40x higher than normal

• Heavy Metal Urine (24 hr) Normal level of mercury (25 microgram/

liter urine)

Elements Analysis

• Adequate: zinc = 70 (norm. range 50-150ug/dl) magnesium = 1.5 (range 1.3-2.2meq/L) selenium = 95 (range 80-150 ng/mL)• Very low: copper = 0.19 (range 0.18-0.6g/L) mercury = 1 (range 0-10 mcg/L)

Fat Soluble Vitamins

Adequate: vitamin A = 100 (norm. range 50-200 ug/dl) vitamin E = 1.11 (range 0.63-1.24mg/dl) vitamin D = 40 (norm. range 16-74 ng/ml)

Lipid Peroxidase Insignificantly low:

lipid peroxidase = 2.0 (range 2.0-2.9nmol/ mL)

Brain Improvement

One leg test Patient can hold for 10sec30secs1minute

Romberg’s and Mittlemeyer’s Tests Start out 50deg. left dev.progress to 25get

improved significantly @ 5 degree.

Hopscotch Show significant improvement in

coordination and joint motion (from phase 13 of care)

Brain Improvement (..continued..)

• Also show Significant improvement in attention and concentration – Better grade in school– Less messing around with classmates– More responding to teachers and parents– More sitting still

Thank You!