Chronic inflammation: stealth infections – principles of diagnosis – which tests to do

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(By Dr Sarah Myhill and Craig Robinson)
Stylistic note: Use of the first person singular refers to me, Dr Sarah Myhill. One can assume that the medicine and biochemistry are mine, as edited by Craig Robinson, and that any classical and mathematical references and quotes or historical and linguistic notes are Craig’s!

Introduction

‘Stealth’ as a means of escape from being attacked occurs everywhere in Nature.

Moths have developed 'stealth coating' so as to avoid being eaten by bats. The furry coating on the moths' thorax absorbs the sonar signals bats use to locate their prey. So, moths got there millions of years before the United States Air Force!

Daily Telegraph, 7 November 2018 - Press reader text view of Daily Telegraph article re stealth moths

There may be clues from the clinical picture – see below, but the definite diagnosis will require laboratory tests. These are expensive, but we can increase the chances of a positive diagnosis by first considering symptoms and signs.

A vital and powerful symptom of a chronic stealth infection is failure to respond to Groundhog BASIC and or Groundhog CHRONIC interventions. See Groundhog BASIC and Groundhog CHRONIC .

Regardless of whether you do or do not test positive for a chronic stealth infection, Groundhog BASIC or Groundhog CHRONIC must be in place for long term good health, especially with old crones like me – so just do it and do it now! Indeed, I know that many of my patients must have been cured through Groundhogs alone. I say that because these stealth infections are common so many of my patients who recovered must, unknowingly, have suffered from them.

Symptoms and signs of chronic infection

This is perhaps the most important tool for diagnosis! Start when the symptoms began – which may be decades previous. The list below is not comprehensive but put in order of probability based on my clinical experience

Symptoms started ……. Possible diagnosis Useful tests to support diagnosis in order of priority
Sudden flu like illness, fever, malaise.

Feeling ghastly. Unable to do anything let alone work! Bedbound for some days. Perhaps swollen glands in neck, armpits, groins. Perhaps went a bit yellow Perhaps pericarditis and chest pain At the time blood tests may have been “A bit wrong but nothing to worry about”

HHV 4, Glandular fever. 'Mono'. Armin laboratory tests: Elispot, IgG antibody titre, IgM antibody titre, DNA by PCR. Tests available from Natural Health Worldwide Lab Test Clinics

A raised IgG is typically interpreted as evidence of past exposure ergo no treatment necessary. But it does not exclude the possibility that microbe is driving pathology.

Ditto HHV6 roseola IgG/IgM antibodies

DNA PCR

Ditto Coxsackie virus IgG/IgA antibodies.
Ditto HHV 5 Cytomegalovirus (CMV) Elispot.
Above with localising signs eg shingles, chickenpox,

Cold sores, genital herpes are also herpes virus but rarely trigger CFS/ME

Other herpes viruses. All herpes viruses target the brain and immune system. Once in the body all herpes viruses persist for life. Elispot for varicella zoster (shingles chicken pox).

Elispot HSV 1 HSV2. IgG antibody titre.

Vaccination – I estimate that 1 in 10 of my CFS/ME patients have their disease triggered or worsened by vaccination These are designed to switch on the immune system with the potential to trigger auto-immunity and allergy There may be positive IgG titres to virus.
We know some retroviruses have been present in vaccination such as SV 40. The jury is still out with respect to XMRV Almost impossible to get retroviral tests done.
Acute gastroenteritis (or indeed any gut symptom such as pain, bloating, reflux, diarrhoea, constipation, abnormally formed stools) Fermenting gut

Inflammatory bowel disease (MAP) Parasite or unfriendly gut microbes eg H pylori, giardia, amoebiasis blastocystis hominis

Comprehensive digestive stool analysis eg Doctors Data or Genova.

I know of no commercial test for MAP. Other tests available from Natural Health Worldwide Lab Test Clinics

Possibly a tick bite and bull’s eye rash but probably none such. As with borrelia, babesia and bartonella any insect bite could transmit many infections.

Possibly rash and arthritic condition Often no clear onset

Lyme disease - borrelia burgdorferi

Borrelia myamotoi

Armin labs: Elispot

seraspot (often antibody tests are negative – this does not exclude the diagnosis). Tests available from Natural Health Worldwide Lab Test Clinics

Like with borrelia, could be acquired through insect bites. Virtually all mammals harbour bartonella.

