Chronic Rhinosinusitis and Irritable Bowel Syndrome: A Case Report.

Integr Med (Encinitas). 2016 Jun; 15(3): 44–54. PMCID: PMC4982648 Mikhail Kogan, MD, Carlos Cuellar Castillo, MS, and Melissa S. Barber, MS Author information ► Copyright and License information ► Go to: Abstract Introduction Chronic rhinosinusitis (CRS) and irritable bowel syndrome (IBS) can be comorbidities that are difficult to treat. In this patient, an evidence-informed treatment pathway guided by laboratory biomarkers was used to address both conditions. Case Presentation A 69-y-old female patient presented with a 50-y history of sinusitis that was worse in the winter, postnasal drip, frequent sore throats, gastrointestinal complaints, headaches, and yeast infections. Two sinus surgeries (in years 2000 and 2002) and multiple courses of antibiotics had not resolved her sinus symptoms. In addition to CRS and IBS, this patient was noted to have intestinal overgrowth of Candida albicans, multiple food sensitivities, and leaky gut syndrome. Conclusion Antifungal medication and dietary changes in the course of 8 mo resulted in the resolution of her CRS and IBS. Chronic rhinosinusitis (CRS) and irritable bowel syndrome (IBS) are common in the United States and microbiome alterations are associated with both conditions.1–4 CRS affects approximately 1 in 8 adults in the United States and is often associated with seasonal exacerbations.5 IBS affects approximately 1 in 10 adults in North America and can be associated with pancreatic insufficiency and food sensitivities—two conditions often untreated in primary care.6,7,8 The 2014 “American College of Gastroenterology Monograph on the Management of Irritable Bowel Syndrome and Chronic Idiopathic Constipation” discussed the prevalence and treatments of IBS and the absence of reliable laboratory biomarkers.9 This case demonstrated the use of laboratory biomarkers for pancreatic insufficiency and food sensitivities for treatment of both CRS and IBS. A timeline of the patient’s medical history and course of care is described in Table 1. Table 1 Table 1 Timeline of Patient’s Medical History and Course of Care Go to: Patient Information A 69-year-old female patient with a 50-year history of gastrointestinal (GI) and sinus symptoms (worse in the winter) was self-referred to the George Washington Center for Integrative Medicine in February 2011. Ten years earlier, in 2000 and 2002, she had sinus surgery that did not relieve her symptoms. She also experienced frequent fatigue, disturbed sleep, headaches, sore throats, runny nose, and chronic cough, and she had a history of recurrent vaginal and intestinal symptoms consistent with overgrowth of Candida albicans several times per year. Her diet consisted of freshly prepared foods with some sensitivity to cheese and yogurt (which she avoided). Despite osteoarthritis in both knees, she walked 3.5 miles (5.6 km) daily and regularly played tennis. The patient was retired, lived at home with her dog, and had 2 adult children; she reported no known toxic exposures at home. She had previously been diagnosed with ovarian cancer with surgery in 2007 and chemotherapy in 2008, which exacerbated her CRS and IBS symptoms. Patient medications at her initial visit included azithromycin for CRS and vitamin D3 supplementation. She had begun taking a self-prescribed dietary supplement—broccoli seed extract (OncoPLEX ES from Xymogen, Orlando, FL, USA). Go to: Clinical Findings Her physical exam was remarkable for boggy turbinates and postnasal drip. Go to: Diagnostic Assessment Comprehensive Digestive Stool Analysis (CDSA) 2.0 (Genova Diagnostics, Asheville, NC, USA) revealed potentially pathogenic levels of C albicans and low levels of pancreatic elastase 1 and β-glucuronidase, supporting a diagnosis of dysbiosis (Appendix 1). An IgG Food Antibody Assessment (Genova Diagnostics) revealed moderate to high reactivity to several different foods, indicative of multiple immunoglobulin G (IgG) food