This blog is a way of sharing the information and resources that have helped me to recover my son Roo from an Autism Spectrum Disorder. What I have learned is to view our symptoms as the results of underlying biological cause, which can be identified and healed. I say "our symptoms" because I also have a neuro-immune disorder called Myalgic Encephalomyelitis.

And, of course, I am not a doctor (although I have been known to impersonate one while doing imaginative play with my son)- this is just our story and information that has been helpful or interesting to us. I hope it is helpful and interesting to you!


Monday, February 20, 2017

Kitchen Help and Cooking Skills

One of the most significant barriers that I see people struggle with in order to implement a special diet is lack of general cooking and kitchen skills.  Over the last few generations many people haven't learned these skills as they would have in the past.  This is especially true for traditional cooking methods, such as fermenting foods and making broth, but is also true for more basic cooking methods as well.  Below are links that demonstrate some of this information.

A nice collection of diagrams and graphics to illustrate and teach cooking.

How to care for cast iron pans

How to sharpen a knife using a whetstone

How to use and season a mortar and pestle

Reference guide for spiralizing vegetables

Learning to cook without recipes (teaches technique)

Cooking hints and tips from What's Cooking America

Cooking Eggs

How to make soft-cooked eggs

How to make perfectly poached eggs

How to make steamed eggs

Friday, February 17, 2017

Central Sensitization Syndrome (and chronic pain)

This is a video made by Dr Sletten of  The Comprehensive Pain Rehabilitation Center at The Mayo Clinic about a condition called Central Sensitization Syndrome which can be a cause of chronic pain and discomfort.  My notes follow the video.



In our peripheral nervous system, we have tiny sensors in every part of our body (aside from hair and fingernails).  These sensors are in our skin, gut, muscles, joints, bones, vestibular system, nerves, vascular system, vision, hearing, taste, and smell.  These sensors pass information on the the central nervous system about our safety and comfort so that we can respond appropriately (drink when we are thirsty, for example).  There can be situations that cause the sensors to be up-regulated (to send a stronger signal), and once this happens they stay upregulated, continuing to send stronger signals.  Sensory symptoms can become very problematic.  This syndrome may start after an injury, illness or disease, surgery, hereditary, or some repetitive injuries.

Once the input from the peripheral sensors becomes upregulated, it sends increasingly stronger signals to the brain.  The somatosensory cortex, which is where all of our sensory input into the brain goes to be analyzed, begins to react more strongly.  Input that may have been mild and easily handled in the past, such as discomfort from clothing, can become much more distressing.  Because the Somatosenosry Cortex is organized by body part, pain and discomfort in one part of the body can lead to other symptoms in the same area of the body.  This leads to another group of symptoms that can be worse over time including pain, fatigue, dizziness, nausea, sensitivity to temperature, touch, tastes, sounds, smells, even barometric pressure.  None of this is psychological, it is physiological. Patients don't bring this on themselves.

There are 4 reactive and maintaining factors which include physical, emotional, behavioral, and chemical.  When patients are on many meds, it can cause confusion in the brain as they interact, they call this "polypharmacy".  In this way "over-medicating" can make the problem worse.  Behavioral reactions to pain such as avoidance can worsen the situation because the muscles can become deconditioned.  The emotional distress about being sick and dealing with pain can itself also be overwhelming to the brain and can increase the overall stress on the brain.  He is careful to point out that emotions are a response, NOT a cause in this condition.

Mayo treats this with The Pain Rehabilitation Program, which is a 3-week program (40 hours a week) in which they work with patients to alter those 4 factors that can amplify the sensory signals.

Friday, November 11, 2016

Medical Dream Team

This is a list of providers who are especially knowledgeable in areas relevant to my family and to people who may be following this blog.  I have not seen any of these doctors and am not endorsing them, I am keeping this list as a reference resource.  I will be adding to this list over time.  Some doctors are listed under more than one heading.

General

The NIH Undiagnosed Disease Network

National Jewish Health - (from website) "National Jewish Health is the only facility in the world dedicated exclusively to groundbreaking medical research and treatment of patients with respiratory, cardiac, immune and related disorders."

MAPS = Medical Academy of Pediatric Special Needs

MAPS Doctors tend to be the most educated about medical issues in people with autism and related disorders such as ADHD, Sensory Processing Disorder, etc.  This is a directory of doctors and other health care practitioners who have attended MAPS training conferences (this list is not an endorsement or recommendation, so you should check them out before working with any).

This page on the ARI (Autism Research Institute) website has suggestions for how to select a provider for your child.

Richard Frye, MD.  is a pediatric neurologist and Director of Autism Research at Arkansas Children's Hospital Research Institute.

Dan Rossignol, MD FAAFP  from his website "Dr. Rossignol has a special interest in autism spectrum disorders, PANS/PANDAS, cerebral palsy, and related neurological and developmental disorders as well as medically complex children and adults."

