NMDC221 Session 8: Immune System Disease Part III had low vitamin A levels when ill with measles, and these children also appeared to have lower measles-specific antibody levels and

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NMDC221 Session 8:

Immune System Disease

Part III


Topic Summary

Immune System Diseases: Part III

o Nutritional management & consideration of drug-nutrient

interactions

o Measles

o Rubella

o Mumps

o Acute food poisoning

o Parasite associated diarrhoea

o Parasite associated chronic diarrhoea

o Candidiasis

o Mononucleosis (glandular fever)


Measles


Measles

o Measles is a highly contagious viral infection of the Paramyxoviridae

family with an incubation period of 8-14 days. Spread is via droplet

infection from 4 days before and until 2 days after the rash onset.

o The eventuation of serious complications and/or death is more likely

for malnourished children, adults or the aged.

o Complications include: stomach problems, pneumonia, ear

infections, sinus problems, convulsions (seizures), brain damage

and possible death.

(Kumar & Clark, 2009)


Measles

Prodromal & Catarrhal (initial) stage

o Malaise, fever, irritability, conjunctivitis, excessive lacrimation,

oedema of the eyelids, photophobia, hacking cough, nasal

discharge.

o Koplik’s Spots (Onset: 1 – 2 days prior to rash): Small red irregular

spots with a blue-white center found on the buccal mucous

membranes opposite the second molars

Eruptive (secondary) stage

o Measles rash (Onset: 4 – 5 days into infection).

The rash will often manifest at the forehead

and then progress down the face, neck,

trunk and feet. Fades in about 1 week



Measles

Nutritional Objectives:

1. Ensure adequate rest and fluids.

Plenty of bed rest and fluids until the rash and fever

disappears (keep patient out of strong sunlight).

Consider the following dietary examples

• Light watery soup (Initially)

• Diluted fruit juices (Initially)

• Slowly increase solid food utilization as vitality

improves.

• Complication: Seek immediate medical attention



MeaslesNutritional Treatment

2. Support the immune system.

i. Vitamin A

o Children <24mths with measles complications (pneumonia and

diarrhoea) recovered more quickly, and has less URTI, when

administered vitamin A within 5 days of measles rash appearing

(Coutsoudis, Broughton & Coovadia, 1991)

o One study illustrated that some children( ≤ 24 months in New York

City) had low vitamin A levels when ill with measles, and these

children also appeared to have lower measles-specific antibody

levels and increased morbidity from measles and higher

hospitalisation rates (Frieden, Sowell, Henning, Huff & Gunn, 1992).

ii. Zinc

o Low zinc levels impact on the absorption & metabolism of vitamin A,

indicating co-supplementation (Christian & West, 1998)


Measles

iii. Antioxidants

o Children with measles have higher oxidation markers

and lower levels of antioxidants (beta carotene, retinol,

alpha tocopherol, ascorbic acid and glutathione) than

healthy controls (Cemek, Dede, Bayiroglu, Caksen,

Cemek, & Mert, 2007)

iv. Blue-Green Spirulina

iv. Calcium - found in spirulina is an inhibitor of enveloped

virus replication, from a blue-green alga Spirulina.

(Hayashi, Hayashi, Maeda & Kojima,1996)


Nutritional treatment

3. Provide anti-inflammatory support

Foods that have anti-inflammatory potential can reduce the

inflammation and fever that presents. These include garlic,

ginger, bromelain and turmeric (Srivastava, 1984; Kiuchi,

Iwakami, Shibuya, Hanaoka & Sankawa, 1992; Limiroli,

Ferrario & Bianchi, 2002; Chainani-Wu, 2003).


MeaslesNutrient Dosage Therapeutic Actions

Vit C

(Ascorbic

acid)

1000-

10000mg

Immune activity, Antioxidant, Synergistic with glutathione &

vitamin E.

Vitamin A 5,000-

10,000iu

Supports vision, cell division and protects cell membranes.

Combats infection, maintain immunity & epithelial cell

differentiation & turnover. May enhance T-lymphocyte and

antibody responses. Reduces measles complications

Vitamin E 100-1,000iu Anti-Oxidant. Affects the expression & activity of immune &

inflammatory cells. Tissue repair and cell regeneration

Zinc 20-100mg Supports cell-mediated immunity. Immune function depends

directly on zinc status for production, regulation, activity &

equilibrium of both cellular & humoral immune responses.

