Case History:
SR is a 30-year-old female who presented with cyclic vomiting syndrome, anxiety, fatigue and suspected Asperger’s Syndrome on the 26th of May, 2017. CVS episodes are described as being unable to stop vomiting, and starting with a migraine and a sore throat that felt raw and or other “flu-like” symptoms. She would often faint from dehydration. SR had numerous hospitalisations for up to three days or more depending on her requirements for rehydration. These hospital stays caused high levels of anxiety. She also stated she “can’t stand” intravenous antibiotics, although requiring two doses or the strongest drug (described as a wafer) was common. Her episodes are typically triggered by stress, menstruation or infection. Migraines and aching legs were common concomitant symptoms. Her presenting complaint contributed to her being unemployed.
She reported poor energy 4/10 (10/10 = best energy), and 5:00pm was her best time of day; stress levels 9/10 (10/10 = worst stress); hayfever, allergies to lavender, cat hair, dust and sand pit sand, constant itchy nose and ears; wildly variable appetite; sticky faeces and heartburn. Her anxiety required her mother to be in the room for the naturopathic consultation.
History:
Her mother described her health as having gone “downhill” at the age of six months on the introduction of cow’s milk formula. As a baby, she often had high fevers and once needed a spinal tap. Her CVS began at eight or nine years of age. She did not grow out of it as expected.
With disbelief that CVS can occur in adults and her appearance of unconventionally closely-cropped hair led some hospital staff to suspect her mistakenly, of drug abuse. This created an additional stressor for her. A stressful work environment also affected her health. Recently, being unemployed has added to her level of stress.
Examination:
- Dull appearance to eyes, dark circles underneath.
- Poor eye contact
- Anxiety required mother to be in the room during her first appointment, who assisted her with answering questions.
- Highly emotional when describing health problems.
- Blood pressure 108/66; pulse 63 bpm.
- Iridology: Inflammation sign in digestive zone.
Medications:
Antiemetic drugs administered in hospital during acute episodes. Stated she often needed the “strongest one” described as a wafer (most likely Ondansetron), or a double dose of intravenous antibiotics. Stemetil contributed to her anxiety and caused palpitations.
Diet and Lifestyle:
She described her diet as “what I can afford”, leaning towards veganism. Feels sick in her stomach after eating pork, poultry and eggs, but enjoys other meats. She does not tolerate black tea or coffee and tries to avoid gluten.
- Breakfast was often gluten-free toast with peanut butter and herbal tea.
- Lunch varied and was typically bought, often potato bake or nachos.
- Dinner included steak, potatoes and other vegetables.
- Snacks – occasional chips or chocolate.
- Fluid intake – mostly water, as much as possible, with occasional Gatorade and Hydralyte, as she dehydrates easily.
- Physical activity – walking, commonly for hours every day. If she was able to, she would do “more adventurous” activities like outdoor climbing.
- Work – Rejection at work due to health issues was a major stressor and lack of driver’s license.
- Fear of heights, even over bridges was lesser but still significant issue.
- Sleep – Often only 3-5 hours per night, waking at 2-3:00am or waking at 1-2:00am.
- Listening to ASMR (Automatic Sensory Meridian Response) videos online, of the gentle whispering type, prevented waking at night.
Treatment Plan
First consultation
Herbal Formula:
Melissa officinalis (80mL), for its mood-lifting, antispasmodic and antimicrobial properties. Glycyrrhiza glabra (60mL), for its gastrointestinal demulcent and adaptogenic properties. Viburnum opulus (60mL), for its smooth muscle antispasmodic properties. Dose: 5mL tds
Supplements: Mediherb Probiotica
Diet and Lifestyle:
Avoid cow’s milk. Pre-prepare meals to avoid buying lunch, regular vegan broth and/or osso bucco for gut healing, ASMR videos every night that have been helpful.
Second consultation – 3 weeks later
On 16/06/2017 she reported being “very tired”, however, she rated her energy as improved since using the herbal formula, now 8-9/10. No CVS episodes for the last 3 weeks. She was anxious as she was menstruating and in the past this often triggered CVS episodes. She had experienced carsickness. Hayfever allergies and irritation had mostly resolved. Heartburn had improved. She had complied with the dietary advice, and taking the herbal formula. She did not take the probiotics, because a respiratory infection had warranted antibiotic use.
Herbal Formula:
Withania somnifera (80mL), Melissa officinalis (40mL), Glycyrrhiza glabra (40mL) and Zingiber officinalis (10mL). 5mL twice daily. Viburnum opulus in 100mL simplex; 3mL after dinner.
Withania somnifera was added for its adaptogenic properties in cases of severe fatigue; Zingiber officinalis was added for its antiemetic abilities.
Supplements: Mediherb Probiotica (did not fill prescription first time)
Diet and Lifestyle:
Continue previous advice; consider MTHFR cheek swab test as poor methylation of folate may contribute to neurological issues such as Asperger’s Syndrome and anxiety.
Third Consultation – 05/09/2017
No CVS episodes. Asperger’s Syndrome confirmed as “type 1 bordering on type 2”. Support was now being offered by a psychologist. Reports migraines and headaches. Influenza for nearly two weeks. She continues to be compliant with dietary advice, herbal prescription and the probiotics. She did drink milk one week. Continues to have Improved energy, improved hayfever allergies, and reduced nausea.
