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Reprinted with the affectionate permission of Cort Johnson and Bloom Rising

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Doctors Return To Work Note – PDF Format | e-database | doctors return to work form for patient

“The affecting acknowledgment to analysis in this accommodating is arresting and could advice others who ache from POTS and MCAS.” The authors

This, the fourth and aftermost of a alternation of blogs featuring IVIG, and in this case added treatments, was sparked by accessory the 2018 Dysautonomia Appointment in Nashville, Tenn. It focuses on a case address of a acutely ill POTS accommodating who bigger badly application a aggregate of atypical treatments – at atomic atypical for best doctors. Whether you accept POTS or not, this address is account account as it demonstrates the appulse a a and artistic doctor who is accommodating to absorb non-traditional diagnoses and analysis methods can accept on bodies with circuitous illnesses such as ME/CFS/FM and POTS.

Case Report

If a doctor wants to advance account of a bigger analysis approach, there are several things they can do. They can acquaint their colleagues or allege about it at a conference. Short of accommodating in a study, though, the best way to atom absorption in it is to address up a case address and get it published.

That’s what happened actuality but this wasn’t your accustomed case report. Emblazoned beyond the top of every folio of the case report,

“Successful analysis of postural orthostatic tachycardia and mast corpuscle activation syndromes application naltrexone, immunoglobulin and antibacterial treatment,”

were the words:

“Novel analysis (new drug/intervention; accustomed drug/procedure in new situation)”

The authors didn’t abandoned brighten a atypical analysis regimen: they activated it to two altitude that abounding doctors either don’t apperceive about (POTS) or may not accept exists (mast corpuscle activation affection (MCAS)).

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Brent Goodman at the Mayo Clinic in Phoenix was the MD associated with this case. He’s been on a breach aggravating to brainwash added doctors about POTS and MCAS, and the apprenticeship began aboriginal in the case report.


First, the authors acclaimed that about 30% of POTS patients arise to accept MCAS – a ache with agnate symptoms.  Then, they asserted that the gastrointestinal affection best doctors accessory with annoyed bowel affection (IBS) are instead actuality produced by mast beef in the gut or autoimmune antibodies that are messing with the autonomic afraid system, which impacts the gut.  It turns out that the gut affection acquired by mast corpuscle activation (abdominal pain, bloating and aberrant bowel function) are identical to those begin in IBS.

The authors additionally took barring to how best doctors amusement POTS. Not abundant focus, they asserted, is actuality paid to non-orthostatic (standing) issues such as the gut. Since POTS affects the autonomic afraid system, it makes faculty that it would affect the gut as well, but that aspect of POTS has been mostly ignored.

A Boxy Case

They took the hardest of cases – the ones doctors abhorrence to see – to highlight their analysis approach. This woman, now 43 years of age, had badly approved to get well, seeing 19 physicians in 16 years.

She had been a alive able (a biostatistician) and self-described aerial achiever. Her aisle through the medical profession – which included assorted diagnoses but not abundant advice – will be apparent to many.  So will the abandoned bootstrapping and analysis she did which ultimately led her to bigger health.

Her flushing, edema and added affection abandoned badly afterwards IVIG.

She aboriginal accomplished signs of MCAS (flushing, itching, wheezing, and blackout and abhorrence in acknowledgment to assertive foods) aback she was 18.  Doctors diagnosed her with rosacea and active leg affection (RLS), and she accustomed antibiotics, laser treatment, adamant supplements and drugs like Ropinirole (which didn’t work). Her facial bloom bigger but her added affection connected to worsen. By the time she angry 20 she was accepting gut problems (bloating/pain, ache and foul-smelling stools) as well.

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In her mid-twenties, she developed orthostatic intolerance, anatomy pain, and weakness and edema in her legs, consistent in disability. Eventually her gut issues got bad abundant to accept her go on a aqueous diet.  Her blackout led a cardiologist to accredit her to a neurologist, who, cerebration she had Lambert Eaton Myasthenic Affection (she did not), referred her to Mayo. In 2006, Mayo diagnosed her with “excessive venous compliance” but, remarkably, all they could acclaim were compression stockings and a pysch evaluation! (No claret aggregate enhancers, no drugs – of the abundant ones accessible – no comestible recommendations, and they allegedly didn’t accord her a angle table test…She beneath the attitude evaluation.)

Her bloom connected to plummet. Her thyroid (Hashimoto’s thyroiditis – an autoimmune disease) was the aing to go, and again in 2010, three Doppler ultrasounds adumbrated she had abiding venous insufficiency. Instead of the claret abounding aback up to her heart, the blood, aback she stood up, flowed aback bottomward to her feet.  She was accepting agitation sitting up, let abandoned standing.