ME/CFS and other Neuro-Immune Disorders:

Nevada Center for Biomedical Research focuses on research into neuro-immune disorders including ME/CFS, autism, and fibromyalgia and the underlying immunological, inflammatory, mitochondrial
and other factors.

Stanford Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS) Initiative - they are leading the way in studying the role that immunological and infectious factors play in chronic diseases such as ME/CFS.

Steven Jacobson, Ph.D. - is a senior investigator at the National Institute of Neurological DIsorders and Stroke with a specialty in viral immunology and neurovirology, with a focus on herpes viruses and their role in progressive neurological disease.
Paul Cheney, M.D. - is medical director of The Cheney Clinic in North Carolina and a leading doctor in the treatment of ME/CFS, in particular immune system involvement and cardiac involvement.  

Mito/Metabolic

Fran Kendall, MD. - one of the leading doctors in the US for mitochondrial and metabolic disorders.

Mark Korson, MD - is a leading metabolic and mitochondrial specialist.

Robert K. Naviaux, MD, PhD - is an expert in mito and metabolic disorders and how they relate to the cellular danger response, and neurological disorders including CFS, autism, PTSD, Parkinson's, and more.

The Foundation for Mitochondrial Medicine Program at UAB - this is a new multidisciplinary center with the mission of developing new techniques for diagnosis and treatment of mito disorders.

Gastroenterology

Timothy Buie, MD - pediatric gastroenterologist with a focus on treating children with autism and other developmental disorders, as well as children with motility and allergic disorders that affect teh GI tract.

Alessio Fasano, MD - specialist in pediatric gastroenterology and nutrition with a particular expertise in celiac.

Philip Miner, MD - G.I. doctor with an expertise in mast cell disorders and how they affect the digestive system.

Mast Cell Disease, Eosinophilic Diseases, and Other Allergic Diseases:

J. Pablo Abonia, MD. - specialist in eosinophilic and mast cell disorders and immunodeficiency at Cincinnati Children's Hospital (sees adults too).

Lawrence Afrin, MD. - Leading doctor in US for Mast Cell Activation Syndrome.

Theo Theoharides, MD - Leading mast cell researcher and doctor with a particular specialty in the study of mast cells in the brain and their role in neurological and psychiatric disorders. 

Philip Miner, MD - G.I. doctor with an expertise in mast cell disorders and how they affect the digestive system.

Anne Maitland, M.D. - expertise in both Mast cell disease and it's connection to EDS/connective tissue disease.

Cincinnati Center for Eosinophilic Disorders - International leaders in researching and treating eosinophilic disorders including EGIDs.

Margaret H. Collins, MD. - is the leading pathologist for evaluating biopsies for eosinophils (and an expert with mast cells too) and is part of the CCED listed above.  

The Mastocytosis Center at Brigham and Women's is probably the best place to go if you have Systemic Mastocytosis.

PANDAS/PANS

Rosario R. Trifiletti, MD - pioneering specialist in identifying and treating PANDAS/PANS.


Susan Swedo, M.D. - is Chief of Pediatrics & Developmental Neuroscience Branch at the NIMH, and the researcher who led the team that first identified PANDAS.

EDS/Connective Tissue Disease

Clair A Francomano, M.D.- molecular geneticist with expertise in Ehlers-Danlos Syndrome and other connective tissue disorders.

Paolo A. Bolognese, M.D. - one of only a few doctors in the US with expertise in atypical chiari presentations, cervical instability, and other neurological manifestations of EDS.

Fraser Henderson, Sr. MD. - one of the only other doctors to specialize in atypical neurological problems in patients with EDS.

The Medical Genetics division of the University of Washington Department of Medicine has several doctors who specialize in inherited connective tissue diseases.

Petra Klinge, MD, Ph.D - neurosurgeon with expertise in hydrocephalus, disorders of cerebrospinal fluid such as Spina Bifida, also with a focus on the most rare and complex disorders of the spine and nervous system.

Other

The Stanford Center for Narcolepsy.  They are world leaders in researching, understanding, and treating narcolepsy.

Martha U Gillette, M.D. - is a neuroscientist doing pioneering research into circadian rhythms and how they are involved in various diseases.

Dr Claudia Miller, MD -  is an allergist/immunologist and a leader in understanding environmental illnesses and the role of toxic exposure and chemical sensitivity in chronic disease.

Carol Duffy, M.D. - is a professor of microbiology with a focus on herpes viruses and herpes infections (including encephalitis) in humans.

New Pediatric Dysautonomia center at UT 

Eric Lowell Singman, M.D., Ph.D. - is a professor of ophthalmology with expertise in neuro-ophthalmology, EDS, and the effects of traumatic brain injury on vision.

Alternative Modalities (non MDs)

Eve Prang Plews LNC, IFMCP has been highly recommended to me by other EGID patients.  She is trained in finctional medicine, homeopathy, and nutrition.


Julie Matthews is a leading nutrition specialist for Autism Spectrum Disorders, ADHD, Sensory Processing Disorders, and related issues.