Classically follows cat scratch, but absence of such does not exclude the diagnosis

Bartonella – may cause a PUO - pyrexia of unknown origin (PUO), sometimes referred to as fever of unknown origin (FUO) Armin: Elispot.

IgG/IgM antibodies DNA PCR. Tests available from Natural Health Worldwide Lab Test Clinics

Insect bites. Babesia – may cause a PUO Armin: Elispot IgG/IgM antibodies. Babesia DNA PCR. Tests available from Natural Health Worldwide Lab Test Clinics
Rickettsia Elispot Ehrlichia.

Elispot Anaplasma.

Yersinia Elispot Yersinia
Chest infection or pneumonia (may be atypical “walking pneumonia” ie the patient is not very ill). I seem to be seeing many new cases – at least 4 this year 2019! Mycoplasma pneumoniae IgG antibodies
Ditto Chlamydia pneumoniae Elispot. IgG antibodies. Tests available from Natural Health Worldwide Lab Test Clinics
Sexually transmitted disease Chlamydia trachomatis

HIV, Hepatitis C, syphilis, herpes, HPV, gonorrhoea, trichomonas, bacterial vaginosis

Get screening tests at a Special Clinic.

Elispot. IgG antibodies.

Recurrent chest, upper respiratory or sinus infections Chronic septic focus eg bronchiectesis

Fungal infection such as aspergillosis

Chest X ray, sputum sample (but often false negatives).

Aspergillus precipitin test. IgG IgM and IgA antibodies.

Joint pains and arthritis Inflammation driven by allergy to microbes from the fermenting gut

OR allergy to a virus – so called “reactive arthritis”

No direct tests

Auto-antibody studies may help Investigations for the fermenting gut: Comprehensive digestive stool analysis eg Doctors Data or Genova. Tests available from Natural Health Worldwide Lab Test Clinics

Current symptoms and signs

Chronic infections often start with local symptoms of inflammation such as sore throat, head cold, chest infection, gastroenteritis, urinary tract infection or whatever, but as the microbe makes itself comfortably at home in your body then the symptoms become more general and indeed may start to trigger pathology. Many chronic so called “degenerative” conditions we know are infection driven. This includes most cases of dementia (herpes viruses, Lyme), Parkinsons (Lyme), many cases of auto-immunity, cancer, arterial disease, arthritis and of course chronic fatigue/ME. Indeed, with any inflammatory pathology always think and look for an infectious cause!

When I was at medical school I learned that syphilis was the great mimic because it can cause almost any pathology. Syphilis had to be thought of in almost every differential diagnosis. Lyme too is a spirochete with similar potential for damage and mimicry. This case report demonstrates the possibility for mimicry:

“Lyme disease –induced polyradiculopathy mimicking amyotrophic lateral sclerosis” – [ALS is a form of motor neurone disease]: “The initial electrodiagnostic test showed widespread active and chronic denervation findings. The initial physical and electrodiagnostic findings were suggestive of Amyotrophic Lateral Sclerosis (ALS). However, blood serology indicated possible Lyme disease. Thus, the patient was treated with doxycycline. The clinical and electrodiagnostic findings were resolved with the treatment”

See “Lyme disease –induced polyradiculopathy mimicking amyotrophic lateral sclerosis”.

Interpretation of tests

No test is perfect – all must be interpreted in the light of that patient’s history……..and all patients are unique. This is what makes medicine an art as much as a science. So much modern Western medicine has been condensed to simple algorithms based on a drug end result so that real pathology is missed. Patients suffer and die needlessly. Nowhere is this a greater issue than the interpretation of tests. Any result is taken as absolute. So often I see patients who are told that all the tests are normal and, so they are either not ill or hypochondriacs. Nowhere is this worse than in the field of CFS/ME.

There are several possible mechanisms that form the basis of tests to decide if chronic infection is present:

  • A false negative result means: this does not exclude infection
  • A false positive result means: there may be, or has been, microbe exposure but it is no longer a clinical problem.

