THE ART AND SCIENCE OF CIRS MEDICINE - M.D. MHSA Andrew Heyman, M.D. Ritchie Shoemaker, M.D. Scott McMahon

THE ART AND SCIENCE OF CIRS MEDICINE (eBook)

M.D. MHSA Andrew Heyman, M.D. Ritchie Shoemaker, M.D. Scott McMahon (Autoren)

eBook Download: EPUB

2020 | 1. Auflage
283 Seiten
Bookbaby (Verlag)
978-1-0983-3592-2 (ISBN)

As teachers and long-time proponents of Chronic Inflammatory Response Syndrome (CIRS), we felt that a compendium of current educational and scientific materials on the Chronic Inflammatory Response Syndrome (CIRS) had a place in the approach to the CIRS patient. In our existing training courses, the basics of CIRS medicine is the source of our curriculum. Call the current courses CIRS 101 and CIRS 201, if you will. Fundamental to our courses is student participation in discussion of published papers, often leading to deeper questions regarding the art of CIRS practice. The growing course work, and level of student engagement show us that students want - and need - greater exploration of the topic, access to the primary literature and opportunities to demonstrate mastery of the subject. What we have put together are informal chapters regarding opinions of skilled practitioners based both on published data and on bedside experience that should help guide new CIRS practitioners through the complex maze of treating this unique patient population. These chapters show the art of CIRS Medicine used by the authors. We cover the subtleties and nuances of exposures, symptoms, labs, physical exam, ancillary studies, use of medications and some of the cutting edge science, transcriptomics, that are brought to bear on the fundamental question, "e;How can we help the CIRS trainee become an expert?"e;We will also feature new dynamic published papers that impact our current thinking about inflammation in CIRS, namely (i) metabolism; and (ii) mycotoxin measurements in urine. We include eight demonstrative cases written up by members of the Surviving Mold CIRS Academy. We are grateful for permission provided by each of these authors (see below) to use their excellent studies for educational experiences. Here we see a merging of art and science of CIRS Medicine that translates into an answer to the question, "e;How do I sort out differential diagnosis and quickly identify the right approach to helping complicated patients?"e;Finally, we include published papers that serve as a journal club for our students. Here are the scientific foundations of CIRS Medicine. Sample teaching questions range from the obvious (what is the study design?) to the essence of science (based on these data, how can you logically apply them to patient care?). We all have our dreams for the future, like hopes and fears all rolled up into one package. We have asked Drs. Shoemaker, McMahon and Heyman to share with us their ideas on the expansion of CIRS Medicine-what is possible now and what will be possible in the future. To help on this quest, we have included a research module based on the work of Ken Hudnell PhD and Ritchie Shoemaker MD that forms a starting point for good scientific studies. Finally, the advances in transcriptomics tell us far more about metabolism and inflammation than any writings published to date. These are exciting times!Taken together, the chapters, papers and sidebars of The Art and Science of CIRS Medicine are part of the ever-expanding extrapolation of CIRS to medicine in general.

CHAPTER 1: HOW IT ALL BEGAN

Author: RITCHIE SHOEMAKER MD

The story of CIRS, first named in 2010, begins 14 years earlier along the banks of the Pocomoke River of the Eastern Shore of Maryland. Back then, Ritchie Shoemaker, MD, was happy to be a rural, solo Family Practice physician working adjacent to wetlands of the tidal blackwater swamps around Pocomoke, Maryland. There was no need then to lock doors at night. People could walk to school without fear. Seeing patients by day, making house calls too, left ample time for a growing family to be outside in fields, forests and ponds nearby. It was an idyllic life for Dr. Shoemaker.

Life changed abruptly when Pfiesteria was found to be active in the Pocomoke River estuary where the downstream flow met the incoming salt wedge. All told, the new carrier of a never-before seen plague affected 22 tributaries of the Chesapeake Bay, possibly putting millions of people at risk for what the CDC later called Possible Estuarine Associated Syndrome (PEAS). This dinoflagellate was later identified in Bay sediments at least 100 years old, but in 1996 was acting like a newcomer, causing mysterious lesions on fish of all species. By 1997, the “Cell from Hell” expanded its activity to causing fish kills and creating an unusual illness in among watermen, people who harvested fish and crabs from the rivers and the Bay.

The public health uproar that followed the outbreak was magnified by an earlier book, The River Turned to Blood, that chronicled the Pfiesteria outbreak in North Carolina several years earlier. Only no one from Carolina admitted that anyone there was sickened in the wild. People stopped eating seafood from the Chesapeake Bay; they stopped boating on the Chesapeake Bay; life that revolved around the Bay was changed. Perhaps the scenario then was not as dramatic as COVID-19 is now regarding changing lives and changing activity because of an unknown pathogen, but the principles were the same. Fortunately, only one person was known to die from Pfiesteria.

Shoemaker was a wetland enthusiast. Everybody in Pocomoke, all 2000 people, knew him or JoAnn, his bride, an early childhood teacher in the local elementary school. He was asked by the watermen to get involved by trying to answer the questions “What is wrong with me and what do I have to do to get better?” Despite his best efforts in 1996, Shoemaker was of no help. All labs on the river, including nutrients, were unchanged; no infectious diseases were found. Every human test was non-conclusive but how could the illness be identified? What he needed were some actual confirmed human cases!

By early spring 1997, Pfiesteria was back. Shoemaker did fish autopsies, learned about wetland ecology, porewater physiology and emergent palustrine vegetation; his later insights about causation of Pfiesteria blooms were shaped by finding massive increases of heavy metals, especially copper, in the water column and in porewater directly adjacent to tomato farms and tobacco fields right next to subsequent fish kills. There, older fungicides, dithiocarbamates, had been added to copper to kill a resistant fungus that was destroying valuable crops.