Mary Coyle, D.I. Hom. - is a homeopathic doctor specializing in homotoxicology and the treatment
of Autism Spectrum Disorders, ADHD, Sensory Processing Disorder, and related issues using homeopathy and other natural approaches.


Friday, October 28, 2016

Many of the Diseases on the Rise Now seem to be Interconnected

In this commentary piece by Dr Stephen Genuis MD, Pandemic of idiopathic multimorbidity, he makes the argument that there is a relatively sudden increase in certain types of diseases, particularly allergic diseases.  He calls this condition "multimorbidity" which simply refers to a patient with 2 or more chronic diseases or complaints.  He argues- as many have regarding autism- that a sudden and dramatic increase in a medical condition is not well explained by claiming that the condition is genetic, as genes don't change that quickly.  A sudden and dramatic increase in a disease implies an environmental influence.  He has noticed, as many others have, that some symptoms and diseases often appear together including headache, joint pain, fatigue, brain fog, bloating, chemical intolerance, muscle aches, itchy skin, abdominal discomfort, and fibromyalgia.

Dr Genuis conforms what many of us living with these symptoms already know- that many, if not most doctors do not believe that this constellation of symptoms is caused by physiological illness, but rather is a psychiatric somatic illness requiring anti-depressants for therapy.  In his attempts to uncover a common physiological explanation, he says "A foray into the recesses of the scientific literature reveals discussion of a condition called sensitivity-related illness (SRI), with description of a credible causal mechanism to account for much of the emerging pandemic of multisystem health problems. This condition results when toxicant accrual within the human organism— typically from exposure to adverse chemicals—induces a state of immune dysregulation and hypersensitivity resulting in physiological disruption within various organ systems. The pathogenesis relates to an intriguing phenomenon called toxicant-induced loss of tolerance, a finding that represents a considerable advance in medical science pertaining to the origins and mechanisms of disease."

It seems that more and more doctors and researchers have begun paying attention to the co-morbidity of diseases and symptoms such as Mast Cell Disease (MCAD), Eosinophilic diseases (EGIDs and HES), other digestive disorders and symptoms, allergy and other forms of atopy such as eczema, migraines and other headaches, Ehlers-Danlos Syndrome (EDS) and other joint and connective tissue symptoms and disorders, psychiatric symptoms such as ADHD, OCD, panic disorders, and anxiety, neurological and neurodevelopmental disorders including autism and seizures, as well as many others.  In particular, the three disorders of EDS, MCAS, and Dysautonomia (usually POTS) occur together so often that they are sometimes referred to as "the trifecta".

Unifying Theories:

Researchers identify new spectrum disorder called ALPIM syndrome
"Panic disorder itself may be a predictor for a number of physical conditions previously considered unrelated to mental conditions, and for which there may be no or few biological markers," explains Dr. Coplan.  In the study, published in the Journal of Neuropsychiatry and Clinical Neurosciences, the researchers proposed the existence of a spectrum syndrome comprising a core anxiety disorder and four related domains, for which they have coined the term ALPIM."  These are: A = Anxiety disorder (mostly panic disorder); L = Ligamentous laxity (joint hypermobility syndrome, scoliosis, double-jointedness, mitral valve prolapse, easy bruising); P = Pain (fibromyalgia, migraine and chronic daily headache, irritable bowel syndrome, prostatitis/cystitis); I = Immune disorders (hypothyroidism, asthma, nasal allergies, chronic fatigue syndrome); and M = Mood disorders (major depression, Bipolar II and Bipolar III disorder, tachyphylaxis. Two thirds of patients in the study with mood disorder had diagnosable bipolar disorder and most of those patients had lost response to antidepressants).

A New Disease Cluster: Mast Cell Activation Syndrome, Postural Orthostatic Tachycardia Syndrome, and Ehlers-Danlos Syndrome

Dr Meglathery, herself a patient with this combination of diagnoses, has developed a theory called The RCCX Theory that argues for an underlying genetic connection between these conditions.
Dr Diana Driscoll has developed a theory she calls The Driscoll Theory that connects POTS, MCAS and EDS, and ties in some of the other symptoms/issues as well (including cranial hypertension).  She also has a number of videos on her site that explain the connections in more detail.

The blogger over at Oh Twist describes in a post called The Chronic Constellation the list of disorders that so many of us as patients have noticed.  She also includes mitochondrial diseases, autism spectrum disorders, and many autoimmune diseases in this cluster of disorders.

Scientific Papers That Support These Connections:

Ehlers-Danlos Syndrome Hypermobility Type: A Genetic Predisposition to the Development of Various Functional Somatic Syndromes

Neurological manifestations of Ehlers-Danlos syndrome(s): A review

Chronic fatigue in Ehlers-Danlos syndrome-hypermobile type

Orthostatic intolerance and chronic fatigue syndrome associated with Ehlers-Danlos syndrome.

