An unresolved infection is any infection that has not reached a complete clinical resolution. These invaders are simmering in the background, lurking in various tissues, waiting patiently for moments of weakness cultivated by other infections or stressors.
Annalies Corse is a Medical Scientist, Lecturer and Naturopath and joins us today to talk us through her own clinical experiences of what these infections are, how to identify them and strategies used to walk patients through overcoming them.
Covered in this episode:
[01:07] Introducing Annalies Corse
[08:06] What actually is an "Unresolved Infection"?
[10:50] Does this only happen to immunocompromised?
[12:52] Painting the clinical picture
[18:39] When is an infection deemed "unresolved"?
[20:59] Are certain body systems more at risk?
[24:43] Are there specific pathogens to blame?
[29:06] What is cell wall deficient bacteria?
[41:17] Treatment approaches
[54:28] Caveats to therapy
[1:02:18] Final thanks to Annalies
Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining me on the line today is Annalies Corse. Annalies is a medical scientist, lecturer, naturopath, and author based in Sydney, Australia. She's worked as a medical scientist at Charles Sturt University, the Australian Institute of Sport, Australian Biologics, and both public and private hospital pathology labs.
Annalies has been a practicing naturopath and lecturer since 2008. She lectures in human biochemistry and the medical sciences for ACNT and SSNT, as well as conferences and seminar presenting for fellow health professionals.
Annalies is a past board member of the NHAA and is on the scientific advisory board of the Mindd Foundation. Most recently, Annalies has contributed to a natural medicine textbook due for publication in October 2017 with Elsevier.
Welcome to FX Medicine, Annalies Corse. How are you?
Annalies: Hello, Andrew. I'm really well. Thank you so much.
Andrew: Now, today, we're gonna be talking about something that's a little bit quizzical, unresolved infections, but I think, first of all, we need to delve back into your background. How did you become a naturopath? What inspired you to do that?
Annalies: Well, I probably wasn't inspired until I was about 23 years old. So that was quite a few years after leaving school, but I've always been obsessed with science. I think anyone who knows me will attest to that. So, a lifelong obsession with knowledge, anything to do with the human body, anything I could get my hands on, in terms of books or experience to do with the human body, I wanted to learn it. So, for me, that meant a Bachelor of Medical Science degree as soon as I finished school. And I did that at Charles Sturt University, 1997.
Andrew: Yeah, now, I have to ask then, you know, those naysayers of natural health and natural health practitioners would say that naturopathy isn't science and science isn't naturopathy. How did you ratify the two?
Annalies: Well, for starters, I completely disagree with that statement, as anyone knows me knows. But I do have to say that when I was studying for the first time, back in medical science, I didn't give a lot of thought to natural medicine. I did obviously have a great understanding of how the body works naturally and that it did have a very robust capability to heal itself, given the right conditions, given the right biochemistry, given...and I thought, the right diet at the time.
But in terms of using food as medicine or even herbs, I didn't really have any inkling about how that would work or how that could work. So, my, I guess, development in my mind about the body moving towards natural healing and using herbs and food, that came later after a few years of work. It definitely, it didn't happen when I was studying the first time around.
Andrew: Okay. So, what tweaked your interest? What piqued it?
Annalies: I think what turned it for me was when I started working at the AIS, to be honest. I was still pretty young. I was only 21 years old, but that was my first job after I left medical science. And I started looking at these young, fit, elite athletes with everything at their doorstep in terms of health. They had nutritionists, they had physiologists, they had sports medicine physicians, they had everything that they could possibly need to be healthy, but many of them weren't. Many of them struggled with their immunity. Many of them struggled with their energy levels. Many of them struggled even, with mental and emotional health.
For me, there was a huge question mark. What is it about these people that they can't...even though they've got the natural talent and the natural ability, they're still getting sick? So, there were all those question marks coming up for me, and I was in the sports medicine lab, so we ran their tests. We did all the blood tests. We were helping out with VO2 max testing and all the performance-based tests. So, I could see there that diet could help some, diet might not help others, but again, a lot of them weren't well, to be honest. And I think stress had a huge impact on a lot of them, and that's when I started to think, "Here's this thing in our lifestyle that can have a huge effect on our well-being," and I think that's when I started to look at the natural side of things and not so much the medicines, but lifestyle. That was starting to, I guess, pique my interest.
Andrew: Yes, I think what's interesting is that the lifestyle choices that we make is now really headlining, even confounding conditions and frustrating conditions like depression, and not lightly taken either, we're talking about severe depression. So, I think it's very interesting how the world turns, isn't it?
Andrew: But I also agree with you because, you know, back in the day, as I said, I was a total naysayer. Now that I'm a little bit wiser, and hopefully a little bit less arrogant, I think it's really interesting that even medical science, even those based only in an orthodox science, let's say, will say and will quite readily accept that trees need certain nutrition to give a certain yield for the benefit of humankind. Animals need certain nutrition to have a certain yield to benefit mankind.
But they don't talk about humans giving a certain yield to benefit mankind. We're talking about working, providing for our families, you know, having a social network and existing in society. I think that's an interesting and somewhat of a shortfall in their sort of thinking.
