The diagnosis & effective treatment of candida overgrowth

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Source: Townsend Letter for Doctors and Patients

The diagnosis and effective treatment of candida overgrowth

by Alan Broughton

Editor:

The candida genus is a dimorphic fungus that can exist as a yeast or

in mycelial form. There are many species of candida but the main

species affecting humans is candida albicans. Other species rarely

affect humans but include, tropicalis, parapilosis, and krusei.

This fungus is normally a saprophyte but can become a pathogen

causing the following problems: Superficial Candidiasis,

Mucocutaneous Candidiasis, Systemic Candidiasis, Candida Overgrowth.

Superficial Candidiasis

This is a superficial infection that usually involves areas of the

skin and mucous membranes such as the axilla, toes, and fingers

(including the nail bed), the groin, mouth, and vagina. The

diagnosis is made by clinical examination and a swab with direct

microscopy identifying the yeast form. There is also an elevation of

IgM and IgA to candida when performed by a sensitive test such as an

ELISA procedure.

Mucocutaneous Candidiasis

This is a serious condition and is mainly associated with a genetic

defect of T cell function. The diagnosis is made by lymphocyte

stimulation using PHA, Con A, Candida Albicans, Tetanus Toxoid, and

Diphtheria. A specific defect against the stimulation by Candida

Albicans is demonstrated (failure of the lymphocytes to respond to

the simulation of Candida Albicans).

Systemic Candidiasis

Systemic invasion by the candida yeast is a very serious condition

and occurs in patients with profound immunodeficiency. This

immunodeficiency is usually secondary to AIDS, chemotherapy for

malignant disease and terminal leukemia. These patients can have

lesions in the lungs, liver, kidney, and brain. The diagnosis is

usually made by history, the demonstration of lesions and the

appearance of circulating candida antigen.

Candida Overgrowth

Candida intestinal overgrowth was first described by Brabander and

associates (1) in 1957 and has remained a controversial subject.

They described symptoms of bloating, itching and skin rashes in

their patients, symptoms that were further added to by Truss (2,3)

and Crook. (4) The syndrome has been misnamed systemic candidiasis,

and candida overload syndrome. It has been implicated in a variety

of ailments from chronic fatigue to immune deficiency. The diagnosis

of this syndrome has always been difficult to confirm.

Questionnaires have been devised, and stool testing has met with

limited success. (6) Serum antibody tests either measuring total

antibody production or very sensitive procedures to detect the

isotypes IgG, IgM and IgA, have also met with limited success when

compared to clinical symptoms, (4,5) thus fueling the controversy

about the very existence of the syndrome. What is needed is an

objective and sensitive marker for candida overgrowth.

Candida Immune Complexes

An objective and highly specific and sensitive marker of candida

overgrowth

In 1987, Dr. Alan Broughton developed a unique assay to measure

candida specific IgG immune complexes. Candida immune complexes

consist of antigen (candida albicans) bound to IgG antibodies

specific to candida albicans and fragments of complement and are an

indication that there is active removal of candida antigen. Candida

Immune Complexes are also present in direct proportion to the

candida antigen load and levels decrease quickly when the candida

load is reduced. Candida Immune Complexes have been reported to be

an objective, highly specific, and sensitive marker for candida

overgrowth. (6,18)

In his studies, Dr. Stuart Lanson has reported that candida immune

complexes performed by AAL Reference Laboratories, Inc. are an

effective and objective marker for Candida Overgrowth. (6) His study

found that 80% of patients with elevated candida immune complex

levels respond to antifungal treatment with the candida immune

complex level returning to normal when the patient reported

improvement. The average length of treatment for patients with post

treatment normal immune complexes was 154 days. The average symptom

score from pre and post treatment questionnaires were as follows;

pre treatment 6.6 and post treatment 1.8 which is a highly

significant reduction (p=<0.001, Student t test). This demonstrates

that 80% of patients who presented with candida overgrowth symptoms

and had elevated candida immune complexes were cured after treatment

with an antifungal regime.

The 20% of patients whose immune complexes remained positive after

nine months of treatment showed no reduction in their symptom score.

These patients were diagnosed with chronic unresponsive candida

overgrowth.

Chronic Unresponsive Candida Overgrowth

These chronic unresponsive patients were further studied and

reported in a recent paper by Drs. Lanson and Broughton. (7) Chronic

unresponsive candida overgrowth patients were compared to patients

known to have elevated candida immune complexes but not under

treatment, and a group of apparently healthy volunteers who were

selected as controls.

