A case study by Simon Mills
Introduction
Chronic immunological and inflammatory problems feature largely in the modern herbal case load. They are very daunting: there are always entangled layers of trouble and they often present after many years of contributory problems. Autoimmunity is the norm and I remember wondering in my early years of practice, that if we claim our remedies optimise health, how do we step in when the damage to the body is being done by a (moderately) healthy immune system? We know the medical approach is to suppress the immune response. How do we frame an alternative that does not do that?
In almost 45 years of practice these conditions have been the most substantial challenges, and also the most rewarding work. In the initial hour in the presence of the sufferer, the task is to unpick the tangled web of symptoms, to figure our as far as possible the âprimary lesionâ and then secondary and further exacerbations, and then to target treatment, as far as possible in the same order. This usually ends up doing things that are a long way from addressing the symptoms the patient complains of. However the first reward is to share this âthought mappingâ with the patient at the time. Almost always they take this as revelatory, that their disruptive chaotic symptoms and fragmentary medical interventions over the years start to make sense! We emerge with a plan, even a schedule, taking one step at a time, âpeeling away the layers of the onionâ, always looking for signs we are making progress along the way, even within a day or so, checking in, tweaking, feeding back again. Mostly it is a long slog, although usually worth doing, with some improvements to be expected.
Occasionally we get a âhole in oneâ. This is one such case, years of very concerning and confusing symptoms gone within a couple of months. That is so rewarding it is worth sharing!
Presentation & Case history
Heather (not her real name although I have asked permission to use her story) is 65, Caucasian, of light build and height, and has recently retired as a former high-flying executive in an advertising agency. She has three children between the ages of 21 and 27. She visited me in my practice in the lockdown summer of 2020, braving the open windows and doors that I applied to allow us to converse from opposite ends of the consulting room without masks!
Heather presented with widespread, severe and chronic erythema multiforme, augmented by a diagnosis of bronchiectasis after a confirmed Covid-19 infection in the first wave of infections in late February. Erythema multiforme (EM) is a distressing dermatitis marked by quite large âbulls-eyeâ patches, with a blister or crust at the centre, a pale surround and darker outer ring. In her case they are all over her trunk and limbs. EM is often associated with a short-term reaction to a medication or infection (examples are herpes and Mycoplasma pneumoniae), and can be accompanied by systemic inflammatory symptoms such as painful joints, fever, muscle stiffness and malaise. In Heatherâs case the first outbreak was in 2017 after a respiratory infection. As is usual the EM resolved a few weeks later, but in 2018 she had a urinary infection and the EM returned. EM can be relapsing but in her case it has been mostly with her since, often itchy too. She showed me some of it: it was severe, with at least the consolation that as it did not affect her head, hands or feet it was hidden by long-sleeved tops and trousers. However it did not improve in sunshine and she was forced to cover up through the summer. There were separate problems on her hands: the EM in later months was associated with swelling of her hand joints.
The Covid infection was not severe, marked by loss of smell and taste and a cough that persisted for some weeks. The bronchiectasis was spotted in her upper lungs post-Covid by CT-scan (though missed on X-ray). Perhaps because her lower lungs were spared this has not interfered with everyday activities and she has been able to walk her dog, even up hills, do yoga and even sing without great difficulty. However it emerged that Heather had a history of respiratory and pulmonary problems, starting with bronchitic problems as a young child, and then after a relatively healthy adolescence and 20âs, a bout of pleurisy in her 30s.
She also had a history of bacterial urinary infections until her first child, involving the taking of frequent antibiotics, but since then has mostly kept trouble at bay by taking potassium citrate. The infection in 2018 was unusual.
More significant was that Heather has pernicious anaemia and relies on vitamin B12 injections every two months to prevent a disabling fatigue. This was diagnosed 12 years ago and was definitely not present during her pregnancies. As the date for her regular injection approaches she reports that her sleep becomes increasingly broken and she gets more run down. She is about halfway between injections when she first sees me. There is an exacerbation of her EM before injections.