Neurodevelopmental attributes of joint hypermobility syndrome/Ehlers–Danlos syndrome, hypermobility type: Update and perspectives

Unexpected association between joint hypermobility syndrome/Ehlers-Danlos syndrome hypermobility type and obsessive-compulsive personality disorder.

Joint hypermobility is more common in children with chronic fatigue syndrome than in healthy controls.

[Fibromyalgia: an unrecognized Ehlers-Danlos syndrome hypermobile type?].

High prevalence of eosinophilic esophagitis in patients with inherited connective tissue disorders

Eosinophilic gastrointestinal disorders associated with autoimmune connective tissue disease.

Involvement of mast cells in eosinophilic esophagitis.

Gastrointestinal symptoms associated with orthostatic intolerance.

Symptom overlap and comorbidity of irritable bowel syndrome with other conditions.

Characterizing Gulf War Illnesses: neurally mediated hypotension and postural tachycardia syndrome.

Neurally mediated hypotension and chronic fatigue syndrome.

Neurological Manifestations of Angioedema

Sleep research in autism and connective tissue

New Epidemics: The Possible Connection Between CFS/ME, Narcolepsy and PANS

New study shows severity of tinnitus (ringing in the ears) is related to emotional processing

Food Allergy Common in Joint Disorder

Kids with food-triggered eczema are at risk for developing life-threatening food allergy, study suggests

Psychological Functioning of Children and Adolescents With Eosinophil-Associated Gastrointestinal Disorders

Psychiatric disorders and symptoms severity in pre-school children with cow's milk allergy.

Association of atopic diseases and attention-deficit/hyperactivity disorder: A systematic review and meta-analyses.
Cow's milk protein intolerance in adolescents and young adults with chronic fatigue syndrome.

Wednesday, September 21, 2016

Products We Like for Managing Our Health Conditions

There are quite a few products that we have found that we need to help us live as best as we can with our health conditions.

MASKS:

Vogmask These face masks are more comfortable than most, partly because the straps go behind your ears instead of behind your head.  They come in several sizes and many colors and patterns.  In my experience they work pretty well but some smells, etc do make it through.  This is a good "everyday" mask.

I Can Breathe! Masks These masks, made by a family-owned business, are similar to vogmasks but can be washed and have replacement filters, whereas Vogmasks don't.  I haven't tried these yet but have heard that they are good.

Pure Non-Scents Face Masks I have found this mask to be more effective than Vogmasks at filtering out harmful exposures, but it is much less comfortable.  The one linked to here has silver in it for added protection from viruses.  Some people need to avoid silver so be aware which one you order if you get one.  They have another one that is especially good at filtering out mercury here.

PHYSICAL THERAPY

TheraCane This tool is helpful for getting bones back into place if they sublux or dislocate, which happens frequently for many of us with EDS (Ehlers-Danlos Syndrome). I use mine almost daily.  It can also be used to do trigger-point massage and myofascial release on yourself.

CranioCradle This is a soft foam device that can be used to relieve tension and pain in the neck, back, and sacrum.  It can be placed under the back of the skull to reset your craniosacral rhythm.  I also use this almost every day.

Silver Ring Splint Company Many of us with EDS have difficulty using our hands and fingers for some tasks because they are hypermobile (too flexible) or double-jointed.  These splints are expensive but are effective and are actually nice enough that they can feel like jewelry.

IntelliSkin This company makes clothing that can help keep joints in place with gentle pressure and traction which reduces the rate of subluxations and dislocations for people with EDS.

CLEAN AIR:

IQ Air makes some of the best air filters available.  They are expensive but worth it if you can afford one and need clean air.  I have one and it has allowed me to live in environments that I otherwise would not have been able to.

Activated Charcoal This company sells a variety of products made with activated charcoal (carbon) including air filters, water filters, carbon cloth that can be cut to fit specific needs (like covering vents), even capsules for internal use.

CLEAN WATER:

AquaSauna This company makes water filters that are installed at the point-of-entry for the home, so that all the water in the home is filtered and clean.  I found this to make a major difference with showers and baths which can smell of chlorine otherwise.  They also sell filters for sinks and water bottles with their filters in them.

This product (bone char) can be used to filter water and is especially good at removing heavy metals and fluoride.

FEEDING (TPN, Tube feeding, etc)

Pitch It IV Pole This is a lightweight IV pole that is collapsible and portable.  It is sturdy enough to hold a full TPN bag for an adult plus other things, but very lightweight.

Cord keeper This is a cover for the lines that go from a feeding or medical pump to a PICC or port, to help keep the line protected and from getting caught on things or wrapped around things.  It's a handmade product and come sin cute fabrics.  I haven't tried this yet but plan to get one when my port is placed.

SENSORY AND OCCUPATIONAL THERAPY PRODUCTS:

Autism Community Store has a big variety of products for sensory needs such as swings, trampolines, and weighted products.  They also have things for adaptive living, speech therapy, teaching materials, and toys.