The following tests were performed on all three groups: Candida

Immune Complexes, IgA and IgG antibodies to casein and gliadin and

Total Phagocytic Index and Ingestion Index.

This study found that chronic unresponsive candida overgrowth

patients had the following:

* Significantly higher candida immune complex levels than the other

groups.

* Increased intestinal permeability as shown by the presence of

antibodies to casein or gliadin (IgA antibodies suggesting current

permeability and IgG suggesting past permeability). (8-12)

* A decrease of leucocyte phagocytosis both adhesion (Total

Phagocytosis Index) and ingestment of particles (Ingestion Index).

This study also demonstrated that there is an inverse relationship

between the candida immune complex level and the total phagocytosis

index. But the ingestion index was independent of the candida immune

complex level. This demonstrates that the presence of chronic

candida overgrowth is associated with difficulty in the first phase

of phagocytosis (adhesion of particles prior to ingestion).

Increased Intestinal Permeability

Increased permeability will allow the passage through the bowel of

metabolites usually prevented by an intact bowel. These metabolites

include the casomorphines and gliadomorphines from casein and

gliadin respectively. These metabolites have been reported in the

urine and serum of other conditions of increased intestinal

permeability such as regional ileitis, (11) and may account for some

of the symptoms associated with chronic unresponsive candida

overgrowth. These patients develop intestinal permeability because

of the progressive colonization of the gut wall by the candida that

results in damage to the protein barrier in the lumen of the bowel.

The appearance of symptoms related to delayed food allergy may also

be related to increased intestinal permeability which allows foods

across a normally intact membrane.

Removal of particularly gliadin and casein from the diet will

produce temporary relief of some of the symptoms. After three months

gliadin and casein should be reintroduced and the Intestinal

Permeability Evaluation #2330 repeated one month after the

reintroduction of casein and gliadin. If the IgA antibodies have

disappeared then the intestinal permeability has been cured. But if

they still have IgA antibodies then the patient should return to the

casein and gliadin free diet. At this point gluten sensitivity

should be excluded by testing for endomysial and reticulin

antibodies (test #369 & 370). If the endomysial and reticulin

antibodies are positive, the patient must stay on the gliadin free

diet for the rest of their life. If these antibodies are negative

then the patient has a bowel with active intestinal permeability

which may take months to heal.

Leucocyte Phagocytic Function

Similar defects in phagocytosis to those described in Drs. Lanson

and Broughton's study (7) have been seen in other intestinal

diseases such as ulcerative colitis and Crohn's disease. (3-15)

These defects in phagocytosis prevent the normal destruction of the

yeast (16) by the leucocytes, and despite frequent changes in

antifungal therapy the patients only have transient improvement at

best. Therefore it is important to understand why these patients

have a failure of phagocytosis. As discussed by Drs. Lanson and

Broughton, (7) the recurrent oxidative bursts produced by

polymorphonuclear cells during repeated attempts to phagocytose the

yeasts generates free radicals which progressively damage the

polymorphonuclear cells.

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Treatment with antioxidants, such as vitamin E, (d alpha

tocopherol), vitamin C, and beta carotene may help to restore the

phagocytosis activity. The amino acid taurine may also be helpful

because it is not only a free radical scavenger in the white cells,

but also may act as a detoxifer of xenobiotics in the liver.

Suggested Protocol

The patient who presents with symptoms of candida overgrowth should

have the candida immune complexes (#323) performed. If this test is

normal then the patient does not have candida albicans overgrowth

but a different problem such as overgrowth due to some other species

of candida (unusual but occurs in approximately 1% of patients), or

a problem unrelated to candida.

If the test for candida immune complexes is positive, the patient

should be treated with an antifungal regime and diet modification

for at least three months and then have the candida immune complexes

(#323) repeated. If the candida immune complex level has fallen and

their symptoms have improved, the patient has been cured (80% of

patients with increased candida immune complexes responded to

antifungal treatment).

If the candida immune complexes are still increased and their

symptoms are still present, the patient has Chronic Unresponsive

Candida Overgrowth and should be evaluated accordingly. The

Intestinal Permeability Evaluation #2330 should be performed as well

as assessing for additional factors such as chemical exposure,

chronic fatigue, and viral diseases.

If the candida immune complexes are normal and the patient still has

symptoms, the candida overgrowth has been eliminated, but some other

problem is causing the persistent symptoms such as intestinal

permeability, chronic fatigue or chemical exposure.