There are multiple forms of urticaria and many different driving forces behind these itchy, uncomfortable skin welts. The causes can range from physical contact to a reaction to a medication. One of the lesser-known forms is called chronic spontaneous urticaria (CSU), and its causes are still hotly debated. However, intestinal parasitism is well-linked to CSU occurrence.

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CC: Chronic Spontaneous Urticaria; Diarrhea and urgency after eating; Asthma

Conner was 12 years old when he initially presented to my office with complaints of spontaneous urticaria. It would last anywhere from 2-40 days in the previous six months. After a deeper investigation into his digestive history, the patient was also suffering from diarrhea regularly and having up to 4 bowel movements daily as well as bowel urgency following large, heavy meals. The patient was dealing with low energy and trouble gaining weight over the last year, pushing him to the 10th percentile of his ideal body weight for his height and age.

Additional History

Conner was an active kid participating in sports daily and had a balanced diet overall, with his mom commenting in the office that "he ate for two, but it ran right through him." He frequently went to bed between 8-9 pm because he was so tired, but he didn't feel any fatigue during the day.

For the last four months, Conner and his family have been investigating the causes of his ongoing urticaria issue. They saw an allergist who performed a skin allergy test, and the results indicated a low-level positive allergy to dog and cat dander. They put an air purifier in their house but had no pets then, so there was no direct connection.

Initial Lab Work

Comprehensive Stool Test Results:

• Pancreatin Low
• Fecal Secretory IgA High
• Eosinophil Protein X Moderately Elevated
• Commensal Microflora Low
• Blastocystis spp., Dientamoeba fragilis both seen on direct microscopy as well as PCR

Lab Analysis

Conner's lab work points to three core issues that are contributing to his CSU and digestive imbalance:

1. The stool panel indicates a high level of dysbiotic imbalance consisting of low commensal bacteria and high parasitic overgrowth of multiple strains. This is contributing to his high level of inflammation noted with the elevated secretory IgA and high level of immune system response seen with the elevated eosinophil protein. This, paired with his multiple high levels of food sensitivities, could be linked to high IgE-mediated urticaria formation.
2. The low pancreatin contributes to his bowel urgency after meals and prevents optimal food digestion and absorption, contributing to his poor weight gain and symptoms of fatigue.
3. His Blastocystis spp parasitic strain is a known overgrowth that can drive chronic spontaneous urticaria.

All additional labs were normal, ruling out other factors contributing to his nighttime fatigue: thyroid, vitamin D, B12, folate, iron panel, and blood glucose were within normal ranges.

Interventions

The first month consisted of gut healing and diet changes. We began eliminating all the foods on his food intolerance panel, concurrently putting him and his family on a paleo diet with a 30-day elimination of citrus. Organic produce and meats were recommended to limit toxin exposure. Daily bone broth as a soup base, mixed into smoothies or sipped on to support gut healing, and one serving of fermented foods daily to support microbiota growth.

Daily protein shakes with additional gut lining support:

• Collagen powder to support gut lining and provide easy-to-absorb amino acids
• Powdered serum-derived colostrum to bind parasitic toxins and support stressed secretory IgA immune response
• Acacia powder to provide prebiotic support to drive up ideal commensal bacteria species

For mast cell stabilization to prevent and reduce the severity of urticaria, a supplement was recommended that was a combination of vitamin C, quercetin, bromelain, NAC, and stinging nettle leaf.  

Mindful eating techniques were reviewed with the patient for pancreatic support: calm, seated meals with ample chewing of each bite, avoiding stress around/during meals, limiting liquid intake around meals, avoiding overeating, and focusing on complete meals all day.

After 1-month, the patient was instructed to begin his parasitic protocol:  

• Broad Spectrum antimicrobial liquid: wormwood, black walnut, milk thistle, echinacea, shiitake, goldenseal, and garlic bulb, to name a few. 6 weeks total on a high dose of 14 drops daily in divided doses.
• High-dose olive leaf extract for additional anti-parasitic effects
• Broad spectrum toxin binder for parasitic die-off endotoxin release containing activated charcoal, zeolite, apple pectin, and humic acid.
• To ensure the parasitic overgrowth was resolved, Conner was instructed to pulse supplement load for an additional six months. This entails resuming the high dose of the supplemental regimen above for three days before and after the full moon when parasitic egg production and maturation tend to occur at higher rates.

Follow-Up 1.5 Month Later:

Conner was doing well at his first follow-up. He has had only three incidences of hives lasting more than 24 hours, but the severity was significantly less. The longest duration was five days and occurred nine days into using the antimicrobial drops and protocol recommended. He was feeling really good on the diet. His dietary compliance improved after finding a balance after the first three weeks. He had more formed bowel movements but still had urgency after large meals and three daily bowel movements. He was still dealing with his nighttime fatigue as well.

Follow-Up 4 Months Later:

At the 4-month follow-up, the patient was doing remarkably better. He had gained 6 pounds since our initial visit and could stay awake till 10 pm nightly without issue. He also noticed a significant increase in energy during the day. He had not had a single incidence of CSU since his first two weeks on the antimicrobial drops and was following all supplemental recommendations as instructed.

His bowel urgency following meals had finally resolved, and he was having 1-2 bowel movements a day. They were well formed and normal formation (bristol stool chart 4 indicated). His stool panel was also repeated at this time due to his marked symptom improvement.

Comprehensive Stool Test Results:

• Pancreatin Low normal
• Fecal Secretory IgA high normal
• Eosinophil Protein X Within normal limits  
• Commensal Microflora: much improved
• Blastocystis spp., Dientamoeba fragilis Negative

Food Sensitivity Panel:

• 3+ none
• 2+: wheat/gluten
• 1+: soy, dairy

Following the stool panel results, the patient was instructed to begin a high dose probiotic consisting of a combination of 100 CFU strains while continuing the protein shakes with gut lining support originally recommended to continue driving down high normal fecal secretory IgA. Conner had no digestive symptoms then, so continued mindful eating was recommended over introducing digestive enzymes to help support ongoing pancreatic enzyme restoration.

Parasites have a notorious life cycle that can result in long hibernating eggs and sporadic reinfection downstream. The patient was instructed to continue the pulse antimicrobial dosing for two more months to ensure the parasitic strain was eradicated. He was also encouraged to bring citrus back into his diet and raw or fermented organic dairy once every ten days to assess for a reaction. Gluten and soy were still avoided due to family preferences.

Summary

Conner was in a unique position as the duration of his parasitic overgrowth was largely unknown. He had been dealing with loose stool and urgency most of his life. Being from a lean family, his primary care physician never was concerned about his low BMI, and he expressed no other overt symptoms of parasitic overgrowth. The connection between his chronic spontaneous urticaria (CSU) and the parasitic overgrowth was reliant on functional stool testing, which detected the full extent of its growth and its effect on the microbiome, gut lining, and overall immune system response. Conner is an excellent example of the deep connection between gastrointestinal health and its wide-spreading effects when imbalanced.