Herbal Formula: repeated.
Supplements: Bioceuticals Glutenzyme, to take on accidental exposure.
Diet and Lifestyle: Avoid gluten, enzymes are for accidental exposure only.
Discussion
Treatment for this client was aimed at improving health of the gut/brain/immune axis, balancing the autonomic nervous system, relieving debility and regulating smooth muscle contractions. Stress was identified as underlying fatigue, CVS and digestive difficulties because it affects the autonomic nervous system (Hechtman, 2014). Poor stress management, fueled by adrenal fatigue and debility, can impair the parasympathetic nervous system (PNS). The PNS is responsible for digestive functions.
Autism spectrum disorders such as Asperger’s Syndrome are associated with intestinal dysbiosis and inflammation. The description of her stools indicated gastrointestinal inflammation and dysbiosis. Iridology examination also found signs of this. Gastrointestinal inflammation and dysbiosis can also cause systemic immune dysregulation; linking to the hayfever, and possibly to the dark shadows under her eyes.The neuroendocrine and gastrointestinal dysregulations in CVS may respond to improved stress management and normalising the gut/brain/immune axis.
CVS is a rare condition. This case is a good example of how well naturopathic approaches work even in rare conditions. Migraines and CVS involve smooth muscle spasms. Viburnum opulus was chosen for its spasmolytic properties (Bone & Mills, 2013). Melissa officinalis is also a spasmolytic as well as anxiolytic and may lift the mood (Scholey et al, 2014). Glycyrrhiza glabra is soothing and protective in the GIT for heartburn. It is an adrenal tonic, improves fatigue, as well as a mild immunomodulator useful in treating allergies. It may support the oesophagus healing from the damage caused by acid reflux, and reduces stress on the adrenal glands as it is cortisol-sparing. Withania somnifera is an adaptogen, relieves debility, adrenal tonifying properties and is an immunomodulator. Zingiber officinalis has antimicrobial, antiemetic, anti-inflammatory and aromatic digestive properties addressing dysbiosis and symptomatic relief.
The aim of prescribing probiotics was to colonise the intestines with the anti-inflammatory species of bacteria seen in the gastrointestinal tract of humans. Avoidance of trigger foods and the recommendation of red meat and vegan broths were intended to allow the gut lining to gradually heal. These foods preserving an anti-inflammatory microbiome. The gut repair balances the nervous and immune systems as well as restores energy decreases anxiety and inflammatory hayfever symptoms. Gluten and casein may worsen the symptoms of autism spectrum disorders.
Conclusion:
Successful remission of cyclic vomiting syndrome was achieved, along with relief of fatigue and hayfever allergies. Identifying the priority issues for this unique client and using the main principles of treating the whole person, identifying and treating the cause, gave this client improved quality of life and resolution of her debilitating symptoms. Conventional treatment only offered symptomatic relief.
Naturopathic Principles:
When mainstream options were not offering lasting recovery this case demonstrates the power of Naturopathic approaches. First, Doing no harm (non nocere) in choosing a treatment plan for this client was a priority as she had side effects from her conventional treatment. Listening to her without any preconceived notions that CVS was only found in children was important. This unusual presentation made treating the underlying causes all the more important (tolle causam). It was necessary to break down each symptom and find and treat the underlying mechanism. This was a complex case involving various body systems. Smooth muscle was involved in both migraines and CVS. Treating the whole person was important and the intention was to stimulate the body’s own healing power (vis medicatrix naturae). Empowering and teaching the patient self-care (docere) was also important for prevention of any future recurrences.
Conventional Treatment for CVS:
Conventional treatment for CVS involves pharmaceutical, dietary and lifestyle interventions. Antimigraine drugs such as amitriptyline and propranolol, as well as anticonvulsant drugs including phenobarbital, are often used as prophylactics. They all have side effects such as sedation and cognitive impairment. Sedatives such as lorazepam; antiemetics, often Ondansetron; and other antimigraine drugs are prescribed to relieve CVS episodes. Avoidance of dietary triggers such as cheese, caffeine, MSG and nitrates may reduce the frequency of vomiting episodes. Lifestyle modifications include avoiding triggers of anxiety, excitement and/or fatigue, and can involve support from a psychologist or counsellor.
References:
Bone, K & Mills, S, 2013, Principles and Practice of Phytotherapy – Modern Herbal Medicine, Elsevier Health Sciences
GlaxoSmithKline, 2005, Product Information: Zofran® Injection, Tablets, Syrup, Suppositories and Zofran Zydis Wafers, viewed 5 February 2018, http://www.gsk.com.au/resources.ashx/prescriptionmedicinesproductschilddataproinfo/95/FileName/B04E66A7A692B605D0A8196CBC881255/PI_Zofran.pdf
Hechtman, L, 2014, Clinical Naturopathic Medicine, Elsevier Australia
Scholey, A, Gibbs, A, Neale, C, et al., 2014, ‘Anti-Stress Effects of Lemon Balm-Containing Foods’, Nutrients, vol.6, no.11, pp.4805-4821. doi:10.3390/nu6114805.
Sunku, B, 2009, ‘Cyclic Vomiting Syndrome: A Disorder of All Ages’, Gastroenterology & Hepatology vol.5, no.7, pp.507-515, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2886424/