Regulates T-lymphocytes, CD4cells, NK T cells, IL-2. Antioxidant

Tissue and cell repair.

(Pzzorno & Murray, 2006)


Rubella


Rubellao Rubella (also known as German measles) is an airborne virus with an

incubation period of 14-21 days. The spread is via droplets before the

onset of the rash and while the rash is present.

o In children under 5 years of age the symptoms are mild or absent.

o Infection during pregnancy can cause miscarriages, stillbirths, or birth

defects.



Rubella

Prodromal (initial) stage

o Malaise, fever, mild conjunctivitis, lymphadenopathy.

Can present with Forchheimer spots – small petechial

spots on the soft palate. Splenomegaly can present.

Eruptive (secondary) stage

o Occurs within the first week of initial symptoms.

o Rash is pink to red and first appears on the forehead

then spreads to the trunk & the limbs.



Rubella

Nutritional Treatment

o Rubella is a self-limiting infection, and does not require

specific medical or nutritional management targeting the

virus itself

o Nutritional management revolves around general

immune support and convalescence

• Bed rest

• Adequate fluid intake

• Removal of refined and allergenic foods

• Inclusion of nutrient dense foods

(University of Maryland Medical Centre, 2006)


Mumps


Mumps

o Mumps is an acute systemic viral infection of the

Paramyxovirus family with an incubation period of 14 -

24 days. Spread is via droplet infection from 2-3 days

before the onset of parotitis and 3 days post.

o Prodromal (initial) stage

• Fever, headaches, malaise, lethargy, anorexia

o Inflammatory (secondary) stage

• Sore, swollen throat, difficulty swallowing, one or two

swollen parotid glands.

• Epididymo-orchitis



Image: Mumps


Mumps

Acute Phase Management includes :

o Plenty of bed rest and fluids.

o Maintain adequate nutrition.

o Slowly increase solid food utilization as vitality improves.

o Support mouth health.

o Complication: Seek immediate medical attention

o Anti-inflammatory foods can be beneficial (volatile oil rich

herbs & spices, bioflavonoid rich foods)



Mumps

Nutrient Dosage Therapeutic Actions

Vitamin C

(Ascorbic

acid)

500-

5,000mg

Immune activity. Synergistic with glutathione & vitamin E.

Anti-oxidant

Vitamin A 5,000-

10,000iu

May enhance T-lymphocyte and antibody responses. Supports

vision, cell division and protects cell membranes.

Combats infection, maintain immunity & epithelial cell

differentiation & turnover.

Vitamin E 250-

1000iu

Anti-Oxidant. Affects the expression & activity of immune &

inflammatory cells. Tissue repair and cell regeneration

Selenium 25-

250mcg

Co-factor for glutathione peroxidase, essential for immune

proliferation. Potentiates the antioxidant effects of vitamin E

Zinc 20-100mg Supports cell-mediated immunity. Immune function depends

directly on zinc status for production, regulation, activity &

equilibrium of both cellular & humoral immune responses.

Regulates T-lymphocytes, CD4cells, NK T cells, IL-2.

(Pizzorno & Murray , 2006)


Measles, Mumps, Rubella

Measles, Mumps, Rubella Management

o For all three conditions divide the treatment plan to

include short and long term immune strategies.

o Analgesics can be given to support pain

o Antibiotics can be given if secondary infections present

o Topical creams can be applied to aid the rash symptoms



Measles, Mumps, Rubella

Drug Action Side Effects Interactions

MMR Vaccine Live attenuated vaccine

generates cell-mediated

& anti-body responses to

create a strong

immunological response

(one dose). Utilized to

reduce the severity of the

symptoms that present.

Not given for treatment of

these viruses,

prophylactic agent.

Transient site

inflammation, fever,

headaches,

dizziness, malaise

& nausea.

None listed

(Kumar & Clark, 2009; Bullock & Manias, 2007)


Acute Food Poisoning


Food Poisoning

o A notifiable disease that is due to the ingestion of

infected water or food

o The noxious agents can be bacteria, parasites, viruses

or toxins. Most commonly caused by a staphylococcus,

E. coli or salmonella. Consider Hepatitis A infection

differential diagnosis.

o Symptoms include abdominal cramping, diarrhoea, fever,

chills, headache, nausea, vomiting, weakness.