Annalies: Absolutely. I agree with you. And I often wondered myself, why do we think of humans as mammals as being so removed from the rest of the animal kingdom? It doesn't make sense to me. And again, if you do expect someone who has spent decades and decades as a medical scientist or a physiologist, they would say the same thing. But I think there's this...I don't know if it's based on society or based on our ego as humans, that somehow we're different to the rest of the natural world around us. I would disagree with that, totally.
Andrew: Yes, absolutely. And of course, one of the things that happens to us as a mammal, as an animal, is that we get infections from time to time, and normally they would resolve. But today, we're going be talking about unresolved infections. So firstly, can you take our listeners, and indeed me, through what you mean by this?
Annalies: Okay. So, for me, an unresolved infection can be established by any microorganism. That might be an organism that's been treated previously through drugs, diet, herbs, or maybe it has been left untreated. But it hasn't achieved a full clinical resolution.
So, usually, these infections occur when you've got a combination of high microbial virulence, so you've got a highly virulent strain of a microorganism, and then, on top of that, you often have decreased host defence mechanism. Usually, these unresolved infections occur when you have that really unfortunate combining of those two factors, the microbial virulence plus the diminished host.
So, it's a really broad area. This is part of the problem that I find myself in clinic as a practitioner over the years, and also with other practitioners, when we speak about this by presenting most tissues, most physiological systems are vulnerable to chronic infection, and what we need to look at is try and identify the actual bug or whatever it is that might be causing these. But it may not be the first question or the first, I guess...it's not the first thing we think of when we're looking at someone in front of us because, you know, we have such good training in nutrition and we have such good training in other areas, but we may not be so confident as naturopaths to think about bugs, or think about infection, or think about doing testing because it's not necessarily our forte.
We're not trained in labs as naturopaths. You know, I came from lab, so I feel pretty confident in this area, but we need to be thinking about them more because infections are becoming much, much more of a problem in modern practice and they're becoming resistant to drugs, so they're showing up more and more.
Andrew: So, I guess the orthodox or the sort of obvious way to look at this would be an unresolved infection that keeps on sort of, you know, simmering away and then breaks out with, you know, another, a fistule or a pustule, something like that.
Annalies: You see it in both. You have people walking into your clinic who appear quite robust, fairly strong. They have no other co-morbidities. They're functioning well in their jobs, but they have this hacking cough that won't go away that's been there all winter. Or they have this wound that just won't seem to resolve, or they have STIs that won't resolve. And usually, it's when you start digging a little deeper that you find other things going are on.
So, there's other things in terms of the stress level that might be contributing to a diminished host immune response. You might do some testing and you find that they have some disorders with their white blood cells, and these might be related to nutritional deficiencies, or it may be that they've got a relatively common issue with an inherited neutropenia or something like that.
But it's only after you start digging that you start to find the reasons why these people are immunocompromised, but they can present as being fairly robust and they'll often tell you how good their diet is. But when you start to dig deeper, as any naturopaths or nutritionists would tell you, you know that the definition of a good diet for someone in the general public is often not a good diet at all.
So, yes, they can look the picture of health, but physiologically, biochemically, that's probably not the case.
Andrew: I think dietarily, I think it's interesting that the standard Australian diet and the standard American diet are the same thing, they're both SAD.
Annalies: Yes. Yes, exactly. Yeah, it's a really unfortunate acronym, isn't it? Yeah, yeah.
Andrew: So, just before you are sort of reminding me, I guess, or you're forming a picture in my mind of, let's say, a heralding infection, an unresolved obvious infection, but maybe another culprit that might be underlying the true nature of why the first one is becoming...is remaining unresolved. Is that what's happening here, like a, you know, a chaperone, a spy, if you like?
Annalies: Yes, that can be the case, and a lot of these infections are latent. So, a lot of the viruses that later unresolved infections are latent. They are residing within our cells, our glands, and in our epithelial tissues, and they are just waiting for that moment, waiting for that chance to set up a new infection.
So, I guess, latent infections and ones that are lying dormant within our tissues, we can lump them into this category, but then we also have infections that do basically set up an infection because they are brand-new. They've been acquired through the community somewhere, but the reason they were able to, I guess, inoculate and colonise our tissues is because the, again, the terrain, this term we use all the time, was in such a poor state that it was very easy for them to do something like this.
So, we have the combination of those latent dormant infections popping up and we have the combination of acquired infections from the community that may not be associated with latency or recurrence but they just jump in and they can just take over because our tissues are so unhealthy and our immune system is just not able to respond in a robust way.
Andrew: So, the two, I guess, opposite ends of the pole for me that I'm thinking, just picturing in my mind here, would be like EBV and herpes - herpes simplex 1.
So, in my mind, like the EBV, I thought we contracted it later on in life, but indeed, apparently, if we contract it earlier it becomes a problem, around the teenage-ish years, right?
Andrew: So, whether the first recurrence or a recurrence of the symptomatology of EBV is this fatigue, this flu-like thing, the glands come up, that sort of feeling of, let's say, a fluey-type syndrome.
Whereas herpes would be more like a fulminant or acute type infection where you get the blisters, the itching, the...you know. And unless somebody is fulminantly immunocompromised by another complex disorder, then they normally resolve in an acute way over a period of days, perhaps weeks, if they’ve got a really bad case.
