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Constant severe nausea accompanied by weight loss in a 24 year old male.

Blastocystis is a single cell parasite that infects the gastrointestinal tract of humans (where it is referred to as Blastocystis hominis) and animals. Previously considered to be a harmless yeast present in normal intestinal flora, B. hominis has more recently and controversially been described as a pathogenic protozoan which is frequently accompanied by intestinal symptoms (Selcuk 2007).

Presenting complaint

Aaron, a 24 year old part time university student and retail assistant, presented with severe ongoing nausea which had occurred daily for the last 18 months and weight loss of approximately 30 kg due to feeling unable to eat without experiencing increased nausea. He was fatigued throughout most of the day.

Aaron's nausea was worse in the morning, immediately before and after meals, with large meals, and with physical exertion of any kind. He reported that his digestive problems had initially begun the morning after a night of excessive alcohol and food intake. Aaron believed it was possible that one of his drinks might have been 'spiked' as he had felt unusually unwell while drinking.

Frustrated with a diet of mainly bread, crackers, pasta and water, and exhausted by his ongoing symptoms, Aaron expressed concern that he may eventually become so ill that he would have to quit both uni and his job.

Medical history

Aaron's childhood history was unremarkable with no major illnesses or injuries. He was not aware of any allergies and could not recall any previous digestive issues apart from the occasional childhood 'bug'.

Family and social history

There was no family history of any serious medical conditions or digestive disorders and none of his friends became ill after the same bout of drinking. He had travelled overseas to China 24 months prior to becoming ill. Aaron admitted consuming excessive amounts of alcohol on approximately a monthly basis prior to the development of his current condition.

Pathology and investigation

Shortly after first experiencing symptoms a fecal sample was found to contain Blastocystis hominis. Aaron was prescribed the antibiotic Flagyl (metronadiazole). He was unsure if he completed the course as he experienced a worsening of symptoms while taking the antibiotic. A follow up stool examination was not performed.

Three months after onset Aaron's doctor referred him for an endoscopy, ultrasound of the abdomen, comprehensive blood tests including liver function and a food movement test. All tests were NAD with the eventual diagnosis being 'possible functional dyspepsia'. Aaron had also performed a finger prick 'self test' for gluten intolerance which had returned a negative result.

Over the following months Aaron's doctor prescribed Nexium (proton pump inhibitor) which worsened the nausea. Several other PPIs were trialled with the same effect. Motilium (domperidone) made no change to symptoms. Two weeks prior to his visit Aaron had commenced taking the tricyclic antidepressant Endep 25 (amytriptyline) at night which had lessened his morning nausea but made him feel dizzy and 'hung over'.

Observations and physical examination

Bowel function was regular producing a stool of formed to hard consistency every second day. Aaron mentioned experiencing diarrhea and cramping around the time he initially developed nausea, but now only experienced these symptoms occasionally.

Ongoing digestive problems included constant severe nausea, occasional belching, some flatulence, no sensation of reflux or regurgitation, fullness after eating even a small amount of food and difficulty swallowing large mouthfuls of food or large tablets.

His current weight was 62 kg (previously 92 kg) and he was 178 cm tall. Dark circles were observed under the eyes and the fingernails had deep vertical ridges. Zinc test recorded little or no taste sensation. Urinary indican test returned a high level result but due to the lack of protein in Aaron's diet the results were considered potentially inaccurate.

Treatment

The initial treatment plan focused on providing symptomatic relief, soothing and regulating digestive function and modifying bowel flora. Aaron was very reluctant to change his current diet at this stage so was instead asked to keep a comprehensive diary of all food consumed, any symptoms experienced and to maintain his water intake. Prescribing options were tailored to suit Aaron's very tight budget and the difficulty he had in swallowing tablets:

Probiotic and vegetarian enzyme combination: one capsule opened and taken with a little manuka honey three times daily 15-30 mins before food.

Ulmus rubra powder (which he had on hand already): one teaspoon combined with a little water or mashed banana three times daily after or between meals.

Zinc supplementation was not started at this stage due to the possibility of inducing nausea.

Herbal Formula
Herb                     Conc.    Total

Berberis vulgaris         1:2     20 mL
Matricaria recutita       1:2     20 mL
Echinacea root blend      1:2     25 mL
Hydrastic canadensis      1:3     15 mL
Althea officinalis        1:5     20 mL

TOTAL                            100 mL

Dose 5 mL twice daily for the first week,
thereafter 7.5 mL twice daily.


All products to be taken at least 2 hours away from prescription medication to reduce the possibility of herb/medication interaction, specifically altered drug absorption or clearance.

