Case Study 4

Patient 4: RECURRENT INFECTIONS, UNSETTLED GUT, BRAIN FOG AND FATIGUENESS.

Female, 
Age 40, 
Teacher Aide. 

This is a real patient history. Their identification details have been removed to maintain the patient’s privacy.

Initial Presentation

  • Feeling sick frequently – for 5 months (in 2019)
  • Sore throat (ongoing)
  • Has had flu needle
  • Very tired all the time
  • Abdominal bloating and moderate tenderness
  • Past Medical History – Nil to note
  • Allergies – None
  • Married – 2 children
  • Mum – Hypertension, no other problems in family history
  • Never smoked
  • Alcohol occasionally
  • Examination
    • Overweight (not obese), weight 85kg
    • Physical Exam was otherwise normal
  • Family History – nil to note
  • Initial Investigations
    • Patient could not afford to pay for additional testing
    • Basic RAST Test – Moderate allergy to house dust mite
    • Iron Studies: TIBC – 65 (Normal), Saturation – 14 (Low), Ferritin 266 (High), CRP – 9
    • Liver Function Test – Normal,
    • Total Cholesterol – Normal
    • ESR – 3
    • Glandular Fever Antibody IgA – Positive.
  • Assessments with Questionnaires
    • Fatigue Questionnaire
      • Score – 92
    • Yeast symptom Questionnaire
      • Score – 196
    • Dysbiosis symptom Questionnaire
      • Score – 29
    • Toxin Questionnaire
      • Score – 107
    • CIRS Screening Questionnaire (biotoxin screening questionnaire)
      • 17/37
    • VCS Screening Test
      • Failed
  • Impression
    • Mold/Candida Infection
    • Dysbiosis
    • HPA Dysfunction (most probably due to gut infections)

Review after 1 month of treatment

  • Improved gut symptoms
  • Increased energy
  • Improved mood
  • No sore throat anymore
  • Memory and focus are improved
  • Sick feeling is gone

Review after 2 months

  • Toxin Score dropped to 35
  • Yeast symptom Score was 74
  • Dysbiosis Score 20
  • More energy and mental clarity
  • Previous protocol continued for one more month

Review after 3 months

  • Energy is very much improved
  • Gut symptoms are completely gone
  • Great mental clarity and focus
  • Lost 5kg (85 à 80kg)