Chronic Inflammatory Response Syndrome (CIRS): What is It? Why Should We Care? What’s Does It Have to Do with Our Brain Function? (36:10 min)
Kirk's video overview of his interview with Dr. Jill Carnahan (8:19 min)
Dr. Jill Carnahan's Personal Story with Breast Cancer, Crohn's Disease and CIRS
Dr. Carnahan always had an interest in nutrition and getting to the root cause of disease during her allopathic medical training. During medical school she was diagnosed with aggressive breast cancer at 25 years of age and was treated with radiation and chemotherapy and her excellent recovery over the last 15 years she attributes to applying functional and integrative medicine approaches to her health care. Shortly after her breast cancer diagnosis and treatment she was diagnosed with Crohn's disease, but now 15 years later she is free of symptoms of both.
Dr. Carnahan's health was excellent until 2014 when she had a sudden onset of being short of breath, fatigue, numbness in her legs, blood shot eyes after work, and then she started getting frequent fungal and skin infections, pneumonias and other respiratory conditions. She eventually got sick enough and she tested her urine for mycotoxins and CIRS blood markers. Then she had her office evaluated and stachybotrys (black mold) was found in the basement below her office and she immediately moved out of her office on December 26, 2014 and never came back.
She was in this office for 2 1/2 years and about 18 months into being there she started getting sick. There was also a massive flood in her town in September of 2014 which allowed water into her office building basement which probably enhanced the mold growth and increased the depth of her illness and symptom expression. Dr. Carnahan has the genetic susceptibility to not being able to detoxify mold toxins and looking back in her life her immune system could have been challenged since childhood by living in an old farmhouse that probably had significant mold.
When Dr. Carnahan uses the urinary mycotoxin test now on patients she makes sure she doesn't miss anyone who cannot detoxify mold well by giving glutathione orally by mouth for 5 days prior to collecting the urine sample, and if possible, has the patient use sauna therapy prior to the urine collection as well. This way of prepping for the urine mycotoxin test appears to give better clinical correlations. In herself, not only did she have elevated urinary mycotoxins, but she also had elevated C4a (acute exposure, very high) and TGF Beta 1 (very high), the later of which can stay elevated even after the exposure.
Testing Your Environment for Mold
When the CIRS blood markers are elevated (or abnormal) suggesting a toxic exposure Dr. Carnahan recommends getting the EPA approved ERMI (Environmental Relative Mold Index) test done first from mycometrics.com because it measure more species of mold. The HERTSMI-2 score is based on the top 5 molds that cause mold illness so you can determine a HERTSMI-2 score from the ERMI test. With a score of more than 15the patient probably will not get well if they remain in that environment, but with a score of less than 11 it is generally safe for the person to return to that environment. Sometimes it can take multiple ERMI tests and multiple inspectors to find the mold, especially if the blood tests remain elevated/abnormal suggesting exposure.
Chronic Inflammatory Response Syndrome (CIRS)
This is the body's "out of control" inflammatory response to a toxin (i.e. mold, Lyme, etc.) it can't get rid of that causes a cascade of inflammatory and hormonal changes that can cause fatigue, pain, gastrointestinal and neurologic symptoms, sleep disturbances, and other damaging effects to the body. This most frequently happens in the 24% of the population who have the genetic susceptibility (HLA DR/DQ genotype) who can't detoxify mold well.
Testing for CIRS
There is a Mold CIRS Panel through Life Extension that is a reasonable cost of $400 for MSH, MMP9, TGFB1, ADH and Osmolality. Dr. Carnahan follows her patients with C4a, TGFB1, MSH, MMP9 and VEGF levels though when adequate medical insurance is available she does all the Shoemaker suggested CIRS tests (click here for test explanations). She uses C4a as a marker of exposure which usually last a couple of weeks after an exposure.
CIRS, Brain Effects and Neurologic Decline
Dr. Carnahan when seeing these CIRS patients started noticing cognitive decline in younger and younger patients who had this mold illness. Then when she read Dr. Bredesen's paper on "Inhalation Alzheimer's" and patients being treated for mold having subsequent improvement in their cognition the neurologic impact of mold illness (CIRS) became more evident and she "sees" it more frequently.