But, like, I get that I'm not picturing this right. I get that there's...what I'm picking up from you is that that's not the complete picture.
Annalies: Well, I think no, I think what you're saying is right. We have these latent infections that can present in a way where normally we'll be able to cope with them very, very well, but often, another illness on top of them will bring them out. And that's definitely the case with EBV, we know that. That's definitely the case with HSV as well. So that's when you're talking earlier about them being like a chaperone, other infections on top can actually create the condition for these ones to present again.
Annalies: I think the other part of the issue is, is that some of these infections don't...we never remember the first encounter. We can never recall that first microbial encounter. And it may have happened when you were young and when you were a little bit more robust with your health. And then, all of a sudden, it presents when you're older and you might be a teenager or at university or working or whatever, and then it presents and that is a chronic infection that's been there the whole time. It's just that now, it's very, very obvious and you're starting to get those clinical signs and symptoms.
So, those infections, I see those as chronic infections. They are somewhat unresolved because...but we can't get rid of them completely either. They are always there. But for me, I think what I'm trying to say is that they can be controlled, but we need to make sure that we create the conditions to make them behave, if that makes sense.
Andrew: Yeah. So, to keep them in check. Look, I think this is very interesting because I was speaking with Dr. Mark Donohoe...
Annalies: I listened. I loved it. It was amazing.
Andrew: About EBV, okay. So, now to me, it was like Prometheus. I was like, "What?"
Andrew: So, basically, there's nothing that we can do to thwart a virus invading our tissues, given that we have contact with it and given that it's a pathogenic virus. I mean, indeed, we have a viriome, a gut viriome. So, it really is we just need to broaden our horizons for more than bacteria to include fungi and bacteria as part of our normal commensals.
Annalies: Absolutely. Absolutely, yes.
Annalies: Okay. For me, they become unresolved when they start to interfere with life and they're starting to produce these low-grade symptoms that are interfering with people's wellbeing.
So, I mean, if you...again, Mark is a great expert on EBV and a lot of people with this particular infection, even though they may not have, you know, actual, overt, really strong signs and symptoms of EBV, they're often wandering around with low-grade fatigue most of the time. Or they're feeling swelling in the gland within their throat most of the time. If they run down and they're working hard, they feel like this most of the time. It's only when they start to take a break, or work settles down, or a stressful time in their life starts to calm down a bit, that they think, "I don't talk feel so glandy anymore, I don't feel so tired anymore."
So, EBV is one of them, but HSV can be a little bit like that as well because a lot of people may not get the actual open sores or wounds or cold sores on their face when they're experiencing a resurgence of this chronic infection, but they will say things like, "I have pain down the side of my face," or these little vesicles are popping up. They haven't turned into the, you know, the full-on wound or the crusting-over and the weeping wound that's shedding virus. But they feel often, most of the time, that there's something there. And for me, that's when I think, "Okay, the virus is in there. There's not much we can do about that." But this is a sign that your body is not coping if it's able to cause you symptoms and your immune system is just not coping with that. So for me, I see that as a red flag, but if they were to get something else on top of this, another infection, the influenza virus, if it happened to be winter, I'd be pretty worried about them, about how badly another virulent virus or bacterial infection might actually affect them.
Andrew: Are there any systems that are more prone to this sort of unresolved infections? You know, we would obviously think lymphatics because we, as you said, you know, we feel ‘glandy' and, you know, the Snuffleupagus, that sort of thing.
But one thing that really interests me, and I remember, this was a naturopath who used to come and visit to me, where I used to consult, and he was a Canadian bloke, I'll always remember, and he had this pain in his foot, could not get rid of it. Whatever he tried, whoever he saw, orthodox medicine, tried everything, could not get rid of it. Finally, ended up on the doorstep of a certain naturopath in the south, the southern suburbs of Brisbane. And he said, he came up with a naturopathic diagnosis of, "You've got a virus, sort of, that's located, it seems to be embedded in the tissues of your foot."
Now this naturopath, this Canadian naturopath, and I laughed. We went, "Wah, what a load of rot! Like, come on! Pseudoscience..." This guy treated it and it got better. Now...and it was like...and we were both dumbfounded. We were like, "What's going on here?"
Now, you could say it was self-limiting, you could say it was going to happen. You could talk about placebo and psychosomaticism and things like that, but the fact of the matter is no other treatment approach of the orthodox branch worked. Despite him wanting resolution. So, how come the psychosomaticism didn't happen with those treatment approaches. So, that was my big question. So therefore, I go back to my question, are there more systems that tend to be more prone to symptoms?
Annalies: Yes, I often find that anything that's an epithelial surface is going to be an anatomical target or an anatomical tissue where these critters can take up residence. And if anyone thinks back to their anatomy and physiology lectures, epithelial tissue covers, I don't know what the actual percentage is, but it's most of the human body. So, we're talking about the lining of the gut, the lining of the reproductive tract. You've got epithelial tissue, obviously, your skin.
That's not to say that, you know, if it was that bad, as bad as I'm making it sound, we would have unresolved infections everywhere, on every epithelial tissue, and we don't. So, we have to think about the environment of the epithelial surfaces and we have to think about what the environment, what the chemical conditions are, or what even the anatomical conditions are of those epithelial surfaces in any organ system, and how are they behaving in a way that's encouraging this growth and this colonisation and this replication of microbes.