All those academic exercises were interesting but what was making people sick was undetermined. In the thought that possibly Pfiesteria was making a toxin, a simple experiment was done with river water. Two containers, approximately 55 gallons each, were filled with river water from Shell Town, Maryland, a known hotspot just downstream from Pocomoke and then stocked with river fish of a variety of species. Into one of the containers was placed permanganate, a potent oxidizing agent that would inactivate biotoxins; the other tank was the control. Fish in the permanganate bath looked purplish but were still happily swimming the next day. Fish in the non-permanganate container were floating on the surface of the water, covered with the now-typical Pfiesteria lesions. Clearly, something poisonous was in the water that could be oxidized and removed. An unknown toxin seemed likely.

The first big fish kill of 1997 was in July outside Shell Town at Williams Point. There, a group of 10 people were recreating in the water, water skiing, swimming, drinking beer, all normal Eastern Shore activities. Surprisingly, three of ten became acutely ill but even more surprisingly, seven people stayed well. There was nothing obviously different about the seven controls versus the three cases. Shoemaker had his cases, but how was anything he thought of going to help? And who knew that HLA DR (what was that?) was the crucial susceptibility factor?

As luck would have it, the 3rd patient of the group sickened in the Pocomoke River developed a terrible secretory diarrhea. All three patients came to Shoemaker for help; he treated the 3rd with cholestyramine (CSM), an orally administered, anion binding bile sequestrant resin, to stop the secretory diarrhea. It is an old trick that country doctors know. To stop bad diarrheas, simply add a constipating, bile salt-binding cholesterol drug. The drug normally is used to lower cholesterol and is still made available on a generic basis in the United States. Off label use is legal.

Two days later, the patient on CSM called Shoemaker to say that the diarrhea had stopped (of course it did!) and her brain fog was gone. Her cough stopped, her muscle aches were gone and even the trouble she had remembering where she left her car was a thing of the past. CSM had to be binding-and removing-the causative compound!

The following week was the big State-scheduled Pfiesteria meeting held at Salisbury University. The State of Maryland was going to show everyone, especially the media, that the Cell from Hell problem was taken care of and no one was sick. Shoemaker arrived with his 8x10 colored photos of sickened people, complete with skin lesions, showing everyone who crowded around him that the illness was real and here was a possible cure. The media frenzy began.

What would you do next if you were in Shoemaker’s shoes? Would you treat everybody like Shoemaker did? Or would you say an N=1 study is not enough evidence of successful treatment? Some observers were not too happy that the country doc was making waves treating patients.

Nearly all the 200 patients he saw from 1997-98 felt better after CSM. Shoemaker published the first paper 9/97 on acquisition of Pfiesteria Human Illness Syndrome, (pronounced “fish”) in the wild, and then followed that up with a paper in February of 1998 on treatment with CSM.

Considering he discovered the underlying cause of this illness it is difficult to comprehend how much criticism of Shoemaker followed. Politics and public health make for strange friends. As you can imagine, the public health arguments were such that all the experts had opinions and who would listen to the country doctor anyhow? For the definitive history of Pfiesteria in the Bay, and there is a lot more, read, Crossing Dark Water, by Ritchie Shoemaker MD.

Fortunately, Frank Fuzzell, in Florida, heard about this medical oddity and called Shoemaker about problems with people with similar illnesses present in the St. Lucie River - including fish with lesions creating human health problems. Add to the list the lakes full of blue green algae, including Microcystis and Cylindrospermopsis, making those with close contact ill. Then there were the people sickened after they were exposed to areas on tropical plant nurseries where a fungicide called benomyl had been used. Was there a unifying explanation?

Certainly, all these illnesses improved with cholestyramine. They all had multiple symptoms with multiple systems involved, just like Pfiesteria did, and they all had visual contrast sensitivity (VCS deficits), just like Dr. Ken Hudnell of the USEPA showed in July 1998.

With treatment, symptoms went away, VCS was fixed; life was good.

That changed in 1999 when researchers in Boston, in the lab of Sam Donta, M.D., showed that Borrelia burgdorferi, the causal bacteria of Lyme disease, made a neurotoxin. If the Lyme patients were sickened by a neurotoxin and they had a multisystem, multi-symptom illness, let us give them cholestyramine after the antibiotics. Oops, patients were much, much worse. What could this “intensification” be from?

It turns out that there was a sequence of a cytokine storm, reminiscent of what we see with COVID virus these days, making people felt terrible. When Shoemaker figured out how to block the cytokine storm, patients with a history of Lyme disease, previously treated appropriately with antibiotics, but still having persistent symptoms, began to improve on CSM. But more importantly, what was clear was that worsening with CSM was driven by massive inflammation. What else did we not know?

For the next 22 years, Shoemaker doggedly pursued the underlying pathophysiology, diagnosis and the treatment of CIRS. He, and noted research colleagues, especially Jimmy Ryan, PhD, published extensively unveiling the complexity of CIRS, demonstrated how we can now control differential gene activation that underlies CIRS, like it does for all chronic disease.

In 2010, in a consensus publication co-authored with Scott McMahon, MD, the Chronic Inflammatory Response Syndrome was officially christened as CIRS. Most cases stem from exposure to the interior environment of water-damaged buildings (WDB), as one will see.

The rest, they say, is history as this compendium of medical information about CIRS will show. All professors can do is teach you what they know. It will be up to their students, the reading audience, to take the science...

Erscheint lt. Verlag	24.9.2020
Sprache	englisch
Themenwelt	Sachbuch/Ratgeber ► Gesundheit / Leben / Psychologie
ISBN-10	1-0983-3592-9 / 1098335929
ISBN-13	978-1-0983-3592-2 / 9781098335922

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