Basho Case – Hanna Notes
I think you are on the right track for sure with suggesting there is a likely link between
her allergic reaction to antibiotics and there is a possible link between a damaged gut
biome and food reactivity. But this case has some unusual layers.
Chief Concern summary:
~ Client is experiencing reactivity to foods and smells. Symptoms include:
hives/rashes, migraines, diarrhea, wheezing, fatigue, liver pain, jittery
feelings.
This is a really interesting case in terms of ‘pattern differentiation and pattern
recognition”. It is also a bit unusual in that it fits the profile of a condition we have not
discussed in class and that is not on most practitioner’s radar very well. It’s much more
studied in the UK, but this is the second time this week I hear a case that has a symptom
picture that fits close enough it’s worth exploring. This condition is Histamine Excess
and Histamine Sensitivity or Intolerance.
Excessive histamine (if not broken down by the body), from a variety of different
sources, will result in symptoms often indistinguishable from allergy. This is not
surprising since the early symptoms of an allergic reaction are mediated by the histamine
released during the progress of the allergic response. Histamine is a key player in the
immune system, but when the body can’t break it down (a specific enzyme deficiency) or
the body is sensitive to histamine, the histamine can become a destructive force.
Some Specific Red flags:
 All of her physical symptoms : )
 The onset of problems after an infection
 The onset of problems after an infection that was treated with antibiotics
 The onset of problems after an infection treated with antibiotics to which she had
an anaphylactic response.
 That she is reacting to many different types of foods that are difficult to
categorize.
 Her “sympathetic nervous system feels jacked up all the time.” – this is the
experience during allergy attacks as well when histamine levels are high.
 The fact that she has all of these symptoms and is worse on a paleo or high
protein diet.
o
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“Many of the bacteria that live in the human large bowel produce histidine
decarboxylase and are capable of converting the histidine in any protein that enters
the bowel into histamine. Therefore, the more microorganisms that produce
histidine decarboxylase that are present in the colon, and the greater the amount of
protein material that enters the bowel, the higher the level of histamine in the
digestive tract. From here, histamine can be conveyed through the bowel wall to
various sites in the body.”
The fact the she has these issues and is taking the below medications (which all
can reduce the effectiveness of the enzyme (diamine oxidase) that breaks down
histamine, especially in a poorly functioning liver.
Baclofen: 20mg, 3x per day
Tylenol: 325mg, 2x per week
Ativan: .5mg, 2x per month
“A person with histamine intolerance will typically experience a constant fluctuation in the signs and
symptoms of histamine excess in response to changing conditions. For example, when a person is
experiencing allergy to air-borne allergens such as seasonal pollens, the histamine released in the allergic
response alone might put them into the symptom range. In such a case, avoiding histamine-associated foods
will no longer relieve their symptoms because their total level of histamine will remain above their limit of
tolerance. This explains the observation that during their "pollen allergy season" many people find
themselves reacting to foods (usually histamine-rich foods) that they could normally eat with impunity.”
The Protocol for Histamine Intolerance is simultaneously simple and incredibly
difficult.
1. Avoid all high histamine/histidine containing foods.
2. This means anything, cured, aged, and fermented including: meats, cheeses,
wine, beer, yoghurt, many probiotics, fermented vegetables, green teas, black
teas, soy products, yeast breads.
a.
Cheese of all types, alcoholic beverages, vinegar, fermented vegetables such as sauerkraut,
fermented soy products such as soy sauce, and processed meats such as pepperoni, bologna,
salami, and frankfurters that are produced by a process of fermentation, all contain substantial
levels of histamine
3. There are long lists of foods to be avoided including many fruits and
vegetables: citrus fruits, strawberry, raspberry, tomatoes, apricot, cherry
and plums, and some vegetables, spinach, eggplant, pumpkin, avocado.
4. Cooked protein stored in the refrigerator – the longer stored, the more
histamine.
5. Ground meat is worse than cut pieces.
6. All fish and shellfish – unless just caught.
7. “Histamine-releasing” foods – chocolate and many others. – there are long
lists online.
8. A long list of food additives – avoid all processed foods (more or less)
A longer more comprehensive list is included below with references.