(Merck, 2010; Kumar & Clark, 2009)


Parasite Associated Diarrhoea


Parasitic Diarrhoea

Helminths (threadworm, hookworm, dog tapeworm)

o Infection via ingestion (less commonly through skin

boring or through insect bites carrying infection).

Symptoms include;

o Anal itching worse at night, mild diarrhoea (threadworms)

o Mild respiratory symptoms, epigastric pain, nausea, mild

diarrhoea, iron deficient anaemia. In a well-nourished

person they may present as asymptomatic (hookworms)

o Abdominal discomfort, diarrhoea, anorexia. May be

asymptomatic (tapeworms)



Parasitic Diarrhoea - GiardiaProtozoa (Giardia)

o Giardia is a single celled protozoa ingested through drinking

contaminated water

Giardiasis symptoms

o Symptoms usually appear 1-2 weeks after infection. Can be

asymptomatic

o Bloating & cramping in the GIT, Watery & foul smelling diarrhoea

o Belching, Nausea, Anorexia (Merck, 2010; Kumar & Clark, 2009)

o CDSA

o Quite responsive to nutritional treatment consuming a whole-food

based, high-fibre, diet that is low in fat, lactose, and refined sugars.

Additionally, ingestion of probiotics and wheat germ may assists in

parasite clearance (Hawrelak, 2003)


Parasitic Diarrhoea

Diagnosis

o Thorough travelling history, stool sample, presentation of

eggs or worm carcass around anus or in bedding

(Merck, 2010; Kumar & Clark, 2009)


Parasite Associated Chronic

Diarrhoea


Parasite Associated Chronic

Diarrhoea

o Unchecked, diarrhoea can lead to extensive losses of

water and nutrients essential for good health.


o Check for food intolerances/allergies

o Check for inflammatory bowel disease (IBD), irritable

bowel syndrome (IBS) or bile acid malabsorption

o Determine if a bacterial, protozoan, helminth, viral or

fungal infection presents

o Check for concurrent drug therapies – antibiotics,

laxative abuse, metformin, chemotherapy agents




Therapeutic Actions

1. Assess nutritional status

- Electrolyte replacement

o Maintaining hydration and electrolyte levels is a primary

concern with diarrhoea. Solutions providing glucose,

sodium and potassium are most indicated

2. Support Immunity

-Zinc

o Has an antimicrobial effect on enteric pathogens, and

therefore helps to resolve infectious diarrhoea

o Note: zinc deficiency can cause diarrhoea

(Pizzorno & Murray, 2006, p. 1806)



3. Microbiome support

-Probiotics

o Evidence supports their use in antibiotic associated

diarrhoea, travelers diarrhoea, bacterial overgrowth and

pediatric diarrhoea. May also have a role in prevention of

future episodes

o Lactobacillus rhamnosus GG, Saccromyces boulardii, L.

bifidus and Streptococcus thermophilus are all known to

be effective (Pham M 2008)

(Pizzorno & Murray, 2006; Mahan, Escott-Stump &

Raymond, 2012)



4. Mucous membrane support and repair

Glutamine

o Improves energy metabolism and stimulates

regeneration

o Prevents mucosal damage & prevents bacterial leakage

o Animal studies have demonstrated improved water and

electrolyte absorption

o Use in children significantly reduced the duration of

diarrhoea




5. Dietary interventions

BRAT diet (Banana, Rice (white), Apple & Toast (white) or

Tea)

o Proposed by some to be very useful, and evidence

supports bananas and rice

o A modified version would be better as this diet is low in

protein, fat and nutrients

(Pizzorno & Murray, 2006; Durro & Duggan, 2007)



-Oral Rehydration Therapy

o WHO recommends this as the first line of therapy.

