Case Study: Sore Throat, Intermittent Achiness, Heartburn, Insomnia

(This is a sample entry from the SAFM Q&A Treasure Chest, a tool with hundreds of entries to support students with their client needs. Students get unlimited access as part of SAFM’s functional medicine training program.)

Student Question:  

I would appreciate your comments about this case. A 52 yr old male, happily married with grown children living outside the home. He likes his job very well. Has a 12 year old dog but just got a new puppy in April- hence the timing of the sore throat????
Main health concern is: After being healthy and feeling great for years … last year 2013 …had aches from January to May. After several months of feeling fine now has had a sore throat since April 2014 only on his right side and only when he yawns. some aches again recently but attributes that to a cold or something. Would like to lose 20 lbs. He felt his best in 2011.
RBC lab work is normal per doctor – I am waiting for an WBC and RBC and MCV level
negative for lyme disease – His doctor thought maybe he would need to see an infectious disease doctor even labs were normal but aches went away.

• CRP normal,
• Homocysteine though was 11.7.
• Lipid panel showed LDL was 148
• B12 636
• Vit D 40
• HA1c 5.3
• TSH 1.79
• CMP normal
• Colonoscopy normal.

Consult/scope with an ENT early summer showed nothing, he ruled out cancer and feels as if its probably a classic sign of acid reflux and was put on a regimen of Pepcid prior to bed. It seemed to do the trick but now sore throat is back.
Just went off all supplements to see if there was a correlation, which there may be. Sore throat has lessened to a degree

For s/s questionnaire

• Headache 1
• Insomnia 4
• Stuffy nose1,sinus prob 3, excessive mucus 4
• Need to clear throat 3, sore throat 3
• Acne 1
• Passing gas, heartburn 3
• Restless leg 1
• binge eating, excessive weight, compulsive eating 4, craving certain foods 1
• fatigue 3
• poor concentration, focus 3
• mood swings, anger 1
• frequent illness 4
• low libido 4

He has attempted to go off gluten and dairy but never cold turkey, just can’t do it – really limited it a lot!  He sleeps very poorly, especially when he restricts calories. He says he loves a bowl of cereal at night after dinner as well, and when he doesn’t have that, he says he sleeps awfully.  He can fall asleep but wakes up and has a hard time getting back to sleep. He has tried Neuro-Mag and feels as if it may help.  Tried some 5- HTP but to no avail.

I believe there to be a huge dairy, gluten connection, adrenal stress/hormone impairment and methylation concerns with the insomnia- not having the cofactors to make melatonin? Besides the reflux, no constipation etc.

Thank you already for your insight!  LOVE your courses.

SAFM Answer:  

Great case summary!  Indeed, acid reflux is likely a major contributor to his sore throat. This is likely secondary to insufficient magnesium, food sensitivities, and imbalanced adrenal function. I am also suspicious of suboptimal stomach acid and perhaps an intermittent (simmering) H Pylori infection. Good sleuthing!

It makes sense to me to rule out the more straightforward possibilities first and then, if he finds no or only limited relief, proceed to testing to investigate other causes. Specifically, I would address the following three items first:

1. Boost magnesium. Symptoms such as acid reflux, headache, insomnia, achiness, and restless leg can all have insufficient magnesium as a root cause. I would encourage your client to have his RBC Magnesium checked to ensure it is (ideally) in the upper third of the reference range. If testing isn’t available quickly, I would recommend a trial of ~300mg magnesium glycinate twice daily with food.  I have written about magnesium many times. 
2. Address likely food sensitivities. As you know, a food elimination must be 100% cold-turkey in order to yield valid results, so I would encourage him to give this a full one-month elimination with a structured reintroduction of only one food at a time. I agree that both gluten and dairy are likely culprits, especially the dairy given the sinus congestion, mucus, and post nasal drip symptoms. Low adrenal function can set the stage for the development of food sensitivities, as the immune system becomes more hyper-reactive.  A very detailed post about food sensitivities is here.
3. Support methylation. As you well said, the slightly elevated homocysteine is indicative of at least some minor methylation impairment. And methylation is required to convert serotonin into melatonin for continuous sound sleep throughout the night. I would encourage him to try again the 5-HTP trial but to choose a supplement that includes the activated (“P5P”) form of Vitamin B6 and to be sure he takes enough (100-200mg depending on body size). If this boost doesn’t help, then I think it’s likely that imbalanced adrenals are causing low blood sugar in the middle of the night. The resulting epinephrine surge can easily awaken someone and make return to sleep difficult. The cereal he savors is likely helping both to increase blood sugar and also serotonin just prior to sleep.
4. Assist throat healing. Slippery elm drops used 2-3x/day will help to heal the sensitive mucosal lining of the esophagus (I often recommend Thayer’s brand).

Given the intermittent nature of the sore throat, I think it’s possible that H Pylori or other microbial dysbiosis in the GI tract is causing the acid reflux, along with the fatigue, achiness, and insomnia (both directly and via adrenal fatigue). H Pylori infection can cause insufficient stomach acid (hypochlorhydria) which increases the likelihood of other microbial imbalances and also immune system reactions to food. Low stomach acid would also impair his protein digestion, making it a challenge to provide readily all the amino acids needed to make neurotransmitters (e.g. serotonin for craving control and sleep, dopamine for focus and motivation). A comprehensive stool test (choose to add the optional H Pylori assay or else have this tested in other ways) would perhaps be prudent to rule out other more persistent causes beyond the initial points above.  I highly recommend the GI Effects Comprehensive test which can be ordered online at resources such as www.MyMedLab.com or via a functional medicine physician.  Testing (vs. guessing!) is ideal, but even in the absence of testing, you can still do a low stomach acid challenge (note this topic is covered in-depth in the Disease Begins in the Gut 101 course).

A four-sample salivary adrenal hormone test will help to identify specific cortisol imbalances and how they can best be supported.  I currently use Labrix tests which are conveniently available online at Amazon.  (Adrenal function and this testing is covered in-depth in the Adrenal-Thyroid Balance and Dysfunction and the HPATG Axis course).

As you know, homocysteine is an amino acid that can build up in the body and be an independent risk factor for cardiovascular disease (I have written about this before).  Given the elevated homocysteine, I would recommend to him an MTHFR genetic SNP test in order to resolve whether long-term supplementation with a methylation-targeted B-complex is merited to allow optimal health.  These are also available online or via most functional/integrative physicians. (Methylation is covered in SAFM’s Anchoring Essentials couses.)

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