Therapro This company sells a wide variety of specialized items for therapy and adaptive living, including products for eating, hygiene, speech and adaptive communication, fine and gross motor skills development, and more.

Fun and Function This site sells sensory products such as swings, fidget toys, weighted and compression items, items for eating, sleeping, school, communication, and more.

Privacy Pop These are bed tents that are similar to one we used with Roo when he was younger.  It seemed to help him feel safe and secure in his bed.

CLOTHING FOR SENSORY NEEDS:

Independence Day Clothing  This line of clothing was designed to allow people with several kinds of challenges to be able to dress themselves.  The clothes don't have a front or back or inside or outside so they are simple to put on.  

Hanna Andersson This clothing company makes long johns/pajamas with flat seems that are very soft and comfortable for many people with sensory needs that can make a lot of clothing uncomfortable.  Some of these products are also made with organic cotton.

SmartKnit Kids This company makes clothing such as socks and underwear without seams, tags or elastic bands that bind.  At least some of the clothing is chemically treated because it claims to be "anti microbial", so something to be aware of if this is a problem for your family.

Kozie Clothes This company makes sensory-friendly clothing, without tags or internal seams, and also makes clothes for babies and children with special medical needs (such as clothes with a hole for feeding tubes or other medical devices, and clothes that help with temperature control).  They also have weighted and compression items.

NoNetz Is a company that makes swim trunks without the mesh interior that can be so hard for some people with sensory needs to tolerate.

MISC.:

These are glowing strips that you can stick inside the toilet bowl to help with aim, especially at night.

LowBlueLights This company sells products that block blue light which can help people to fall asleep at night.  This includes blue-blocking glasses, computer monitor filters, and lights.  The idea is that this helps the body to produce enough melatonin.

A new font is available that was designed to help people with dyslexia to read more easily.


Sunday, September 11, 2016

Acute Intermittent Porphyria (AIP)

Acute Intermittent Porphyria (AIP) is one of a group of disorders known as the Porphyrias.  All forms of Porphyria are the result of a genetic defect that impedes the functioning of one of the enzymes that is part of the process of making heme, which is needed for hemoglobin among other things.  Which enzyme is affected determines which form of Porphyria a person has.  AIP is due to a deficiency of the enzyme porphobilinogen deaminase (also known as hydroxymethylbilane synthase) that leads to accumulation of the heme precursors delta-aminolevulinic acid and porphobilinogen initially in the liver.  When any step in the process of heme synthesis is reduced or blocked, the accumulation of the precursors in the cell can lead to oxygen depletion.  The precursors (called porphyrins) generally build up in either the liver, the bone marrow, or the skin.  

SYMPTOMS

Symptoms vary from one form of the disease to another, between patients with the same form of the disease, and from one attack to another in one patient. Symptoms generally affect the skin or nervous system and include: abdominal pain, constipation, nausea, vomiting, mental agitation and confusion; anxiety, depression, psychosis and even hallucinations; insomnia, muscle weakness (can progress to breathing muscles, and can take months or years to recover from), tremors, and sometimes seizures, dark urine, tachycardia, high blood pressure, sweating, irregular heart rhythm, also pain in arms, legs, back, and neck (for a longer list of symptoms, and their relative frequency, see the NIH page on AIP).  One of the characteristic features of AIP is the intensity of the pain.  It is described as unbelievably painful, one patient describes it as "not compatible with life".  The abdominal pain is described as being a burning pain, as if there is an actual fire inside the abdomen.  In AIP symptoms occur as distinct "attacks" that can last hours to days and often require hospitalization due to the severity of the pain.

AIP attacks occur when too many of the heme precursors build up, which can occur when the body encounters something that increases the demand for and production of heme. Some of the known triggers cause the enzyme ALAS1 to be upregulated which increases production of heme precursors (glucose and heme downregulate this enzyme).  This includes many drugs, premenstrual hormone changes in women (elevated progesterone), alcohol, smoking, exposure to organic solvents, emotional stress, infection, low-calorie/low-carb diet.  Any one factor on its own is often not enough to trigger an attack, it may take several factors occurring together.  In AIP levels of sodium and chloride can drop suddenly and this is the cause of some of the symptoms.  Occasionally AIP attacks also include a severe adrenergic crisis.  If the disease has progressed far without diagnosis and treatment nerve damage can result, which can lead to long-term muscle weakness among other things.

DIAGNOSIS

Porphyrias are diagnosed with blood, urine, and stool testing, as well as genetic testing.  The Porphyrias Consortium has more information about testing here, and more detailed information specific to AIP here.  From the site "The most common tests used for porphyrias are measurements of substances that accumulate in large amounts in the body, especially when someone has active Porphyria. These substances, porphyrin precursors and porphyrins, can be measured in red blood cells (erythrocytes), blood plasma, urine and feces. Measuring enzymes in cells and looking for changes (mutations) in DNA is useful for confirmation and for family studies."  In AIP it is the HMBS gene that has the mutation.  Some of these tests will only be abnormal during an acute attack, such as the levels of the precursors that can build up.    