Assessment of Cognitive Decline Patient
A "Tier 1" type of approach using the Bredesen protocol of testing may start with a comprehensive metabolic panel (COMP), a complete blood count (CBC), hemaglobin A1C, homocystiene, B12, folic acid, insulin, sex hormones (estradiol, progesterone, testosterone, DHEA, pregnenelone, cortisol), thyroid (T3f, T4f, TSH, T3rev), magnesium, vitamin E, zinc:copper, toxic metals and other basic testing, and then asking appropriate environmental and symptom questions to determine if the CIRS testing should be added. Or, if it is obvious there is a Type 3 Alzheimer's presentation with a sudden onset in the mid 50s and there is word finding difficulties, this would be an appropriate person to add-on the CIRS testing.
Neuroquant (MRI) Testing
Dr. Carnahan has done a lot of Neuroquant evaluations of MRIs (about $500 cost). You can track over time putamen, caudate or hippocampal changes with treatment. But as far as it helping her with a mold-related cognitive decline diagnosis it hasn't been helpful to her that she would change her treatment plan. Most of the patients (80%) showed the mold pattern and 20% showeda Lyme pattern. She does a baseline MRI with Neuroquant and then maybe a followup in 2 years. The test compares the volume of these brain structures which can be correlated to changes with treatment and symptom improvement. It is clear that brain structure can change size and volume with the appropriate treat of the mold toxicity.
Genetic HLA DR/DQ Mold Genetic Testing
Twenty-four percent of the population has a genetic weakness in detoxifying or excreting toxins from mold. The genetic test is paid for by some insurances but Life Extention can do the test for under $400. One hundred percent of those who Dr. Carnahan has been suspicious of having the HLA genotype type for susceptibility to mold toxicity have been positive for this gene. She likes doing this genetic screen because of nuances of the presentation of the gene variations such as HLA DR/DQ 43-53 whose patient presentation is more severe fatigue, depression and mood disorders with the mold exposure. HLA DR/DQ 11-3-52B subjects present with more collagen vascular issues, joint issues, very high TGF-Beta1 and are more prone to autoimmune diseases.
When Do You Start Treatment For Mold Detoxification and Treat The Infected Sinuses (Multiple Antibiotic Resistant Coagulase Negative Staphylococci)?
While Dr. Carnahan agrees that the ideal is to remove the subject from the mold exposure prior to therapy for removing the mold toxins from the patient, she will start to treat with binders and treat MARCoNS in the sinuses during the remediation or testing process of the patient's home or work environment. Admittedly it is not the optimal sequence of the treatment protocol but sometimes the "cleaning" of the patients environment takes time to become mold toxin free, or maybe it never does.
She will start with the binder cholestyramine (9 grams 3-4 times daily 30 minutes before or 60 minutes after meals), but has found significant gastrointestinal side effects of bloating and constipation (25-30% of patients can't tolerate it) and she really likes to use Welchol® (colesevelam HCl) in 625 mg tablets 6 at one time or 3 tablets two times daily one hour away from food or supplements. Dr. Carnahan personally took Welchol herself during her mold toxicity healing journey. She also recommends routinely using clay and charcoal (Biobotanicals; GI Detox) therapy as additional binders to go along with the medications, and uses sauna therapy concurrently (she has one in her office) to clear toxins through the sweat as well.
Air Filters Are Very Beneficial in CIRS Patients
Dr. Carnahan is a big believer in air filters, especially for those who haven't cleared their home or work environments. She sees clinical benefit almost immediately within 24 hours with their use. Good HEPA filters with a good VOC filter. There is Austin Air, IQ Air, Air Oasis (UV generated filters may aggravate some people with lung issues) air filters and are all beneficial.
Gut Assessment Is a Foundational Assessment
Dr. Carnahan uses a GI history and stool tests such as the methane and hydrogen breath test for SIBO (small intestinal bacterial overgrowth), GI Effects from Genova Diagnostics (DNA probes are less effective for parasites and candida) or the stool exam from Doctors Data as screening tests for the gut. She will do organic acids to look for yeast and clostridia (organic acids from the NutrEval or OAT Test). For parasites she uses Parasitology Inc. or GI MAP (PCR testing for parasites, fungal species and H. Pylori).