Especially important in infants, children & the elderly or

anyone with vomiting and diarrhoea over 24 hours

WHO 2006

http://www.who.int/maternal_child_adolescent/documents/fch_cah_06_1/

en/

http://www.who.int/maternal_child_adolescent/documents/fch_cah_06_1/en/



o Starchy carbohydrates & small amounts of fruit and

vegetables can be introduced next

o Lipids should be considered in the next stage, but

ensure digestive mechanisms for fat still functional

(Kumar & Clark, 2005; Mahan et al.2008)



o As the acute phase resolves, a low residue diet is

introduced (avoid maldigestion, foods that stimulate fluid

secretion or increase rate of GI transit).

o All sugars may need to be limited as they may worsen

osmotic diarrhea

o Low residue diet/Low fibre diet, available Medline Plus

http://www.nlm.nih.gov/medlineplus/ency/patientinstructi

ons/000200.htm

(Mahan et al. 2008)

http://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000200.htm


Parasite Associated DiarrhoeaNutrient Dosage Therapeutic Actions

Bifidobacterium

bifidus

L. Rhamnosus

10-40

Billion

org/day

Recolonize bacteria. Anaerobic pleomorphic rods (club

shaped organisms) that have the role in breaking down

dietary CH2O & interact directly with the host metabolism.

Glucosamine 600-

3000mg

Precursor to the ground substance/gap junctions for

epithelial cells

Soluble fibre 1tsp/bd Mucosal support/repair, Bulking agent. Mucopolysaccharide

Glutamine or

glutamic acid

500-

3000mg

Tissue repair, Restores gut wall integrity & normal intestinal

flora colonization (great with probiotics & zinc); substrate for

HCl production

Bromelain

pineapple

150-

400mg

Anti-inflammatory, Proteolytic enzyme, COX – 2

(Pizzorno & Murray, 2006)



Drug Action Side Effects Interaction

Antibiotics:

Quinolones

Bactericidal

(reduces

replication &

repair of bacterial

DNA).

Neurological is

most common:

Dizziness,

drowsiness,

restlessness.GIT symptoms, diarrhoea.Allergic responses: Photosensitivity, hypersensitivity, rash

B vitamins & Probiotic

interactions

Quercetin: may reduce drug

effectiveness (compete for

binding sites)

Calcium, Iron, Magnesium &

Zinc: reduced drug absorption.

Separate by 2 hours before & 4

hours after

Caffeine: May alter drug

metabolism

(Bullock & Manias, 2007; Braun & Cohen, 2010)



Drug Action Side effects Interactions

Antibiotics:

Macrolides

Bacteriostatic (inhibit bacterial RNA synthesis)Used for respiratory tract infections,. Including mycoplasma

CYP450 metabolism

GIT symptoms,

lethargy, dizziness,

headaches,

hypersensitivity

reaction (rash),

thrush (oral / vaginal)

B vitamins: concurrent

usage can reduce

absorption & bioavailability.

Vitamin B1 & B12 have

reduces bacterial

metabolism.

Probiotics: reduce drug

side effects

Nitroimidazole:

Metronidazole,

Tinidazole

Alters anaerobic

protozoan &

bacterial DNA

replication

Dark brown urine.

Dizziness, vertigo,

numb fingers & toes.

Confusion,

hallucination,

depression.

B vitamin & Probiotic

interactions

Avoid concurrent alcohol

consumption s it can cause

violent vomiting

(Bullock & manias, 2007; Braun & Cohen, 2010)




Anthelmintics:

Benzimadazole,

Albendazole

Not absorbed. Action in

GIT causing starvation,

immobilization & death of

helminths. Hookworm,

roundworm, whipworm &

some tapeworms.

Tapeworm cysts in the

liver can be treated with

Albendazole

Benzimadazole is not

systemically absorbed

so reduced side effects

(headache, dizziness,

abdominal cramps).

Albendazole can

increase liver enzymes

& is highly teratogenic

None listed

(Bullock & Manias, 2007)




Anthelmintics:

Pyrantel

Not systemically

absorbed. This drug

paralyses the worms

allowing for the

dislodgement and

excretion of the

parasites.

Poorly absorbed so

has reduced side

effects. These include

diarrhoea, vomiting,

cramping in the GIT,

nausea, drowsiness.

Avoid in individuals

that are dehydrated or

malnourished.

None listed

(Bullock & Manias, 2007)


Candidiasis


Candidiasis

o Candida albicans is one of 70 different species of

Candida yeast that resides in the mouth, throat, intestine

and genital/urinary tract of all humans.

o Candidiasis is excessive proliferation in the mouth,

oesophagus, intestines or vagina.

o Systemic candidiasis involves the over-proliferation of

Candida albicans throughout the body.

o In unchecked overgrowth, the yeast-fungal form converts

to a mycelial-fungal form that is able to break down the

protective barriers between the intestines and the blood.