Pretty good excerpts of histamine intolerance from:
“http://www.foodsmatter.com/allergy_intolerance/histamine/articles/histamine_joneja.html”
Histamine is a neurotransmitter (a chemical that conveys messages between cells of the nervous system)
and is involved in the regulation of stomach (gastric) acid, the permeability of blood vessels, muscle
contraction, and brain function. Histamine appears in various concentrations in a range of mammalian
tissues. In humans, the highest histamine concentrations are found in the skin, lung, and stomach, with
smaller amounts in the brain and heart.
Histamine is also essential in defending the body against invasion by potentially disease-causing agents
such as bacteria, viruses and other foreign bodies.
Histamine is made and stored within white blood cells (leukocytes) such as mast cells in tissues and
basophils that circulate in blood. When the immune system is activated in response to foreign material
entering the body, histamine is the first "defense chemical", or more correctly, inflammatory mediator
released in the process called inflammation. Inflammation is the clinical evidence that the immune system
is responding to a potential threat to the body. Histamine is always present when inflammation occurs, and
excess histamine will result in symptoms that resemble inflammation.
In addition to its role in controlling vital body processes and defending against foreign invaders,
histamine is a key mediator in the symptoms of an allergic reaction. Since allergy is essentially an
inflammatory reaction, histamine, together with other protective inflammatory mediators is released
in response to the allergen.
Everyone has a level of histamine that they tolerate without symptoms. Exceeding that level (called a
person’s “limit of tolerance” or “tolerance threshold”) can result in symptoms. Even healthy persons
may develop severe headache, or flushing as a result of consuming massive amounts of histamine in a
meal, but if ingested at lower concentrations only a few sensitive individuals will experience an
adverse reaction. It has been speculated that the differences in the level of histamine that people can
tolerate may be of genetic origin. In addition, disease, various abnormal physiological conditions,
hormone changes, especially in women at various stages in the menstrual cycle and at menopause,
and medications, can reduce the tolerance threshold of any individual. People with a low tolerance
threshold are designated “histamine intolerant”.
What Causes an Individual to be Histamine Intolerant?
Several abnormal physiological conditions may lead to histamine intolerance, in particular a defect in the
process of histamine breakdown (called catabolism). Under normal physiological conditions excess
histamine is degraded by two enzyme systems: histamine N-methyl transferase (HMT), and in the intestine
by the mucosal enzyme diamine oxidase (DAO). Of the two systems, it is deficiency in the DAO enzyme
system that has received most attention as the probable cause of "histamine intolerance".
Under normal conditions, when histamine levels from any source rise above a certain level, these enzymes
rapidly degrade the excess. However, when the rate of breakdown of excess histamine is insufficient to deal
with the excess, the total level of histamine in the body rises. At a certain critical level, signs and symptoms
occur that are the result of histamine coupling with histamine receptors on specific cells, producing a
clinical picture that is often indistinguishable from allergy.
The etiology of excess histamine can be varied. For instance a “bad infection”, a course of antibiotics. It is
possible that an infective organism, and/or any antibiotics cause a change in the bacteria that inhabit the
large intestine. The bacteria now in the intestines may be the types that make histamine from incompletely
digested food materials that pass into the bowel. This can result in more histamine entering the body than
previously, and augmenting both the body’s natural histamine (that we require for a various functions in the
brain and digestive tract as well as processes in the immune system), and histamine in the diet. Another
reason can be “histamine intolerance”, a complex process, we are just beginning to understand.
Histamine and Eczema
In addition to the symptoms listed above, excess histamine can make some existing conditions worse.
Eczema is an example. Eczema is an inflammatory condition in the skin, sometimes called atopic (allergic)
dermatitis. When high histamine foods are consumed, people with less than efficient histamine tolerance
may experience an increase in the severity of their eczema.
Histamine and Anaphylaxis
There is some evidence to suggest that people who are prone to recurrent anaphylactic (severe allergic)
reactions may be experiencing histamine intolerance in addition to their allergies. In such situations the
histamine released in the allergic response quickly rises to a dangerously high level, leading to a situation
that may be life-threatening.
Histamine and Hormones
Histamine-intolerant women often suffer from the symptoms listed above, especially headaches and
menstrual pain, during certain phases of their menstrual cycle. Histamine levels tend to fluctuate with the
level of hormones, especially oestrogen, at ovulation and just prior to the onset of menstruation. In contrast,
many women with both allergies and histamine intolerance find significant relief of their symptoms during
pregnancy; this is because the placenta makes a great deal of DAO, the enzyme that breaks down
histamine. The result is that the level of histamine no longer exceeds the woman’s tolerance threshold, and
she remains blissfully free from her symptoms throughout her pregnancy. Unfortunately, the symptoms
tend to recur once the DAO from the placenta is no longer available after the birth of her child.