Diet for CIRS
Dr. Carnahan recommends eating a whole food diet and going grain-free (especially corn, peanuts, cashews and pistachios which can be sources of mycotoxins), gluten-free, dairy-free and sugar-free. Fermented foods may not be tolerated because of histamine producing foods. Dr. Carnahan uses U.S. Biotek or Cyrex for IGG food sensitivity testing which also gives an idea of intestinal permeability if there are many positives foods. Food elimination helps heal the gut.
Sinus (Tooth and Jaw) Treatment for MARCoNS and Biofilms
If MARCoNS is positive (deep sinus culture for bacteria, fungus and biofilm from Microbiology DX; read About MARCoNS) Dr. Carnahan begins with the BEG (Bactroban, EDTA, Gentamicin) nasal spray for one month. She finds this 50% effective in eradicating the MARCoNS. Sometimes she will use EDTA nasal spray for 3 months to treat the biofilm and retest. She will also use for resistant MARCoNS and biofilms other agents such as Argentyn Silver nasal spray 4-5 x per day with Xlear a xylitol saline nasal spray and/ or Citricidal natural biofilm disrupters and antifungals. Dr. Carnahan sometimes recommends a nasal rinse with silver or Agrumax a grapefruit seed extract using the Neilmed or Neti Pot delivery systems.
Effectively treating MARCoNS will improve MSH (melanocyte stimulating hormone) levels. When MSH is low it accounts for hormone disruption with elevations in estradiol, insulin and cortisol initially (then cortisol eventually drops) and lower levels of testosterone and T4 with normal T3 and TSH levels. Bringing up MSH levels is very important for normalizing a cascade of altered hormone production and inflammatory biochemicals which can account for a variety of distressing symptoms (see MSH in Biotoxin Pathway Flow Chart).
MARCoNS can also be found in the jaw (cavitations) and root canals so assessment by a cone CT of the jaw by a biological dentist may be warranted. Dr. Carnahan finds this a "not infrequent" problem.
Hormone Replacement in CIRS Patients
Dr. Carnahan does test and treat for hormone deficiencies in CIRS patients and finds most CIRS patients have elevated cortisol levels which can disrupt sleep so she uses substances like phosphatidylserine and rhodiola to help bring down cortisol and anything that will help the patient sleep. She finds testosterone low in men and women with autoimmune diseases and replacement is beneficial, especially in men with pre-diabetes or metabolic syndrome. She will start many times with DHEA replacement first in both men and women before testosterone to see if levels come up (especially in women) and symptoms improve.
Assessing Cognitive Decline
Dr. Carnahan has begun to use the Moca Test (Montreal Cognitive Assessment Test) and the CNS Vital Signs Testing in her office as ways to assess cognitive function and status quickly. The Moca Test takes 12-15 minutes and one has to take a short certification course to administer the test. The CNS Vital Signs can be done in office in 20-30 minutes. Dr. Carnahan finds both tests valuable.
Dr. Carnahan's Concluding Thoughts on the Role of Mold Illness, CIRS and Cognitive Decline and Alzheimer's Disease
There is no question in Dr. Carnahan's mind that mold illness and CIRS plays a significant role in patients with cognitive decline and Alzheimer's disease. Because of her own personal experience with mold illness and now better tools to assess and treat patients she is seeing mold illness in a lot more patients effecting a wide variety of illnesses such as Crohn's or colitis, as well as cognitive issues.
Keep Updated with Dr. Carnahan's Research
If you are a lay person or a professional Dr. Carnahan has resources, blogs and newsletters for both on her site at JillCarnahan.com.
Dr. Jill Carnahan earned her undergraduate degree from the University of Illinois Champaign-Urbana in 1998 with a Bachelor of Science Degree in BioEngineering. She graduated with honors from Loyola University – Stritch School of Medicine in 2003. She completed her Family Practice Residency from the University of Illinois College of Medicine in 2006. Dr. Carnahan is Board Certified in Family Medicine (ABFM) and Integrative Holistic Medicine (ABHM). She is a frequent lecturer to physicians who are being trained in different aspects of Integrative and Functional Medicine.
Jill Carnahan, MD Office 303-993-7910 Flat Iron Functional Medicine, 400 S. McCaslin Blvd, Suite 210 Louisville, Colorado 80027 Location Phone: 303-993-7910 Location Fax: 303-993-4674, Jillcarnahan.com
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Kirk
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