So, any system can be involved, obviously the skin, and that sounds like it was the scenario for your patient that you're talking about with the foot. But also, bladder, we're talking about genital tract, we're talking about the lungs, we're talking the gut, any of them. And this is where case taking becomes really important. It's very important to ask certain questions because a lot of these infections can mimic other problems, and infection may not be the first thing that we think about. And so, we start going down the track of, oh well, maybe it's an issue with nutrient deficiencies. Maybe, you know, our differential diagnosis has to become forefront in our mind so that we can deal with this infection or is something else. Is it functional? What's going on?
Annalies: Yeah, certain microbes?
Annalies: Yeah, look, we do. First and foremost, I generally think of bacteria and viruses as being the main culprits.
So, with bacteria, there's, you know, there's so many. The common ones, like streptococci, staphylococci, they're sort of the epithelial surfaces to do with your lymph and your tonsils and your skin.
In the gut, you've got enterococci and Escherichia. You've also got a few others, like, in the lungs, you've got mycobacterium, Haemophilus, Neisseria. And then, if you're starting to go towards other systems, if it's something a bit more systemic, you might be thinking mycoplasma, Bartonella, Borrelia. There’s so many. This is where we sort of have to dig out whatever we use as our textbook for microbiology, throughout naturopathy, and start having a think.
And in a lot of cases, we might have to start ringing the labs and talking to the lab staff about what sort of test do you do? I'm surprised how many naturopaths don't ring up labs and speak to the scientists. I really am. Because when I was a scientist, we used to speak with doctors, and even some naturopaths all the time. You know, that's what the lab staff are there for, and I would encourage any naturopath and nutritionist or herbalist that's listening to ring the labs. You might not be able to speak to the scientist then and there, but they will call you back. And you can talk to them about the types of tests that they do and get a little bit more educated in this, you know, it's a service that's there that I believe that naturopaths aren't using enough.
But definitely, bacteria, I also think it's starting to get into the realm of the cell wall-deficient organisms. They are a huge culprit in these unresolved and chronic infections, and the viruses that we mentioned before. So, Epstein-Barr, but also CMV, cytomegalovirus, human papillomavirus. Hep C and HIV, I probably won't discuss because they're a separate issue altogether, but, you know, for most people that have issues with chronic infections, it's the bacteria and the viruses and the cell wall-deficient bacteria.
Andrew: Can I just ask though? With regards to Hep, I know you don't wanna go into it and that's fine because it's so convoluted, but we know pretty well, like, you know, Hep B, yes, we know about Hep A, food borne, Hep C, yep, absolutely. What about the other hepatitis-es? Did someone got a G or H?
Annalies: Well, last time I checked, there was a D and an E.
Andrew: D and E?
Annalies: Yes. There might be others now. I haven't really had a look at it for the, at least the last 12 months. But look, they are relatively common. They're certainly not as common as A and B, but they are measured in labs. When I was working in labs, we didn’t measure them routinely. They were specialised assays that were only at the request of, you know, if there was a particular doctor. Usually, it wasn't GPs, it might be an immunologist or a hepatologist that was requesting them. I have a feeling these days, they might be a little bit more routine and then not such a specialised test. But the, you know, they're fairly straightforward viruses to screen for or measure in terms of the instrumentation that labs have. So, yeah.
And the other thing is they often follow a particular clinical presentation. Some of them often look very similar to, say, Hep B or Hep A. So, yeah, definitely, you can screen for them. Again, if you're not sure whether the labs are thinking of using screens for them, you just call the lab and ask them.
Annalies: It starts a long, long time ago. I think it was in the '30s that that was first described by some microbiologists. And when I was working at Australian Biologics, it was still...for me, it was new. I've never learned about these in medical science, where I was working with Jennie Burke and we could see them. We could see them in people's bloods. And basically, these are completely resistant to antibiotics, so we can't be thinking that we going treat them with our cephalosporins or our penicillins because they don't have a cell wall.
So, at some point in the evolution of bacteria, certain species, certain strains have developed the genetic changes to actually grow and multiply without their cell wall. And usually, it's...that cell wall, it's a peptidoglycan wall, so it's a mixture of all sorts of different carbohydrates, proteins, and lipids. It protects bacteria and it allows it to replicate, it protects it in, I guess, certain situations that may not be favourable for the bacteria.
But these cell wall-deficient ones have found a way to get rid of that cell wall because they can evade the host immune response, but at the same time, they're still able to grow without the cell wall intact. So, clinically, the big issues with these is that they are not susceptible to antibiotics, they are not able to be cultured. So, if you send samples off to labs, they won't be able to culture them, visualise them, identify them, or detect them on any of the routine agar or culture methods.
And I guess the big thing in terms of the research at this point is, well, how much is actually causing disease? Because L-forms, even though they're able to grow and replicate, it's considered...most microbiologists or bacteriologists say that they are quite docile. They don't think that they cause a lot of problems in terms of infection. But then other scientists on, I guess, the opposing side of things, they know that it's completely not true.