TREATMENT

Avoidance of potential triggers is the basis for managing Porphyrias.  A database called Porphyria Drug Safety provides information about which drugs can trigger an acute attack for people with Porphyria.  Once an attack begins, treatment should start as soon as possible to minimize the severity of the attack.  This is usually done by giving large amounts of glucose and/or the drug Panhematin  (Panhematin is now the preferred treatment, while in the past it was often given only after several days of glucose therapy proved not effective enough).  According to the American Porphyria Foundation's site "Three to four mg/kg of Panhematin® given once daily for four days early in an attack produces a highly beneficial effect in most patients. Commonly noted are decreases in pulse rate, blood pressure, abdominal pain, as well as decreased levels of urinary porphobilinogen (PBG). These effects can occur within a day."  According to the European Porphyria Network site glucose can be administered as "Two litres of normal saline with 10-20% glucose given in divided doses of 500 ml over 24 hours through a central venous catheter."  Pain management during an attack is central to treatment, as the pain can be excruciatingly intense.  Carefully monitoring fluid and electrolyte levels is also important. In certain cases additional treatment measures are needed "Recurrent attacks related to the menstrual cycle can be prevented by a gonadotropin-releasing hormone (GnRH) analogue administered with expert guidance. In selected cases, frequent noncyclic attacks can be prevented by prophylactic infusions of hemin, which are titrated to patient response. " (from The Porphyria Consortium). 

Sources:




Disorders of Heme Biosynthesis: X-Linked Sideroblastic Anemia and the Porphyrias



Tuesday, May 17, 2016

Mast Cell Activation in the Brain and Neurological Disorders (especially autism)

This talk given by Dr Theoharides sponsored by The Autism Research Institute provides similar information to another interview with him that I have already published my notes for here, however this talk provides much more information and depth.  You may want to start with the other interview if this is new or overwhelming to you.  Here is more about Dr Theo (as he is affectionately called in the mast cell disease world) from the blurb for the talk "Theoharis Theoharides, MD, PhD is a professor of pharmacology, Internal Medicine and Biochemistry, and the director of the Laboratory of Molecular Immunopharmacology and Drug Discovery; Department of Pharmacology and Experimental Therapeutics, Tufts University School of Medicine. He trained in allergy and clinical immunology at Yale and internal medicine at New England Medical Center. Dr. Theoharides was director of medical pharmacology at Tufts (1986-1993), and became full professor in 1995. He has 300 publications and 3 books, including a Textbook of Pharmacology. Dr. Theoharides was the first to show mast cells and acute stress promote inflammation in autism, cancer, interstitial cystitis, migraines and multiple sclerosis."  So basically, he is NOT some "fringe" quack but rather an accomplished and well respected doctor and researcher whose groundbreaking work is changing the way that autism (among many other things) is understood within mainstream medicine.



Notes:

His central premise in this presentation is that autism, or at least a subset of cases of autism, is essentially an "allergy of the brain".  He tells us what allergies are, what causes them, why there could be an association with autism, and maybe even what we can do about it.  One of the cornerstone beliefs in western medicine has been that the brain does not "get" allergies.  However, many people with allergies do get neurological symptoms such as feeling irritable, having difficulty concentrating, even movement disorders such as tics following an exposure to an allergen.  The diencephalon is the part of the brain that "receives sensory stimuli and then sends them out to other parts of the brain, and then regulates the emotions that we generate against those sensory stimuli- and what do you know, most autistic children have behavior problems that relate to exactly that."  What prompted him to make the connection between autism and brain allergy is that the diencephalon has a high number of mast cells, which are immune cells that are at the center of allergic reactions..yet the brain doesn't get allergies?  Why would a cell that is thought to only be involved in allergic reactions be so plentiful in such an important region of the brain, when supposedly the brain doesn't get allergies?

First, we need to understand what allergies are.  "True" allergies occur when a specific thing that we are allergic to (an antigen) causes our bodies to produce IgE (immunoglobulin E), which then triggers the mast cells to react by degranulating, which means releasing large amounts of preformed mediators that were stored inside the cell.  Many children with autism appear to be allergic, meaning that they show symptoms that look like allergy, but do not test positive for allergies when tested using skin prick testing or RAST testing (looking for IgE in the blood).  He says that due to this many families with autistic children are sent home from the allergist's office being told that "it's all in their heads" when he emphatically states that this is NOT true- this is real.  Recently a new allergic disease has been identified called Mast Cell Activation Syndrome (MCAS) that explains this- a person with MCAS can have any or all of the symptoms of allergy but have no positive allergy testing at all.  One of the significant things about MCAS is that it is the first time that an allergic disease has neurological symptoms as part of it's description.