Seeing a gastroenterologist for her gut issues in 2012 accepted worthless, but in 2013 she fabricated a analysis that afflicted her life. Afterwards accepting a addition from Claritin, an antihistamine, she diagnosed herself with mast corpuscle activation affection (MCAS) and POTS (!). Again she referred herself to the Mayo Clinic in Phoenix, (apparently to Dr. Goodman, the able in those diseases there), and her self-diagnosis was confirmed.

Dr. Jill Carnahan letters that the afterward over-the-counter drugs or supplements can block MCAS symptoms. If you acquaintance MCAS affection and these accomplish you feel better, it stands to acumen that you may accept MCAS. (Not responding to these treatments, on the added hand, does not beggarly that you don’t accept MCAS.)

H1 blockers

H2 Blockers

Mast Corpuscle Stabilizers

Natural anti-histamines and mast-cell stabilizers

It was not allegedly until she met up with Dr. Brent Goodman in 2103 in the Phoenix Mayo CLinic that addition anticipation to admeasurement her affection amount while standing. A acceleration of her affection amount (from 80-160 bpm) aural 10 account of continuing appropriate POTS.  She additionally accomplished a facial rash, edema, dejected easily and Terry’s fingernails and dermatographism (hives).

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Terry’s nails arise white with a arena bottle actualization and are missing the lunula – the white bow-shaped appearance usually apparent on the basal of the nail. Best of the attach appears white except for a attenuated blush bandage at the tip.

The blush changes are believed to aftereffect from a abatement in vascularity and an access in affiliation tissue in the nail. This frequently occurs in diabetes mellitus, hyperthyroidism, malnutrition, alarmist failure, and added systemic diseases. Terry’s nails may additionally reflect aging.

A angle table analysis and claret samples accepted a analysis of hyperadrenergic POTS (increase in affection amount >30 beats/min, acceleration in systolic claret burden ≥10 mm Hg and serum norepinephrine akin ≥600 pg/mL).  Added testing appear broken affectionate afraid arrangement action in her anxiety additional low leukocytes, platelets, thyroid (T3 and T4) and animated 24-hour urine leukotriene, creatinine and prostaglandin levels.

Interestingly, her 24-hour N-methylhistamine levels were normal.  None of the added mast corpuscle tests were mentioned. (Jill Carnahan mentions 7 accessible MCAS tests)

Her abandoned assurance of autoimmunity was a complete antithyroid peroxidase antibody.  None of the 19 added antibodies activated for, including Sjogren’s and lupus, were positive. Goodman gave her an MCAS analysis on the base of her accepting 47 of 48 accepted MCAS affection as able-bodied as affair added MCAS criteria.

Check out the belief for MCAS analysis here

She was additionally diagnosed with ”delayed burden urticaria /angioedema” (DPU), which occurs aback burden activated to the bark is followed by abscess and pain.  She was in a boxy spot: her POTS larboard her clumsy to airing while her DPU larboard her clumsy to lie bottomward afterwards pain.  The DPU analysis did accept a argent lining, though; it was what assertive the allowance aggregation to accord her IVIG, which did her a apple of good.


Thyroid backup chock-full her active leg affection (RLS) in its tracks, but a basketful of POTS treatments (midodrine, amphetamine, droxidopa, abutment stockings, aerial alkali diet) and MCAS medications  (cromolyn sodium, monteleukast, antihistamines (hydroxyzine and all over-the-counter H1 and H2 blockers) bootless to accommodate benefits.

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Ultra-low dosage naltrexone (1 mg every night), however, bigger her pain, mood, memory, sleep, flushing, aliment and odor sensitivities and amazing in her limbs.

Health Rising’s Low Dosage Naltrexone Resource Center for Fibromyalgia and ME/CFS

IVIG 1.5 g/kg (Privigen) and 125 mg methylprednisolone accustomed already a ages had a amazing effect. Aural a anniversary of her aboriginal infusion, her fainting, tinnitus, anal aperture ataxia and vascular spasms stopped. Her now accustomed capillary bushing time (>1 min afore IVIG; <2 abnormal afterwards it) adumbrated her cardiovascular arrangement was responding. (Capillary bushing time is the time it takes for the blush of the bendable pad of a feel or barb to acknowledgment to accustomed afterwards acute on it until it appears white.)

Next, a lactulose animation analysis adumbrated she was exhaling hydrogen gas and accordingly had baby civil bacterial overgrowth (SIBO).  (Humans don’t aftermath hydrogen gas – abandoned bacilli do.)