They’re starting to become implicated as a causative factor within autoimmune disease, but at the same time, a lot of scientists think that they are implicated in these unresolved and chronic infections. So, it's still very much...I would say, we're a little bit in the dark with them, but the amount of research that's come out in the last 10 years since I was working directly in labs and looking at them, has been phenomenal.
So, it's something that, I would say, “watch this space.” Follow the research closely because I think it's just going to become more and more of an issue. There's some new really great research papers out that have only just come out in the last six months, and they've all got titles like “The New Bacteriology”. So, this is something that, we need to start looking at this because all the research is moving away, quite significantly away, from antibiotics, and looking at how we might start to target these cell wall-deficient forms. Because we may not have a lot of evidence as to their virulence yet, but the way that they're able to enter the blood stream, so if they're in the blood stream, they're entering every organ. So, it's a worry.
Andrew: Yeah, and, you know, the days of antibiotics as the first call for treating infections, we know they're already numbered. It's been this way for 10 years. It's just that in the last couple years, people are going, "No, guys, really? Seriously? It's here. It's not going to, it's here. We're already here."
Annalies: Yeah, it's here now.
Andrew: Yeah, it's here and it's now, and it's very interesting that they’re really scrabbling for, you know, new types of antibiotics. I understand there was like three totally different types that were released. Was it last year, 2016, maybe 2015 for... Was it golden staph? Something like that.
Andrew: Yeah, I think it was skin.
Annalies: Probably one of the...yeah, hospital-acquired ones.
Andrew: Yeah, and I think it was more skin-borne rather than visceral.
Take me through a little bit more of these L-forms bacteria. If they don't have a cell wall, how come they don't lyse, how come they don't break apart?
Annalies: Well, it usually has a lot to do with...so there's still some membrane capability there. They still have the ability to stay intact because there are some membrane structures that are retained. So, it's really just that their cell wall is shed, and the other really, I guess, interesting thing with these is sometimes, when you visualise them under the microscope, sometimes they do look very intact. They're very spherical. They sort of sit in these beautiful...they look like little pearls, little clusters of pearls in the peripheral blood. But sometimes, you see them blebbing. I'm pretty sure that's a technical word because I did read it, you know, in a paper.
Andrew: Blebbing, blebbing.
Annalies: Yeah, yes. They bleb, and they have these really amorphous shapes. Not only are they...we sort of think of them as being fragile because they don't have that cell wall, but that membrane integrity that's retained allows them to almost stretch. And often, in some cases, you'll see that they develop these like little finger-like projections, and when you see those, that's showing that that membrane integrity that's still there is remaining intact. To allow them to change shape and to change morphology without lysing, as you said. That's an indication, for me and I guess other scientists that look into this, that would indicate some sort of strength and resilience of this particular form, because if they don't just lyse, then they're obviously quite robust.
Andrew: Yeah. I just think it's really interesting that each generation of scientists, let's call it, let's call them, will say that today is the truth, without realising that, you know, you now lambaste what happened 50 years ago. What do you think is gonna happen 50 years in the future? Do you really think that this is going to be the end of the truth? Facts constantly change.
Annalies: I know.
Annalies: Yes, I think there's a couple of approaches that we need to have at the absolute forefront if we strongly suspect an unresolved infection or there's specific tests that are better with L-forms as well that we can talk about. But I think for me, if you strongly suspect infection, then the source of the infection should be identified if at all possible. Particularly if it's something that's coming from outside and it's community acquired. So, if you know for sure that you don't have something like what you have is not an EBV issue, or a CMV issue, or a HSV issue, and it's an acquired, say, microbial infection from a bacterium, finding the source is really important because this is going to stop reinfection.
So, we need to start thinking, "Where are people getting this infection from?" So if it's a one-off chronic infection that just took ages to resolve, you don't have to worry about this. But definitely, source of infection is a big one, so you might start thinking about, "Where do they work? Do they have pets?" If STI-related, you have to think about what's going on with partners or anything like that. So, we do need to test and we need to identify the passage in and work out the roots of infection, if that makes sense.
Annalies: So, we have routine cultures that we can do, but if we're talking about, say, L-forms or maybe some of these intracellular bacteria, they won't really grow on routine cultures. So, all you're seeing, like your blood cultures, your mucosal surface swabs, any of those things, sputum cultures, they may not show anything, and this is where PCR, polymerase chain reaction testing can be very, very useful. Because PCR, as you know, you and your listeners probably know, it's for detecting segments of DNA. And that's really probably one of the tests of choice.
Andrew: So, you use PCR even with bacteria. Is that what you're saying?
Andrew: Oh, forgive me. Okay.
Annalies: Yes, you can use it with bacteria, absolutely.
Andrew: And does it tend to pick up the L-forms or any infection, like with the normal presentation of the bacteria?
Annalies: Yeah, it can. The thing with PCR is you have to use a sample that you strongly suspect the bacteria, or if it's screened for viruses, it has to be there. So, if it's...again, it sort of depends on the presentation.
So, most PCR, and the PCR that we were doing at Australian Biologics, people were sending us not just blood. We were testing saliva, we were testing swabs, like direct swabs to this bite, we were testing urine, we were testing even tissue and biopsy samples. So the great thing about PCR is that it does pick up the DNA, if you can't culture the microbe, and you can also send a whole, you know, a whole host of different tissues or secretions, it does...it's not just blood.