I recommended repeat fecal testing for Blastocystis hominis and a 'parasite and ova screen'. Blood testing for liver function and a full blood count were also requested. Aaron was confident that his GP would be able to authorise the tests, removing the necessity for referral to a private pathology service.

Follow up

At his second consultation 2 weeks later Aaron reported a significant lessening in the frequency and severity of nausea. Consequently he had been able to eat more and increase his activity levels. He had experienced some bloating initially after taking the digestive enzyme/ probiotic, but this had resolved after a couple of days. Aaron had approached his doctor about reducing the dose of Endep with the intention of discontinuation and planned to do so over the next 2 weeks.

Fecal tests revealed the presence of B. hominis. Fecal testing for other parasites was not performed. Blood tests were all within normal range with the exception of a mild elevation in alanine transaminase (ALT) and aspartate transaminase (AST). Elevated AST and ALT levels can be indicative of liver inflammation or hepatocellular injury: ALT 45 U/L (5-40), AST 49 U/L (10-40).

Treatment

With a repeat positive diagnosis of B. hominis and mildly irregular liver chemistry, treatment was aimed at reducing gut parasite levels, balancing gut flora, supporting liver function and stimulating digestion.

Aaron was advised to continue Ulmus rubra powder as desired for symptomatic relief. Dietary recommendations included reducing wheat based products, reintroducing vegetables and lean protein and implementing five small regular meals daily. Aaron had been given a pure rice protein supplement by a friend and intended to use it to supplement his dietary protein intake if needed.

Herbal treatment

Herbal capsule containing extracts equivalent to dry:
Herb                                                       Total

Juglans nigra fruit hull                                  400 mg
Artemisia annua herb                                      400 mg
Tabebuia avellanedae inner stem                           200 mg
Berberis vulgaris stem bark                               360 mg
Allium sativum bulb                                       720 mg
Citrus paradisi seed                                      250 mg
Thymus vulgaris oil                                        2 mg
Rosmarinus officinalis oil                                 1 mg
Origanum vulgare oil                                       10 mg

Capsule to be opened and mixed with manuka honey three
times daily.


Herbal digestive and liver support formula tablet containing extracts equivalent to dry:
Herb                                                       Total

Silybum marianum fruit                                     2.1 g
Taraxacum officinale root                                 500 mg
Citrus reticulata fruit peel                              500 mg
Gentiana lutea root                                       100 mg
Zingiber officinale rhizome                               100 mg
Citrus reticulata essential oil                           12.5 mg
Matricaria recutita flower essential oil                   5 mg

Dose one tablet to be sucked for 1 minute then chewed
before each main meal.


All products to be taken at least 2 hours away from prescription medication.

Follow up

Over the next month Aaron reduced and then ceased Endep, with the support of his GP. This worsened his digestive but then showed steady improvement. Three months after his initial consultation he was free of digestive problems with the exception of occasional morning nausea. Bowel function improved to one bowel motion every day. Aaron's energy and physical activity levels improved as did the variety of his diet and food intake. I continued to work with Aaron to rebuild confidence in his ability to make sound dietary choices. Further prescriptions included a probiotic formula to restore beneficial gut flora and mineral supplementation. Aaron continues to take the herbal digestive and liver support tablet once daily.

Discussion

Although Blastocystis hominis is often found in asymptomatic individuals, its presence in this case was significant due to the patient's previous good health and the absence of other irregular test results. It is difficult to determine if Aaron's mildly elevated AST and ALT levels were of any clinical significance in relation to his symptoms as these chemical changes have many potential causes including prescription medication reactions and alcohol intake.

Aaron may have contracted the parasite on or prior to his night of overindulgence, but it is possible in my opinion that his extreme food and alcohol intake on that occasion may have resulted in sufficient gastrointestinal irritation to prevent his usual gut based immune defences from dealing with the parasite in an appropriate way.

Aaron's wholehearted commitment to and compliance with treatment, including the less palatable forms of herbal treatment necessitated by his swallowing difficulties, resulted in a swift recovery. Aaron is on track to graduate from university at the end of this year, still works part time and has rejoined his rugby team. He has sworn off binge drinking and is attempting to convince his mates to do the same!

Katarina La Muriac BHSc(CompMed) AdvDipHSc(Nat) DipHSc(HerbMed) DipHSc(Nutrition) MNHAA

Email: naturopath@katarinaalamuriac.com.au
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Article Details
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Title Annotation:Case Study
Author:La Muriac, Katarina
Publication:Australian Journal of Herbal Medicine
Article Type:Clinical report
Geographic Code:8AUST
Date:Dec 1, 2012
Words:1589
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