sensitivities. Her symptoms were suggestive of leaky gut syndrome (Figure 1; Appendix 1). Her vitamin D level was 28.4 ng/mL (low). She was diagnosed with CRS, IBS, overgrowth of C albicans, multiple food sensitivities, and leaky gut syndrome. Figure 1 Figure 1 IgG Food Antibody Assessment, February 2011 and July 2011 Go to: Therapeutic Interventions and Follow-up This patient had 5 visits in 8 months and received therapeutic interventions—antifungal medication, nutritional, and dietary supplements—guided by laboratory testing (Table 1 and Table 2). Table 2 Table 2 Prescribed Interventions in Course of Care At the third visit (April 2011), the patient was much improved and grains, fruit, and dairy were gradually reintroduced. In June 2011, a repeat stool test showed resolution of C albicans overgrowth and improved pancreatic elastase 1 levels (increase from 121 mg/g to 273 mg/g) and β-glucuronidase levels (increase from 367 U/g to 1475 U/g) (Appendix 1) and the nystatin was discontinued in July 2011. Repeat IgG F-actin antibody (FAA) results (Figure 1) revealed a nearly 4-fold decrease in the number of highly reactive foods and a 30-fold increase in nonreactive foods—suggestive of normalized intestinal permeability. At her fourth and fifth visits, the patient continued to improve and noted resolution of her CRS and IBS symptoms as well as an increase in energy. In September of 2011, she was instructed to continue with the yeast-free, anti-inflammatory diet, nasal lavage, probiotics, fish oil, and vitamin D3 (Table 1). The patient was seen in March 2013 after noting relapse of some of her CRS and IBS symptoms, which she attributed to increased sugar consumption and dietary indiscretions. She was counseled to continue on the yeast-free, anti-inflammatory diet as much as possible—to which she adhered. Patient Perspective I am a very active person and enjoy playing tennis and gardening. My symptoms prior to coming to George Washington (GW) Center for Integrative Medicine prevented me from participating in the leisure activities that I enjoy. The quality of my sleep and my overall quality of life were not good. After coming to the GW Center for Integrative Medicine all of my symptoms improved and I experienced a drastic improvement in my quality of life. I did not follow an “Elimination Diet” per se, but rather was instructed to follow a diet with foods to avoid based on my testing. I experienced a relapse of my sinus symptoms when I deviated too much from the diet, but am now able to control the symptoms by adjusting my diet accordingly. Go to: Discussion and Limitations CRS- and IBS-related symptoms are commonly reported complaints by patients.5,6 A recent case-controlled study of 133 subjects found a statistically significant association between CRS and IBS (odds ratio [OR] = 17.8; 95% confidence interval [CI] = 4.9 to 64.2; P < .001).2 When CRS has been present for 50 years, it is difficult to treat—particularly in a patient with a history of unsuccessful sinus surgeries and antibiotic use. Smith et al10 estimated direct and indirect costs for CRS in the United States at more than $20 billion in 2014. In addition to sinus surgery and antibiotics, the medical management of CRS commonly includes steroids and nasal lavage with saline.11 More than 1 in 5 antibiotic prescriptions are for treating acute and chronic rhinosinusitis.12 Antibiotics often provide little benefit, contribute to the occurrence of adverse events, alter the microbiome, and contribute to antibiotic resistance.13,14 Dietary supplements and nutritional recommendations have some evidence in treating CRS15—long-chain polyunsaturated fatty acids (LCPUFAs) may be helpful to patients with CRS that are refractory to treatment with antibiotics.16,17 Such LCPUFAs include docosahexaenoic acid (DHA) and arachidonic acid (ARA), found in fish oil or DHA/ARA-enriched foods. IBS is both prevalent and costly with the annual cost burden of IBS estimated at more than $20 