Mast cells were discovered in 1887 by Dr Paul Ehrlich.  He had no idea what the cells did- he thought they were feeding something because of the little granules inside of them.  About the same time, the term "anaphylaxis" was coined when two French researchers were doing experiments in which they injected dogs with ground up jellyfish tentacles in the hopes of causing immunity to the toxin.  They intended to call this effect "prophylaxis" which means "to protect", but when the dogs were re-injected with the toxin, rather than being protected as expected, they died.  The cause of death was then called "anaphylaxis" because the treatment had had the opposite effect.

An allergic reaction is when a mast cell is triggered by IgE and an antigen, which causes it to degranulate (or as he says) basically explode like a hand grenade.  Mast cells contain around 500 granules, which rupture and release their contents when triggered, which includes more than 50 chemicals.  We only have medicines to counter one of these chemicals, histamine, however he thinks that it's the other molecules that are more strongly associated with autism.  His lab was the first to show that mast cells could also release chemicals selectively, that is *without* degranulating (rupturing open), including chemicals that "can cause allergic-like reactions, inflammation, and sensitize neurons and cause neuronal damage" (when cells "leak" their contents in this way it will not show up on a biopsy the way a degranulated cell would).

In addition to IgE, other mast cell triggers include some components of the compliment system (associated with blood clotting, so anything that triggers clotting in the blood can trigger the mast cell), toxins released from bacteria and viruses, and more.  Other chemicals released from mast cells (called mediators) include leukotrienes (involved in asthma), cytokines, chemokines, TNF (tumor necrosis factor, which is a major player in Rheumatoid Arthritis), and more.  Interestingly, even in the same sample not all of the mast cells will react to the same stimulus...so what causes this heterogeneous response?  If we can figure out why some cells are not reacting it may lead to treatment options.

Mast cells also have a wide repertoire of molecules used for communication with other cells in the immune system, as well as pathogens including bacteria, viruses, parasites, and fungi.  Mast cells actually orchestrate the immune response to an immune trigger (an allergy is when the mast cell reacts to an otherwise harmless substance as if it were an invading pathogen).  Mast cells are associated with many other diseases including Multiple Chemical Sensitivities, Chronic Fatigue Syndrome, Fibromylagia, Interstitial Cystitis, and more.  He notes that these disorders are all relatively newly recognized and are increasing along with autism, further evidence that they may share physiology.  He also makes the point that we are also having an epidemic of asthma, despite better treatments, better knowledge, better air filters, and better vacuum cleaners.  So clearly something has been going on recently to drive an increase in allergic diseases.  Why are all of these diseases getting worse?  Do they share a commonality?

He believes the mast cell is the "canary in the coalmine" of the body.  Mast cells have existed phylogenetically (in all species) from long before we had a brain or an immune system.  They must have an important role in sensing the environment in order to be maintained by evolution so strongly.  They are also all over the body- in the gut, the skin, our eyes, our tongue, and of course in our brain (around 15:00 he discusses how mast cells in the brain activate cells differently than in the rest of the body).  He believes that they are there to sense danger and to help the body respond.  The recent rise in allergic (and inflammatory) diseases indicates that something has changed- either the mast cells are over-reacting to stimuli because they are somehow lacking what they need to function properly, and/or because they are being bombarded with too many stimuli to respond appropriately to each one.

His lab tested to see if mercury can stimulate mast cells and found that yes, mercury induces inflammatory mediator release from human mast cells.  He makes the point that mercury is in many things in addition to vaccines (and yes it is still in some), it is also in fish and some pesticides, for example.  They also found that if the mast cells were exposed to both mercury and another chemical released from nerve cells during stress the toxic effect is synergistic (the mast cells release even more mediators).  It's possible then that brain allergy results from more than one toxin, it may be the result of a combination of toxins that have a synergistic effect.

Are there mast cells in the brain?  Mast cells: the immune gate to the brain.  Mast cells are a critical part of the blood brain barrier.  They can be seen wrapped around blood vessels in the brain, with the job of protecting our brains from the toxins that might have made it into our bloodstreams.  Mast cells, along with red blood cells and endothelial cells, regulate the blood-brain-barrier (BBB).  Mast cells in the brain don't get triggered by allergens, they get triggered by other things.  Research also shows that mast cells are the most numerous in the brain during very early development.  So not only are they the most concentrated in the part of the brain very likely to be central to autism symptomatology, but they are also the most numerous at the time that autism sets in.  Also, mast cells are so close to nerves- sometimes even wrapped around them- that when they release their contents it can't but effect the nerves and damage them.

Most mast cell granules contain the enzyme tryptase which acts as a meat tenderizer.  If tryptase is released onto a neuron he believes that it kills the neuron, and that this is part of what is happening in the diencephalon in autism.  This is why he calls it a "focal brain allergy", because the reaction is not happening throughout the brain, but rather in those areas that are particularly important for social behavior and language.  It's known that many kids with autism do not do well with stress, and it has also been observed in the evidence that children born to mothers who were very stressed during pregnancy are more likely to have children with autism.  CRH is the first hormone in the brain released when we are under stress (it is what triggers the fight/flight response) and his lab found that mast cells are located near the neurons that release this hormone.  They found that the extreme states of stress that people with autism can get into can and do trigger mast cells to react.