During her initial EM problems and with her Covid infections she did lose her appetite as expected but now her digestion is good and she eats healthily. Her bowels have a tendency to slow down as her B12 levels drop and before her regular injections, to revert to regular and normal afterwards.
Heather went through her menopause at 55 without any difficulties.
Investigations
Because of lockdown restrictions and with a lack of full PPE, I was not able to auscultate the lungs or take pulses. So all examinations were visual, the skin presentation of course and also the tongue. This was bright red all over, dry and with a medium rough surface, with a pasty yellow coating.
Diagnosis
EM is understood to be a hypersensitivity response to a medication or infection, involving a degree of systemic inflammatory and immunological activity in the body. In most cases it is self-limiting and over with in a few weeks. In some it may relapse at intervals. A potentially life-threatening version of EM is Stevens-Johnson Syndrome, that can also affect the mucosa in the mouth and gut. This has been ruled out in Heatherâs case.
There is the possibility that Heather has been infected with Mycoplasma pneumoniae. This is a stealth pathogen, a small bacterium without a cell wall whose outer membrane adopts characteristics of its host and is therefore resistant to both the bodyâs immune defences and most antibiotics. It usually affects respiratory mucosal surfaces but can also infect urogenital tissues and red blood cells. However reliable routine tests in general practice are not available. One of its most severe manifestations is primary atypical pneumonia, most commonly manifested as tracheobronchitis. However it can cause a wide range of lesser respiratory symptoms including sore throat, wheezing, coughing, fever, aches and malaise. Autoimmune complications of infections can occur in about a quarter of cases.
Heatherâs pernicious anaemia is an important clue. This is caused by the lack of âintrinsic factorâ, the transport mechanism for vitamin B12 produced by parietal cells in the stomach wall. In her case it is apparently of late onset, not being picked up in routine tests during her three pregnancies, and so it can be assumed to be an autoimmune assault on the parietal cells.
In my own reconstruction of her story I start as usual with events in chronological order.
- The âprimary lesionsâ are likely to be in the lungs, with her bronchitic childhood and frequent antibiotic use. We know recurrent or severe lung infections can lead to a lifetime of pulmonary sub-clinical infection with the scope for immunological cross-reactivity (for example patients with rheumatoid arthritis are significantly more likely to have had lung infections in the past than others). Fortunately Heather seems to have recovered well into her early adulthood although picking up a tendency for urinary infections, with more antibiotics.
- Then after from a bout of pleurisy in her 30s her health was good from the time of her pregnancies when she was between 38 and 44 years old.
- However some autoimmune troubles appear to have been generating because she started her pernicious anaemia (PA) in her early 50s. As expected this has become a major disabling influence on her health (PA used to be a fatal condition) and is now largely responsible for the ebb and flow of her health, this being better after routine B12 injections.
- 8 years after the PA was diagnosed Heather had her first significant lung infection for a long time, this time accompanied by EM. A link to Mycoplasma pneumoniae is reinforced by a relapse of the EM a year later with a urinary infection. She has had her EM for almost 3 years since.
- Her Covid infection and upper lung bronchiectasis this year now seem less relevant to her story. The bronchiectasis is likely to be caused by pulmonary microcoagulations characteristic of the Sars-CoV 2 virus. In spite of this and her previous lung infections she is not disabled and her lungs perform surprisingly well.
Her tongue manifests a humoral âheatâ and âdamp-heatâ pattern, perhaps most usefully translated as a persistent inflammatory state with hepatic involvement. This can also signify a robust constitution taking on trouble face on.
Approach to treatment
I considered here that Heather had a background inflammatory state linked to early pulmonary infections and the dysbiotic consequences of frequent antibiotic treatments. She had overcome these factors, especially through her pregnancies, but some immunological stresses had survived to lead to pernicious anaemia. This is turn may have undermined her defences in the face of possible Mycoplasma infections (other pathogens are available!) and the further immunological consequence of erythema multiforme. I am for now discounting her Covid infection.