billion.6 IBS may be associated with exocrine pancreatic insufficiency and overgrowth of C albicans.7,18 Although Candida is part of a normal gut microbiome, increased levels may be associated with inflammation of the GI tract.18 Food sensitivities associated with food-specific IgG antibodies and IBS have been shown to have a response to elimination diets.19 Dietary changes, such as a low FODMAP diet or an IBS-specific diet, have also been shown to reduce IBS symptoms and food sensitivities and to improve nutritional status.20,21 A multistrain probiotic has been shown to improve the symptom severity of IBS and quality of life scores after 8 weeks in patients with IBS.19 A single case using an individualized approach with multiple interventions may have limited applicability to a broader population of patients. This patient’s IBS was diagnosed based on the patient’s self-reported symptoms without using the Rome criteria or a validated IBS quality of life scale. However, this case demonstrates that specific laboratory biomarkers can guide individualized treatment. In this case, addressing biomarker imbalance associated with pancreatic insufficiency and food sensitivities may have led to the resolution of CRS and IBS in this patient. Go to: Conclusion This case reports presents a cost-effective, successful treatment of a patient with chronic CRS and IBS using laboratory biomarkers to guide treatment that included dietary recommendations, antifungal medication, and nutritional supplements. Structured stool and IgG testing reduced the overall cost of diagnosis and guided management of this patient. The testing linked laboratory biomarker abnormalities with therapeutic interventions and outcomes, strengthening the association of specific laboratory biomarkers abnormalities and the diagnosis of IBS and CRS. This case offers testable hypotheses for future research to evaluate the effect of structured stool testing and IgG antibody testing to guide therapeutic interventions and improve patient outcomes. Go to: Acknowledgements This case report was prepared according to the CARE guidelines. Genova Diagnostics provided an unrestricted medical writing grant to assist with the preparation of this manuscript. Go to: Appendix 1. CDSA 2.0 Results Prior to Treatment in February of 2011 and During Treatment in July of 2011 Digestion/Absorption Analyte 02/25/2011 07/12/2011 Reference Range Pancreatic elastase 1 121 273 ≥201 μg/g Putrefactive SCFAs 3.0 6.0 1.3–8.6 μmol/g Gut Immunology Analyte 02/25/2011 07/12/2011 Reference Range Eosinophil protein X <1.2 <1.1 ≤7.0 μg/g Calprotectin <16 17 ≤50 μg/g Metabolic Analyte 02/25/2011 07/12/2011 Reference Range Beneficial SCFASs (total) 44.8 46.8 ≥13.6 μmol/g n-butyrate 6.5 8.5 ≥2.5 μmol/g pH 7.2 6.9 6.1–7.9 β-glucuronidase 367 1475 337–4433 U/g Secondary Bile Acids LCA 1.76 1.20 0.65–5.21 mg/g DCA 2.50 0.73 0.67–6.76 mg/g LCA/DCA ratio 0.70 1.64 0.39–2.07 Microbiology Beneficial Bacteria 02/25/2011 07/12/2011 Reference Range Lactobacillus species 3+ NG ≥2+ Escherichia coli NG 3+ ≥2+ Bifidobacterium 2+ 4+ 4+ Additional Bacteria 02/25/2011 07/12/2011 α-haemolytic Streptococcus–NP 4+ 2+ γ-haemolytic Streptococcus–NP 4+ 4+ Mycology 02/25/2011 07/12/2011 Candida albicans–potential pathogen 2+ NG Parasitology Parasite 02/25/2011 07/12/2011 Cryptosporidium Negative Negative Giardia lamblia Negative Negative Entamoeba histolytica/dispar Negative Negative Additional Tests Helicobacter pylori stool antigen Negative Shiga toxin Escherichia coli Negative Campylobacter Negative Clostridium difficile Negative Occult blood Negative Analyte 02/25/2011 Reference Range Chymotrypsin 5.1 0.9–26.8 U/g Fecal Fat Distribution 02/25/2011 Reference Range Triglycerides 0.8 0.2–3.3 mg/g Cholesterol 3.3 0.2–3.5 mg/g LCFA 3.2 1.3–23.7 mg/g Phospholipids 1.3 0.2–8.8 mg/g Fecal fat (total) 8.6 2.6–32.4 mg/g Metabolic Products 02/25/2011 Reference Range Acetate % 56.8 44.5%–72.4% Propionate % 28.7 ≤32.1% n-butyrate % 14.5 