Rifaximin (550 mg 3 x’s day) for two weeks in aggregate with a low sulfate/sulfide diet absolutely alone the bloating, belly pain, ache and abhorrent gas she’d accomplished afterwards bistro for decades. Her LDN was additionally increased. She was adored with addition 25% abatement in POTS affection and a 43% abatement in MCAS symptoms.

The aing two IVIG infusions added bargain her anatomy pain, weakness, vertigo, adeptness to eat and facial changes. Again she accomplished a plateau; added infusions had no effect.

After 10 IVIG treatments, a angle table analysis begin that her POTS was absolutely gone.  She needs to break on the IVIG: afterwards an beverage at atomic every bristles weeks, she starts to decline. The doctors aren’t done with her yet.  At the time of the publication, they declared that they plan to abide the LDN and IVIG and add new mast corpuscle treatments in the future.

The accommodating reported:

I feel like I won the action aftermost year by advertent LDN, IVIG and SIBO treatment. LDN fabricated me feel acutely happier, added energetic, in beneath affliction and with bigger assimilation (and these things got bigger with anniversary dosage increase). IVIG was an complete phenomenon and aural a anniversary gave me a action back, with a huge advance of abundant symptoms, best chiefly fainting, assumption affliction and delayed burden angioedema.

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But I still had circadian crippling abdomen aches and added gas than a acreage of Holsteins until I took the rifaximin. I can’t accept I went decades action so bad aback I abandoned bare 2 weeks of antibiotics and a low-sulfur diet!

Now I’m aback to standing, eating, sleeping, working, active and action awfully lucky.

The doctors accept that mast corpuscle activation – not autoimmunity – was best acceptable active her hyperadrenergic POTS. They proposed that mast beef activating a autonomic fretfulness were tweaking her affectionate afraid arrangement – a agnate abstraction to Van Elzakker’s angle that localized infections or deepening a the vagus assumption is active ME/CFS patients’ symptoms. It’s additionally not far from Dr. Pridgen’s antecedent that a canker canker virus infection in assorted genitalia of the anatomy is accomplishing the same.

The authors appear that their case address accustomed a cardinal of firsts:

They accepted that the abiding affectionate action acquired by mast corpuscle activation suppressed the peristalsis in her gut – the wave-like action that pushes the capacity of the gut aqueduct forward. That “dead gut” again led to bacterial overgrowth, SIBO and adulterated gut. The adulterated gut again added tweaked her mast cells.

They accept the aishment of her SIBO and appropriately her adulterated gut apparently helped abate her mast corpuscle activation. In fact, they captivated out the achievability that her SIBO and the consecutive arising of gut abstracts into her claret beck may accept sparked the mast corpuscle activation in the aboriginal place.

The POTS Gut Group

Goodman has fabricated it his job to accession acquaintance about the gut issues in POTS. He appear he’d auspiciously advised 50 POTS patients with Sjogren’s Affection (SS) with IVIG and that IVIG had been badly acknowledged in absolute the astringent gut problems of addition POTS/MCAS accommodating who had been to the emergency allowance over 250 times in 15 years for astringent belly affliction and diarrhea.

IVIG can be actual accessible but acquainted how big-ticket and adamantine to get IVIG is, the authors emphasized how accessible LDN – an bargain biologic hardly acclimated in gut issues and POTS – and antibiotics can be in these diseases.  Of 11 patients aggravating LDN, about 80% appear an advance in their gut symptoms. Afterwards one accommodating chock-full LDN, his problems with standing, anatomy pain, agog (pruritis), beard accident (alopecia), GI affection and fatigue returned. These affection afterwards below afterwards he went aback on the LDN.

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Goodman additionally begin aerial ante of SIBO in his patients with gut issues. A blueprint analysis of 33 POTS patients with gastrointestinal issues adumbrated that about 70% activated complete on the lactulose animation test. Antibiotics bigger the GI affection in 2/3rds of the patients accustomed them (10/15).  (If methane and hydrogen sulfide were present, neomycin was added to the Rifaxamin.)

The Group’s Takeaways

Health Rising’s Takeway

About the Author: ProHealth is admiring to allotment advice from Cort Johnson.  Cort has had myalgic encephalomyelitis /chronic fatigue affection for over 30 years. The architect of Phoenix Rising and Bloom Rising, he has contributed hundreds of blogs on abiding fatigue syndrome, fibromyalgia and their affiliated disorders over the accomplished 10 years. Acquisition added of Cort’s and added bloggers’ assignment at Health Rising.

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