Candidiasis

Contributing Factors:

o Medications: antibiotics, OCP & steroids

o Diet high in refined sugar, high GI foods, milk & dairy

products, yeast containing foods - Candida albicans

proliferates by consuming and fermenting simple sugars.

o Underlying food sensitivities

o Decreased digestive secretions & impaired liver function

o Impaired immunity

o Type 1 Diabetes

o Stress: compromises immune system by creating the

breakdown of protective host factors



Candidiasis

Signs & Symptoms:

o Candida albicans produces acetaldehyde from sugar

metabolism. This can produce neurotoxic symptoms;

• fatigue & malaise

• immune system malfunction, allergies & chemical

sensitivity

• depression, irritability, poor concentration

o Digestive disturbances present including bloating,

cramps, altered bowel motions, halitosis

o Thrush; both oral and genital

(Kumar & Clark, 2009; Pizzorno & Murray, 2006)


CandidiasisNutritional Treatment

o Eliminate added sugars

o Nutritional anti-fungal foods i.e. garlic

o Identify and eliminate intolerant foods

o Support HCl production

o Support gut immunity and mucosal repair

o Liver detoxification and facilitate complete bowel elimination

o Support lifestyle and reduce psychological stress

o Daily physical activity to support normal immune and metabolic

function

o Check sexual practices – cross infection in susceptible individuals


CandidiasisTreatment Plan

1. Support proper digestive function.

E.g. Betaine hydrochloride (with protein rich meal)

o Gastric HCl, pancreatic enzymes and bile all inhibit the

growth of C. albicans

o Apple Cider vinegar

o Antioxidants

2. Encourage healthy immune function

o Improve immune response; support membranes.

o Conjugated linolenic acid, vitamin A, vitamin E, zinc are

all required by T cells



Candidiasis

Nutritional Treatment

3. Liver Support

o Poor liver function is a risk factor for C. albicans

overgrowth

o Damage to the liver is linked to immune suppression

o Choline, betaine and methionine should be used to

improve liver functions such as bile synthesis, fat

metabolism and detoxification

o Maintain adequate bowel elimination


CandidiasisTherapeutic Actions

4. Microbiome status

Probiotics & Prebiotics

o Saccharomyces boulardii reduces adhesion of C.

albicans to human intestinal cells (Murzyn et al, 2010)

o Lactobacillus rhamnosus for reducing C. albicans

adhesions to cervical and vaginal cells (Coudeyras et al,

2008)

o Oral candidiasis demonstrated reduced prevalence with

Lactobacillus spp and Propionibacterium freudenreichii

treatment (Hatakka et al, 2007)

o Prebiotics are also indicated to improve elimination and

provide a fuel source for beneficial bacteria



Candidiasis

Therapeutic Actions

Caprylic acid

o Has demonstrated anti-fungal actions on C. albicans

Garlic

o The allicin in garlic shows significant antifungal activity

Propolis

o Has several useful properties indicating its use:

antifungal, immune enhancing, improve effectiveness of

antifungal drugs

(Pizzorno & Murray, 2006, pp. 579-580)


Candidiasis – Nutrient GuideNutrient Dosage Therapeutic Actions

Betaine HCl 100-400mg / Meal Raises stomach acid

Probiotics 10 -40 billion/org

day

Modulate immune system reactivity. Competitively

inhibit candida albicans. Provide SCFA

Sacchromyces

boulardii

200-750mg S. boulardii mediates responses resembling the

protective effects of the normal healthy gut flora

(Kelesidis T, Pothoulakis C 2012).

N-acetyl

Glucosamine

600-3000mg Synthesis of mucopolysaccharides,

glycosaminoglycan's & collagen (strength &

resilience of connective tissue).

Zinc 10-100mg Collagen & protein synthesis cofactor, Immune

function (T Lymphocytes CD4 Cells, NK T-Cells, IL-

2, SOD an Metallothionin), wound healing.

Enhances cell-mediated immunity. Anti-oxidant

effect




Vitamin A 1000-5000iu Stability of cell membranes, Mucopolysaccharide synthesis.