10.8%–33.5% Abbreviations: CDSA, Comprehensive Digestive Stool Analysis; SCFA, short-chain fatty acid; LCA, lithocholic acid; DCA, deoxycholic acid; NG, no growth; NP, nonpathogen; LCFA, long-chain fatty acid. Go to: Appendix 2. Yeast-free, Anti-Candida Diet Yeast-Free Anti-Inflammatory Food Plan Trillions of healthy bacteria live in our digestive tract, making up what is called microflora. These bacteria play a supportive role in your intestines, helping to make vitamins, release natural antibiotics, and break down toxins. Candida, a yeast-like fungus, is commonly present in your intestines, and its growth is usually limited by your immune system and by your microflora. If Candida is allowed to grow due to a weakened immune system or disease such as diabetes, the harmonious balance between it and the “good” bacteria is upset, resulting in intestinal candidiasis. Not only can this imbalance cause problems such as vaginal infections, but Candida also releases byproducts, which are subsequently absorbed into the bloodstream, exposing the whole body to a variety of symptoms as the immune system tries to fight it off. Common symptoms include fatigue, bloating, gas, diarrhea and/or constipation, recurring bladder infections, menstrual irregularities, allergies, chemical sensitivities, and depression. What increases the risk of Candida overgrowth, also called the yeast syndrome? The following list includes the most common factors: Repeated use of antibiotics, oral contraceptives, and/or steroids such as prednisone. Diet high in sweets. Alcohol. Chronic stress. Diabetes. Weakened immune system. How is candidiasis treated? A comprehensive approach is necessary to reduce the overgrowth of Candida organisms. The risk factors listed above must be reduced as much as possible, while supporting immune, digestive, and liver function. Because yeast feeds on carbohydrates, a food plan must be followed that starves yeast of its main fuel: simple sugars. Additional support in the form of healthy bacteria (called probiotics) is also used to compete with Candida in the intestines, resulting in a rebalancing of the microflora. Sometimes, antiyeast supplements or prescriptions are used to kill the yeast. How is candidiasis prevented? It is important to reduce as many of the above risk factors as possible to keep a healthy balance between yeast and microflora. Eating greatly reduced amounts of refined sugars and avoiding alcohol is a good place to start. It is also helpful to begin to develop a practice of mind-body techniques for stress reduction. This might include meditation/visualization, yoga, tai chi, or whatever exercise you enjoy. How will I feel when I start this type of program? Many of the symptoms associated with candidiasis are associated with absorption of yeast breakdown products. As these yeast die off, some of these organisms are reabsorbed into the bloodstream, increasing the load the liver must filter or detoxify. It is common to experience short-term reactions to this die-off, such as headaches, abdominal bloating, muscle and joint aches, or fatigue. It is also not unusual to crave the very food yeast thrives on, such as sweets, breads, and alcohol. (For further reading about intestinal candidiasis or yeast syndrome, refer to The Yeast Connection or The Yeast Connection Handbook by William Crook, md.) Anti-Candida Food Plan Guidelines In general, foods are restricted because of their carbohydrate (sugar) content. Peanuts and pistachios are to be avoided due to their high mold content, which can exacerbate Candida. Mushrooms are in the fungus family and may cross-react with Candida. Fermented foods (vinegars, aged cheeses) may provoke symptoms because of similarities to Candida yeasts and may also feed Candida yeasts. These modifications are usually implemented for 2–4 weeks to assess response to the program. Follow-up modifications are made on an individual basis. Category To Include To Exclude Fruits Fresh/frozen, unsweetened fruit 