Where to apply the therapeutic lever? As a herbalist my first instinct is to start with the gut. That is where our herbs have most of their action and gut responses into the wider body can account for most of their benefits. We have hints of hepato-biliary involvement (although her bowels work fine when she has enough B12) and suspicions of old dysbiosis (again not overtly manifested in gut symptoms). However pernicious anaemia is by definition a gut-wall immunological event.
So we are looking for an approach that can dampen Heatherâs heightened inflammatory and immunological responses, starting by enlightened convenience with the gut wall.
First prescription
Heatherâs first prescription was as follows, mostly using MediHerb extracts made to Australian TGA pharmaceutical GMP standards.
| Galenical | ml | Description |
|---|---|---|
| Golden seal root 1:3 | 15 | From cultivated sources and eye-wateringly expensive but with no competition for mucosal modulation of inflammation as well as cooling and drying hepatic action; probably prebiotic too. |
| Gotu kola leaf 1:1 | 25 | The magic Ayurvedic healing remedy that combines topical and systemic modulation of inflammation and an âectodermalâ nerve/skin orientation. |
| Licorice root 1:1 BP | 25 | The Hercules of the herb world, does everything (!) reduces excessive inflammatory activity at mucosal surfaces and systemically, and a notable lung remedy. |
| Echinacea purpurea/ E.angustifolia roots (60/40) 1:2 | 25 | A combination of the most potent available echinacea preparations with most of their activity originating on the mouth, throat and upper gut wall â I consider these as mucosal remedies with systemic benefits. |
| Willow bark 1:2 | 20 | With salicin, a gut-centred modulator of inflammation. |
| Fennel seed 1:2 | 15 | A powerful carminative complement to the gut-active ingredients above and also a significant pulmonary support. |
| Elecampane root 1:5 | 25 | A favourite pulmonary recuperation remedy. |
| Total | 150 | taken in teaspoonful doses three times a day over about 2 weeks |
Treatment plan
Heather had a healthy diet and lifestyle so this allowed me to adopt my preferred approach not to change anything else and see what the herbal prescription can do in the first two weeks. In a case like this we are hoping things can move quickly and making other lifestyle changes at the same time can confuse observations. (Sometimes a lifestyle change is the most urgent recommendation and I can hold off using the herbs to see what that does â this is not the case for Heather).
Other medication and treatments
Fortunately apart from the vitamin B12 injections (the next one in a month) there are no other prescription medications to navigate.
Follow-up appointments
Heather lives far away and even without Covid we would usually maintain contact by phone with occasional video calls where needed. I have three âOpen Hoursâ each week in which I encourage patients to call for free so that there is maximum incentive to stay in touch, especially in the important first few weeks of treatment.
As she got close to the end of her first bottle Heather rang in an Open Hour to tell me that after reeling from the sensory impact of the herbs (this mix is a powerful hit) she quickly got to like the effect it was having. She reported a very quick change in digestive and bowel activities, with greater appreciation of a good diet and a looser bowel movement (with some yellow stools initially). She felt her itching and joint swelling had already reduced and was feeling easier generally. This was exactly what I was hoping for at this early stage.
Follow-up prescriptions – with rationale for changes
After her first call I dispatched a larger 3-4 week supply of her blend, and emboldened by her initial responses took out the elecampane to give relatively more heft to the other ingredients. She had her next B12 injection during this time and when she reported in again she was having her expected lift in energies. However she also reported that the skin lesions were clearly improving as well.
Final outcome
Over the next two months Heatherâs erythema multiforme completely disappeared and recently we agreed that she could stop herbal treatment altogether.
This was an unexpectedly successful treatment. Complex immunological problems like this usually involve a series of tweaks and adjustments, strategically mixed with various lifestyle manoeuvres, with progress often mixed with setbacks and false starts. This was a rare case where the first treatment did the job and did it quickly. It suggested that Heather was stronger and more resilient than she thought, that apart from the probably permanent consequences of her pernicious anaemia and her reliance on B12 injections she has the capacity to stay healthy.
I do not expect her to call again anytime soon.