Annalies: So, I think probably the main deterrent with PCR for a lot of people is the cost because it's not a cheap test by any means. It's a more intricate testing methodology and it does cost a little bit more in order to get it done. So, what I would say to people is if you're thinking of doing it, you really have to have a good justification for doing it and you have to strongly suspect that certain pathogens are there. You might even have a strong suspicion that there is a pathogen present and you need to identify exactly which one it is.
So, this is where, again speaking to the laboratory and speaking to the scientists who run these tests is very, very useful. It may not be as useful speaking to, say, a GP about it because they don't often, not all of them, but some of them may not have the intricate knowledge of the actual assay and the testing methodology.
Andrew: Yeah, there are too few GPs out there that are specialists in pathology. Some are.
Annalies: Well, yeah, I mean, they've got so much else to learn and think about. So...
Andrew: Well, it's a specialty.
Annalies: But some of them do have that...yeah, yeah, exactly right. And this is what medical scientists do. You know, they're not seeing patients, but this is what they do every single day. They know how the tests run, they know how the assays work, they know how the methodology works, and they know whether certain specimens are going to be right for the test that they run.
Annalies: Look, I think, antimicrobials, without a doubt, has to become your first line of treatment. So, obviously, identifying...getting an identification of the pathogen that's causing this is important through your testing, whether that's routine pathology or specialist pathology like PCR. And then you have to start selecting your antimicrobial agent. So, again, this varies wildly depending on what's coming up. "Is it viral? Is it bacterial? Is it intracellular? Is it L-form?" But I am not averse to people taking antibiotics because I've seen a lot of great resolution of infection from taking antibiotics if people need it, particularly for the big, nasty bugs and bacterial infections.
But having said that, it's also a case of using herbal antibacterials and herbal antimicrobials as well. So, I believe that they have a great impact on these infections. Particularly after they finish their course of antibiotics, you might actually give a course of herbal antibiotics or herbal antivirals as well. And obviously, if they're going to take antibiotics, or they need to take them. That's when a lot of what we do goes into play as well. So, any resolution that needs to occur in the gut with gut health and gut integrity, we have to work there as well.
Annalies: So, I mean, any of the listeners that are herbalist will be starting to think “Oh Yes, Hydrastis canadensis, Uva ursi, Baptisia, Melissa, Hypericum, all those antimicrobials, in terms of antibacterial, antiviral, they work quite well.
Andrew: Given that you...there's a, in my mind, is the propagation of a myth, but anyway, out in the community about the use of adaptogens, for instance, an immune adaptogen or a herbal immune adaptogen of note, Astragalus, or Astragalus. The adage that is constantly touted out there is you should never use it in an infection because it'll set the infection in, which I think is codswallop when you look at the research on it, because the research resolved viral colds, help to resolve. You don't have that sort of thing in a chronic situation. That's an acute thing.
So, I think the...like I'm not a TCM practitioner but I just think we're becoming rather arrogant in our Western ways when we say...when we're using a Traditional Chinese Medicine, but we have this mentality of using it in a Western format, if you like. Do you ever employ Astragalus in these unresolved infections or be it in a chronic situation, or what?
Annalies: Look, I have, and when I started doing it, I did it with a lot of, "Oh, my gosh, what am I going to do to this patient?" But I also had like mentors, herbalists that had been practicing for so long saying, "I've done it and it never caused any problem." But I also thought of that sitting in materia medica classes, learning not to do it. So, I'm a very cautious practitioner. I started out only doing it with the patients that I knew through talking to them and knowing about their history, but with just that little bit more robust.
I've never done it with paediatric patient, or I haven't done it with children. I've never really done it apart from someone that's been a little bit stronger in their constitution. I've never really done it with someone with a huge history of atopy. And that's probably just because I'm a little bit cautious, but I have done it. I have done it with patients that I felt confident that it would be all right, and it has been all right. There's never been this problem where all of a sudden, everything is worse because they had Astragalus during their infection, but I've done it cautiously.
Andrew: I guess I have this picture in my mind of a patient who frequently gets swollen glands and fatigued upon presentation of an acute stressor, but they don't sort of break out in an infection, but they just get these glandy sort of feeling. And I guess where I'm heading to here is, in the old days of medicine, you would say, "Swollen tonsils, cut them out. No more problem. They're gone." We also used to do that of the appendix.
Nowadays, I learned that we've, you know, now that we've realised that the appendix is actually a reservoir of a very important bacteria for your gut and indeed it might help inhibiting the priming for autoimmune disease, that, you know, they're trying to save the appendix. And maybe more than ever today, we're trying to save the, adenoids and the tonsils. I guess, given that there's, at some point, there's a pragmatic decision that has to be made for a child that simply can't breathe and their school work’s going down, and they’re not even sleeping. But, you know, I get that sort of part of medicine where there really is a need, and you don't like it, but you just got to do it.
But apart from that, what about employing, you know...I guess the old naturopathic way would be a diet. You know, get them off milk and things like that, and yet, what we're talking here is more employing antimicrobials to address the infective state of it.