1–2/day Banana, pineapple, papaya; all dried fruits and juices Eggs, dairy, & dairy replacement Eggs; plain unsweetened yogurt (cow, sheep, or goat), with live cultures; plain, unsweetened soy, almond, or hemp milk; coconut milk; unaged cheeses (only mozzarella, cottage cheese, ricotta); fresh goat cheese (unaged) Milk and all aged cheeses; milk substitutes that contain any sweetener Grains 100% whole grains only (brown or wild rice, quinoa, whole oats, barley, rye, buckwheat, whole wheat, whole spelt, etc), 1 serving/day All refined grains, breads, sweetened baked goods Flesh foods Fish (fresh or canned) and other seafood, chicken, turkey, lean beef, pork, lamb, (preferably organically raised meats) Cold cuts or processed meats Legumes/beans Tofu and tempeh; any dried beans, split peas, lentils, edamame, up to 1 cup (cooked)/day None Nuts & seeds Walnuts, hazelnuts, filberts, pecans, almonds, cashews, flax seeds, pumpkin seeds, sunflower seeds, poppy seeds, sesame seeds (whole or as nut butters) Peanuts (often considered a nut but are actually a legume), pistachios Vegetables Vegetable—raw, steamed, sautéed, juiced, or baked (see shopping list) Mushrooms, potatoes, corn Fats and oils Avocado; butter; olives; cold pressed oils: olive, flax seed, coconut, sesame, safflower, pumpkin sunflower, almond, walnut, canola Margarine, shortening, processed oils, prepared salad dressings, spreads and sauces, mayonnaise Acidic & fermented foods Lemon and lime juices and vitamin C crystals as replacements for vinegar All vinegars and preserved foods: sauerkraut, pickles, other products preserved in brine or vinegar Sweeteners Stevia (herbal sweetener) All white/brown sugars, honey, maple syrup, corn syrup, high-fructose corn syrup, molasses, brown rice syrup, fruit sweeteners Beverages Filtered, spring, or distilled water (drink 8 cups/day), herbal tea (chamomile, bergamot, hyssop, alfalfa, angelica root, lemon grass, Pau d’arco) Soda pop, alcohol, coffee, nondairy creamers An Alternative Program Your health care practitioner may decide that your issues with candidiasis indicate a need for a more restrictive regimen for a period after the initial 2–4 weeks. If this is the case, then you will need to avoid additional foods for a 7–14-day period. Additional Foods to Avoid Include All fruit. All grains. All dairy products except for plain yogurt with live cultures. Food Reintroductions At the end of the additional 7–14 days, please add the 3 food groups listed on the previous page into your diet, very gradually: Day 1: Add 1 serving (0.5 cup) whole grain daily, such as quinoa, brown rice, or wild rice. After 3–4 days on grains, assess symptoms and if well tolerated with little or no digestive symptoms (or other symptoms that had been bothering you), add the next food group below. If not well tolerated, stay on only the grains for several more days until tolerance improves. It is best to do this as slowly as needed. Day 3 or 4: Add 1 fruit, such as orange or apple, each day. After 3–4 more days, assess symptoms. If well tolerated, proceed to the next food. If not well tolerated, repeat the above procedure by waiting several more days. Day 7 or 8: Add a dairy product, such as cottage cheese or ricotta. Continue to assess symptoms and report to your health care practitioner. You may proceed at this time on the less restrictive list of allowed foods on the previous page. Meal Suggestions for the Candida Control Diet The following are menu suggestions. Because this meal plan is quite low in carbohydrates, you may experience cravings at first, but this will pass and you will soon feel quite satisfied. If you are hungry, you may increase your portion size because this is not a calorie-restricted program. Any recipe may be used for any meal; leftovers from dinner make a quick lunch. However, on a Candida control diet, it is best to use leftovers within 24 hours or discard. Breakfast Suggestions Eggs: scrambled, hard-boiled, soft-boiled, or poached