From this point on in the presentation he presents many research articles, some from his lab and some done by other researchers.  These include:

Mast cells and inflammation
This paper establishes that mast cells drive inflammation, which he describes as the extreme form of allergy.  

Corticotropin-Releasing Hormone and Brain Mast Cells Regulate Blood-Brain-Barrier Permeability Induced by Acute Stress
A lot of children with autism have symptoms including food allergies, food intolerances, skin eruptions, brain fog, elevated levels of certain markers of brain inflammation (such as IL6 and TNF), intolerance of stress, lack of eye contact, loss of speech, reduced social engagement, and mitochondrial dysfunction.

Autism spectrum disorders: concurrent clinical disorders.
Found a high degree of correlation between eczema and autism and ADHD.

Cognitive function of 6-year old children exposed to mold-contaminated homes in early postnatal period. Prospective birth cohort study in Poland.
Found that children who were allergic to mold from these exposures had a lot of trouble with cognitive function.  In the US these kids would be called autistic.  Mold is not a typical allergen but it does stimulate mast cells.  

He says "So we're talking about environmental toxins, we're talking about mercury, we're talking about mold, we're talking about stress, put them all together, now we're having a crisis."

So he pulled all of this together and wrote a review...
Mast cell activation and autism

Research has shown that in mice acute stress (being confined in a small space) causes the BBB to open up after just 30 minutes of stress.  In genetically altered mice that do not have mast cells there is no breakdown of the BBB from stress.  Both types of mice released the same amount of cortisol from the stress so that wasn't the factor.  There is also direct evidence because they have found receptors on the surface of mast cells for the CRH.
Mast cells as targets of corticotropin-releasing factor and related peptides.

Mast cells also line the gut-blood barrier.  They are also in the Broca area that regulates language.  

He then goes on the hypothesize a fascinating connection between mast cell activation and mitochondrial dysfunction, which is another common finding in people with autism.  Mitochondria used to be bacteria WAY in the past but evolved to live synergistically with our own cells.  If they are to be destroyed they are destroyed in the cell by autophagy, they do not leave the cell.  He hypothesizes that if mitochondria or their components leave the cell the body will mistake them as an infection and will mount a massive immune inflammatory response.  So in autism not only is there the allergic-like symptoms, but also a mistaken "pathogen-fighting" response.  I wonder if this could be why MCAS and PANDAS can look so much alike?

Human mast cell degranulation and preformed TNF secretion require mitochondrial translocation to exocytosis sites: relevance to atopic dermatitis.
This research showed that mitochondria can move.  Once the mast cell is activated the mitochondria move to the cell surface.  The mito also broke down into smaller pieces. 

Stimulated Human Mast Cells Secrete Mitochondrial Components That Have Autocrine and Paracrine Inflammatory Actions
The little mitochondria are released outside the cell when mast cells are triggered.  

Mitochondrial DNA is very different than genomic DNA.  Extracellular mitochondrial components cause neutrophils and mast cells to release inflammatory mediators (IL5?), and cause neurons to die.  

Mitochondrial DNA Toxicity in Forebrain Neurons Causes Apoptosis, Neurodegeneration, and Impaired Behavior 

He found that the level of mito DNA in the serum of autistic children is highly elevated.  

Extracellular Mitochondrial Components Secreted from Activated Live Mast Cells Act as “Innate Pathogens” and Contribute to Autism Pathogenesis

Microglia and mast cells: two tracks on the road to neuroinflammation.
Mast cells work together with the microglia, the brain's primary immune cells.

Abnormal microglial-neuronal spatial organization in the dorsolateral prefrontal cortex in autism.

Most common genetic finding in autism has to do with a molecule called PTEN, which regulates another molecule called mTOR.  (from SnapShot: Genetics of Autism)  (I will update this post to include more information on this topic)

Activation and function of the mTORC1 pathway in mast cells.
mTOR has a high association with autism, so the genes most associated with autism are also governing mast cells.  mTOR means "mammalian target of rapamycin" which was an old antibiotic.  Rapamucin blocks mTOR.  Luteolin is an even more potent blocker of mTOR.  

PTEN deficiency in mast cells causes a mastocytosis-like proliferative disease that heightens allergic responses and vascular permeability.

Luteolin is a mast cell inhibitor.

Luteolin reduces IL-6 production in microglia by inhibiting JNK phosphorylation and activation of AP-1.

Luteolin protects dopaminergic neurons from inflammation-induced injury through inhibition of microglial activation.

Flavonoids, a prenatal prophylaxis via targeting JAK2/STAT3 signaling to oppose IL-6/MIA associated autism.Focal brain inflammation and autism.

Focal brain inflammation and autism.