Do you ever look at things that might not be in concordance with a good naturopathic diet, like, for instance, a dairy product called colostrum, which I love. But do you ever use that sort of stuff?
Annalies: I have. I have used colostrum. Again, it's not something that I would use with everyone. It's not something that I think this is a cure that everyone would benefit from. But look, colostrum has been...it has a lot of research behind it and a lot of really good research behind it. And historically, I have used that in active infection, in chronic infection, and in preventing recurrence of infection. Probiotics are obviously a big, important one here as well because of their immune priming effects, and we know that the gut is absolutely implicated in any issue of poor immunity that's leading to chronic unresolved infections.
I think for me, the way I practice is that I really like to look at how a person is presenting, I love to look at what they're eating, and I absolutely want to get their diet as much as I possibly can, get their body eating the micronutrients and the macronutrients that are actually going to build the tissue from the ground substance up, to be able to defend this person against this latent thing that keeps coming and going. Or these community-acquired infections that they're just not fighting or backing up against very well. So, for me, it's very much about the food that they're eating.
There are certain things that I do take people off for a little while. Most people, I would look at dairy, casein and gluten, and just have a talk to them about that, and they may be off it for a while, it may not be forever. It depends, again, on the person and their unique situation.
But I start looking at things like how much vitamin A are they getting in their diet, how much vitamin C are they getting in their diet. For me, fat and protein is a big one because this is what a lot of these tissues are built upon. If we're not getting enough protein in our diet, if the fats that we're getting in our diet are not the right type or the right quantity, we're just not going to be able to mount immune responses.
And when we are sick, if it's just a mild chronic low-grade infection or a fulminant, raging acute infection, we use up so, so much nutrition, so many micronutrients are used up. Our surfaces tend to get sloughed off and eroded down. We need to replace them. So, those two macronutrients are big for me, fats and protein. And I usually go through someone's diet meticulously, and not just what they're eating now but historically as well, particularly what they've been having and eating in the last 12 months, 2 years, 3 years. However...
Andrew: Oh gosh.
Annalies: Yeah, I know. Full on.
Andrew: There's a recall dietary survey.
Annalies: Yes, yes.
Andrew: Can I ask, what about traditional therapeutic dietary interventions? Like for instance, the Chinese, you know, forgive my ignorance about this, done properly, but to my mind, it was, you know, really well-boiled, double, triple boiled rice, which is called "gak," is that right?
Annalies: Mm-hmm. I remember learning about gak.
Andrew: Okay, great.
Annalies: I have never used it, but I did learn about it, yeah.
Andrew: And of course, the other one that goes, I guess the more Western style of that would be the old chicken broth, for you know, coughs and colds, which in grandma's day would not have been from a little sachet or a tin. It would have actually been made from, what do you know, guys, bone broth and carcasses of chicken. So, what, do you employ that sort of thing?
Annalies: Yes, I do, and there are a lot of old, traditional, I guess you'd call them recipes or formulations that you pretty much you can bring out anytime. Someone doesn't have to be unwell, but you bring them out when they're unwell. So, the...I mean, I tend to use the Western, I guess, formulations or recipes because that's what I'm most familiar with. I haven't studied a lot of the Eastern or TCM approaches.
But when you look at things like the chicken feet, for example, it's full of proteins, and you think about what's in the bones of these animals. It's the same thing, or similar things, that are in our bones. And our bones are where our blood comes from, and within our blood, we have white blood cells, and white blood cells produce antibodies. So, of course, the components for building those structures and tissues in a human body, if we're using the structures and tissues from an animal, then we're going...it's a way of replacing those things.
So, I mean, I'm not vegetarian or vegan, and I really think that if something like this is an issue for people, we do have to look at protein and fat because these things help to build a robust immune system, and they help to fight infection.
And you know, we need to be looking at people's blood test results. I've had so many recently where you look at someone's total protein level on a full blood...not a full blood count, but a biochemistry profile, their total protein is low, and then you start to look at the subsets and their albumen might be low, but also their globulin levels as well, and globulins are what go on to make antibodies for us. So, anything in our diet that can help bring that up is going to be helpful.
So, yeah, the chicken soup is a very, very good one. Everyone's into drinking broth at the moment, and I think it's great, but I sort of think it's really just the liquid. We need to start, especially with people that need to fight infections, eat all of it. Eat the fatty bits that came off with it. Eat the chunky bits that came off with it. You know, it might not look pleasant, but eat all the bits because a lot of that, a lot of stuff being thrown away just to make a clear broth, eat it all. It's all useful, it's all nutritious.
So, what about any caveats, any things that you've got to be careful of when you're treating this sort of patient?
Annalies: Look, I think some of the caveats include, if you are going to use herbs, some of them, particularly any that has a really high alkaloid content such as Hydrastis canadensis or goldenseal, it's got...or anything that's got a huge amount of berberine in there, some of these alkaloid-containing herbs should only be used short term, and you do need to monitor the patient closely, just in terms of their, I guess, their liver function, their gut. You know, you don't really want to create a situation. Yeah, wipe them out, chronic diarrhoea or anything like that.