Scrambled tofu Mexi tofu scramble Curried eggs and vegetables Spiced eggs Spanish omelet Silken smoothie UltraBalance Protein Drink Plain cow or goat yogurt (add real vanilla, nuts, or seeds as desired) Lunch Suggestions Mixed greens salad with tofu or tuna Deluxe tuna, chicken, or turkey salad Stuffed peppers Spinach salad Bean salad Chilled shrimp Chinese soup Vegetable beef soup Creamy cold tomato soup Beans and greens soup Lentil soup Vegetable soup Quick steamed greens Italian tofu Celery root salad Dinner Suggestions Ratatouille Grilled vegetables Roasted veggies Stir-fried pea pods Roasted garlic Roasted red peppers Stir-fry vegetables and tofu, shrimp, chicken, or turkey Curried lentils and cauliflower Broiled lamb chops Coconut chicken with rice Baked Cornish hen, chicken, or turkey; roast leg of lamb or pot roast tempeh stew Broiled fish: trout, cod, salmon, halibut, swordfish, tuna, shellfish Any allowed fresh, baked, steamed, or sautéed vegetables in unlimited quantities, topped with tofu mash Coconut salmon Snack Suggestions Roasted or raw nuts and seeds (without peanuts, pistachios) Turkey chili Plain cow or goat yogurt with live cultures Cauliflower popcorn Fresh, raw vegetables with your choice of the following: nut butter, salsa, hummus, yogurt and dill, tofu mash, roasted garlic, walnut spread, or allowable salad dressing Dipping veggies: celery, carrot, daikon, jicama, red peppers, zucchini, yellow summer squash, whole green beans, broccoli, cauliflower, kohlrabi, endive, scallions, snap peas, cucumber, and cherry tomatoes Anti-Candida Food Plan Shopping List Vegetables □ Artichoke □ Asparagus □ Bamboo shoots □ Beets and beet greens □ Bok choy □ Broccoli, broccoflower □ Brussels sprouts □ Cabbage – all types □ Carrots □ Cauliflower □ Celery □ Cucumber □ Eggplant □ Garlic, chives □ Green beans, yellow wax beans □ Jicama □ Kale, collards □ Kohlrabi □ Lettuce – red or green leaf and all types of greens, (arugula, endive, escarole, radicchio, dandelion, etc) □ Okra □ Onions, leeks, scallions, shallots □ Peppers – all types □ Radish, daikon □ Sea vegetables – seaweed, kelp, nori, dulse, hiziki □ Peas – all types □ Spaghetti squash □ Spinach □ Sprouts (broccoli and bean) □ Swiss chard □ Tomatoes □ Watercress □ Winter squash – all types □ Zucchini Fruits □ Watermelon □ Apples (green), pears □ Peaches, nectarines □ Plums □ Kiwi □ Oranges, tangerines □ Grapefruit Concentrated Proteins □ Chicken, Cornish game hens, turkey, duck □ Fresh ocean fish – Pacific salmon, halibut, haddock, cod, sole, tuna, mahi mahi, etc □ Shellfish □ Water-packed canned tuna, turkey, chicken, wild salmon □ Lamb □ Wild game □ Lean beef or pork □ Eggs □ Tofu – regular and silken □ Tempeh Grains □ Quinoa □ Millet □ Buckwheat □ Teff □ Amaranth □ Brown or wild rice □ Steel cut oats Beans – 1 cup/day □ All beans □ Edamame (green soy beans) □ Hummus □ Lentils – brown, green, red □ Split peas – yellow, green All the above beans can be bought dried or canned without added sugar. Oils □ Almond □ Flax seed □ Coconut □ Canola □ Olive □ Safflower □ Sesame □ Soy □ Sunflower □ Walnut Dairy and Substitutes □ Plain cow yogurt with live cultures □ Plain goat yogurt □ Plain soy, almond, or hemp milk – read labels for sweeteners □ Coconut milk □ Fresh, unaged goat cheese □ Cottage cheese □ Mozzarella □ Ricotta Nuts and Seeds □ Almonds □ Cashews □ Flax seeds □ Hazelnuts (Filberts) □ Pecans □ Pignoli nuts (pine nuts) □ Poppy seeds □ Pumpkin seeds □ Sesame seeds □ Sunflower seeds □ Walnuts All of the above can be consumed as nut butters and spreads (eg, Tahini). Vinegar Replacements □ Lemon and lime juices □ Vitamin C crystals Beverages □ Herbal tea (noncaffeinated) □ Mineral water □ Spring water □ Distilled water Miscellaneous □ All spices □ Olives (without vinegar) Go to: Footnotes Author Disclosure Statement Written consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review. Go to: References 1. 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