Anti-oxidant effect Immune support

Vitamin C 500-

5,000mg

Increases lymphocyte production (neutrophils,

lymphocytes, NK cells), antibodies (IgA, IgG, IgM). Adrenal

support

Chromium 100-300mcg Supports carbohydrate, lipid & protein metabolism. Nucleic

acid synthesis and gene expression



Candidiasis

Drug Action Side Effects Interaction

Azole antifungal

Miconazole,

Viriconazole,

Fluconazole

Fungistatic that blocks

the production of fungal

cell membranes &

increase the

intracellular hydrogen

peroxide levels via

enzyme inhibition

Gastro-intestinal

disturbances including

nausea, abdominal

pain, diarrhoea when

taken orally.

Fluconazole has been

found to have the

potential added effects

of skin rash and

reversible hepatic

damage.

None listed

(Bryant & Knight, 2007)


Epstein Barr Virus and

Cytomegalovirus


EPV and CMV

o Epstein–Barr virus and cytomegalovirus are members of

the human herpesviruses that have an extremely high

sero prevalence in all populations studied.

o The initial infection is usually asymptomatic, or causes a

febrile illness, but can rarely manifest itself

neurologically.

o These viruses are increasingly important in the modern

era of immunosuppression, whether due to AIDS or in

the transplant or cancer chemotherapy population, and

their reactivation gives rise to a wide spectrum of

neurological diseases (Tselis, 2013).


o A febrile pharyngitis with cervical lymphadenopathy was

described late in the 19th century.

o Due to the very high peripheral mononuclear cell counts

was defined in 1920 by Sprunt and Evans and called

“infectious mononucleosis”

o Primary EBV infection is often asymptomatic, especially

in children. In young adults, the infection causes a febrile

pharyngitis with prominent cervical lymphadenopathy

and significant fatigue and malaise.

o Recovery is usually complete within a few weeks,

although cases lasting several months have been

reported (Tselis, 2013).

Epstein Barr Virus


Epstein Barr Virus

o Mimics of EBV IM include primary CMV disease, human

herpes virus 6 disease (HHV6), acute retroviral

syndrome, secondary disseminated syphilis, and acute

toxoplasmosis.

o Other manifestations of EBV IM include severe tonsillitis,

splenomegaly, hepatitis, myocarditis, pneumonitis,

interstitial nephritis, and haemolytic anaemia.

o These are uncommon, but point to the diversity of clinical

manifestations of acute EBV infection (Tselis, 2013).


Cytomegalovirus

o Initial infection is usually asymptomatic or results in a

self-limited mononucleosis like syndrome with fever,

malaise, and sweats.

o Signs of hepatitis are noted in about a third of the

patients and there is less pharyngitis and only minimal

cervical adenopathy.

o The heterophile antibody test is always negative and

helps to differentiate CMV-associated IM (CMV IM) from

EBV IM (Tselis, 2013).


Investigations

o The Mono spot test detects heterophile antibodies.

"Heterophile" antibodies are antibodies that react with

the cells of other species of animals.

o A full blood count (FBC) is used to determine whether

the number of WBCs is elevated and the presence of

atypical WBCs.

o If initially negative and still suspected may test again a

week or so later.

o People with –ve mono tests and non reactive

lymphocytes may be infected by CMV or toxoplasmosis.

o CMV tests involve CMV IgM and IgG

EBV and CMV


Therapeutic aims based on improving immune function

and restoring health.


Vitamin C 500-

5,000mg

Anti-inflammatory, antioxidant, connective tissue synthesis

& maintenance

Zinc 10-100mg Involved in the enzymatic control of anti-oxidant system,

wound healing, white blood cell control and is anti-viral

Garlic 2-25gm Antiviral activity (Daka, 2009)

Glutamine 1-5gm GIT support, mucous membrane trophorestorative,

improves gut immunity and IgA levels (Osiecki 7thed,p.91)

Vitamin E 100-1000iu Anti-inflammatory, Anti-oxidant, enhances T helper cell

synthesis, stabilizes cell membranes

Reishi

mushroom

6 to 12 g Extracts possess both immune-stimulating and antiviral

properties (Lindequist et al. 2005; Maheshwari et al, 2012)



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