So, I mean...but that's, I guess, the case with any herbal medicine prescription that, you know, is just short term and it's treating something. I mean, you're using these like medicines. Like these are...the way I view herbs is that they're drugs. So, we don't sort of say, “Here’s your herb mix, call me later.” I sort of, you know, I monitor anyone closely that I think need herbal medicines. But that's...yeah, anything, where you're using a lot of berberine, I tend to say monitor closely.
I also think that we need to be careful around always treat what's in front of you, and that's something that I always keep in the forefront of my mind, particularly with infections because it can take a little while to get results back. Sometimes, if you're employing PCR or you're sending specimens off away to different labs, it can take one week, two weeks, maybe even longer before the results are back for you.
But I really think that treating what's in front of you is important. You can initiate some kind of treatment straight away. Even if it's just dietary, you don't have to sort of go in with some herbal medicines and antimicrobials straight away, but you can do so much with someone in those early days, having frank conversations with the patients about stress and anything that's contributing to the poor immunity, diet, any of these things.
So, I guess another caveat for me is don't feel unconfident because you think that their labs are going to provide all the answers for you. The answers are there in front of you, so don't neglect them, don't neglect what's in front of you.
I also think that another caveat is to make sure that you don't always suspect an infection. Because I know that the whole topic today has been around these unresolved infections, and I think they are becoming more problematic in clinical practice, but always having a differential diagnosis in your mind as well because we've got things like malnutrition and autoimmune diseases can all manifest in a similar clinical picture.
Andrew: Responsible. Very well done.
Annalies: Yeah. So, making sure that differential diagnosis is always at the forefront of your mind as well. Because it can be easy to just go “Oh, this is infections, it's got to be infection, let's send up all these swabs, let's do some PCR,” but it may not be. So, I think that's another one for me to, yeah, make sure that you always, you've got your DDs written down in front of you and be using them all the time.
Andrew: Absolutely. So, what about expectations of treatment when you're dealing with, you know, unresolved infections of, let's say, a virus, EBV? We're not gonna get rid of it, right? So, are we talking about long-term management?
Annalies: Yes, long-term management definitely involves getting the patient on board and not allowing them to become too passive in this whole process.
So, I know that in your previous podcast that you did with Mark Donohoe, he was talking about EBV as being the great barometer of the patient's health, and that's absolutely true. It's true of EBV and it's also true of HSV. It's true of CMV. It's true of anything that will tend to carry in terms of a virus, but also, it tends to be the case with seasonal infections as well that we pick up. It is the great barometer of our health as to how easily we pick things up. I always say to people, "Don't think that you'll ever get through life," and even for naturopaths, you know, there’s this idea that we've got to be healthier and never get sick and we never get infections and never get the flu. That's not right. We're human beings.
So, the idea is have a look and identify with your patients what are the things that tend to trigger these episodes for you. I always draw up a big list of triggers with my patients. I generally do it with them. And they’ll say things like, "Oh, I know that it's when I work late, you know. I don't get home from work until 8:00, 9:00, 10:00 at night," or, "I know that the trigger..." It might be just things, tiny, little things like, "I stayed up watching Netflix all night and I didn't get enough sleep."
If you can find the contributing factors that affect someone's sleep, which affects their immune system, or affects their stress levels, which affects their immune system. Anything that interrupts their ability to eat a healthy diet, or be organised enough to eat a healthy diet. All of these tiny, little things that we think is so non-significant, you add them up, and that's when people start to say, "Are the glandy feelings coming on again? Oh, I can feel the tingle. Oh, now I'm really tired. I had a really bad year with flu’s this year because I just didn't look after myself."
So, for me, the outcomes and the prognosis are always better when the patient is very well-educated on understanding their triggers. And that often comes from really frank conversations and patients really being quite honest with themselves. And they may not... The biggest, I guess, successes I've had with the patients who are willing to go there. I've had plenty of patients not willing to go there who think, "Oh, you know, sleep's got nothing to do with it. Diet's got nothing to do with it." And unfortunately, we're not going to be able to get through to everybody, and that's...you know, everyone's on a different tangent and a different journey with their health. But I think, yeah, frank conversations with people about stress, sleep, diet, lifestyle, it's very important.
Andrew: I think you and I need to be doing a case history at some stage.
Annalies: Yeah, it's very much...we all know it. All practitioners know that there's an art, there's an art to all of this that you're never taught, that you never get enough practice in, even if you've been practicing for five years, you know, you still don't. You never feel quite on top of it, do you?
Andrew: Oh, look, I think the day you think you know it all, is the day you should hang up you shingle because you've just become arrogant.
Annalies: Exactly, exactly. Exactly, right. Exactly right.
Andrew: Annalies Corse, thank you so much for taking us through unresolved infections today. I think this is just the tip of the iceberg for me. I think I've got so much more to learn, and indeed, I think we will be delving into a case history or two in future times.
So, thank you so much for joining us on FX Medicine today, and indeed, thank you so much for taking that responsible point about the differential diagnosis. Don't always think that it's what we think we see.
Annalies: No, that's right. That's right, yeah, very true. Thank you so much. I've really enjoyed talking to you. I hope it's been useful for people.
|Epstein-Barr Virus: Part 1 with Dr Mark Donohoe|
|Epstein-Barr Virus: Part 2 with Dr Mark Donohoe|