You may need different tests for different microbes depending on where it is living in the body, and whether the immune system is fighting it with antibodies or with white cell foot soldiers.

Test Mechanism Notes
Can that microbe be seen or grown in tissue culture? Not all can be!

Viruses cannot be grown in culture.

False negative results are common.

A positive result makes it very likely you are harbouring that microbe.

PCR (polymerase chain reaction) If positive, then that microbe is present! But false negatives abound. You will only get a positive result if the microbe you are looking for is present in the tissue sample that has been taken.
Are there IgM antibodies to that microbe? This is part of the acute immune response If positive, then the immune system is fighting that microbe.

BUT false negatives abound with stealth infections.

Are there IgG antibodies to that microbe? This forms part of immune memory We commonly see a positive result which may well mean all is well – ie that microbe has been dealt with and kicked into touch by the immune system
However sometimes there are very high IgG responses which may suggest the immune system is still fighting a battle. See note below [1]
Are there IgA antibodies to that microbe? Tests only applies to microbes living on mucous membranes such as mycoplasma pneumoniae False negatives possible
Elispot testing looks at how the white T cell soldiers are reacting with cytokines to a particular microbe. Also known as lymphocyte transformation test because the normally quiet white cells soldiers transform into fighting lunatics! The term "lunatic" derives from the Latin word lunaticus, which originally referred mainly to epilepsy and madness, as diseases thought to be caused by the moon. Interested readers should see Wikipedia article on 'Lunatic' This test is very sensitive, specific and clinically relevant A positive result means the immune system is fighting that infection.

This is a very good test for infection with:
--a high level of sensitivity (ie false negatives are uncommon) and
--a high level of specificity (ie it is the microbe you are looking at and not another)

White cell counts May be high during acute infection Help these with Groundhog ACUTE
May be low with chronic infection…….. ….as the immune system exhausts because it is running out of raw materials or energy. Treat this with Groundhog CHRONIC

[1] For example, finding a high IgG antibody titre is generally thought to be simply evidence of past infection. However, we know that all herpes viruses persist in the body for life – so if they have been there in the past they will be present today! Once comfortably installed in the body they have the potential to drive many other nasty diseases. Their targeting of the brain and immune system explains many symptoms. I suspect it is this group of viruses that are responsible for many cases of post viral CFS/ME. Dr Martin Lerner showed that EBV (also known as HHV4, mono, glandular fever or Epstein Barr Virus) was causally involved in 81% of post viral CFS. See Chronic viral presence in CFS/ME and Valacyclovir in the treatment of post viral fatigue syndrome

A general rule of thumb amongst clinicians is that if the antibody titre is 5 times higher than baseline then consider an anti-viral strategy. What is so interesting is that Dr Lerner showed that the anti-viral titre (EBV nuclear antigen and EBV viral capsid antigen) fell with effective treatment and that this was paralleled by clinical improvement. This allows an objective measure of progress. Armin laboratories now offer Elispot testing for EBV and this is a very useful tool. Again, as the immune system defeats the virus, the level of positivity comes down – this is a very helpful clinical tool. See Armin Order Form October 2018.

Summary

Diagnosis depends on:

  • A high level of clinical suspicion – if you don’t look you don’t see!
  • Good tests and interpretation of such – in this respect diagnostic tests are essential
  • Response to treatment – all diagnosis is hypothesis - which must then be put to the test! However always remember this may not be the sole cause of symptoms.

Finally, once one infection is established then one must recognise that other microbes are more likely to get into the body, perhaps for the same reasons that the first microbes got in - that is, poor defences. So, the existence of one microbe may indicate that other, as yet unidentified microbes, may also be present. The point here is that it will never be sufficient just to target a particular microbe that has been identified. Improving the defences is as vital a part of attacking microbes as is targeting particular microbes. Having had one debilitating infection always return to Groundhog Chronic. You will find Craig and me there too!

Finally, I stress once again, that these chronic infections do exist and that tackling them can be the key to recovery for many patients.

A famous European philosopher well sums up where we are at this moment in time:

“There are two ways to be fooled. One is to believe what isn't true; the other is to refuse to believe what is true.”

Søren Kierkegaard, Danish philosopher, 1813 – 1855

Do not be fooled either way!

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