Histamine and Medications
Some medications can release histamine; others can reduce the effectiveness of the enzyme (diamine
oxidase) that breaks down histamine. As a result, the level of histamine rises and may cause symptoms,
even in a person who has shown no signs of histamine intolerance in the past. Common pain killers such as
aspirin, non-steroidal anti-inflammatory drugs (NSAIDs), some diuretics (“water pills”), antibiotics, and
antidepressants are among the medications that can affect the functioning of DAO. A list of medications
that either release histamine, or decrease the effectiveness of DAO can be found in Reference 6.
The Histamine Restricted Diet
DO NOT EAT THE FOLLOWING FOODS
Meat, Poultry, Fish
Fish and shellfish whether fresh, frozen, smoked, or canned, if processing is unknown

If the fish is freshly caught, gutted and cooked within ½ hour, it may be eaten

a small quantity of cooked egg in a baked product such as pancakes, muffins, cakes is allowed
Egg
Meat
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Processed, smoked and fermented meats such as luncheon meat, sausage, wiener, bologna, salami,
pepperoni, smoked ham, cured bacon
Avoid left-overs: freeze any uneaten protein-based food. Bacteria will quickly act on protein at
room and refrigerator temperatures, resulting in histamine production
Milk and Milk Products
All fermented milk products, including:

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Cheese: any kind of fermented cheese such as Cheddar, Cheshire, Colby, Blue cheese, Brie,
Camembert, Feta, Romano, etc.
Cheese products such as processed cheese, cheese slices, cheese spreads
Cottage cheese
Ricotta cheese
Yoghurt
Buttermilk
Kefir
Fruit
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Orange, grapefruit, lemon, lime, cherries, grapes, strawberries, apricots
Raspberries, pineapple
Cranberries, prunes
Loganberries, Dates
Raisins, currants (fresh or dried)
Vegetables
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Tomatoes, tomato sauces, ketchup, soy and soy products
Spinach, red beans
Eggplant, olives in vinegar or brine
Pumpkin, avocado
Pickles, relishes and other foods containing vinegar
Food Additives

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Tartrazine and other artificial food colours
Preservatives, especially Benzoates and Sulphites
Note: Many medications and vitamin pills contain these additives; ask your physician or chemist to
recommend additive-free supplements and medications
Seasonings
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Cinnamon, cloves, vinegar
Chilli powder, anise
Curry powder, nutmeg
Miscellaneous
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Fermented soy products (such as soy sauce, miso)
Fermented foods (such as sauerkraut)
Tea (regular or green)
Chocolate, cocoa, and cola drinks
Alcoholic beverages of all types
“Dealcoholised” beverages (e.g. beer, ale, wine, etc)
References
1. Dyer J, Warren K, Merlin S, Metcalfe DD, Kaliner M. Measurement of plasma histamine: description of
an improved method and normal values. J Allergy Clin Immunol 1982;70:82-87
2. Hershko AY, Dranitzki Z, Ulmanski R, Levi-Schaffer F, Naparstek Y. Constitutive
hyperhistaminaemia: a possible mechanism for recurrent anaphylaxis. Scand J Clin Lab Invest
2001;61:449-452
3. Jarisch R, Wantke F. Wine and headache. Int Arch Allergy Immunol 1996;110:7-12
4. Joneja, J.M.Vickerstaff Biogenic Amines Intolerance; Histamine. In: Dealing with Food Allergies: A
Practical Guide to Detecting Culprit Foods and Eating a Healthy, Enjoyable Diet Bull Publishing
Company, Boulder, Colorado. May 2003 ISBN 0-923521-64-X Pages 233-246
5. Joneja JMV and Carmona Silva C. Outcome of a histamine-restricted diet based on chart audit. Journal
of Nutritional and Environmental Medicine 2001;11(4):249-262
6. Maintz L, Novak N. Histamine and histamine intolerance. Am J Clin Nutr 2007;85:1185-1196
7. Wohrl S, Hemmer W, Focke M, Rappersberger K, Jarisch R. Histamine intolerance-like symptoms in
healthy volunteers after oral provocation with liquid histamine. Allergy and Asthma Proc 2004;25(5):305311
8. Worm M, Fiedler EM, Dolle S, Schink T, Hemmer W, Jarisch R, Zuberbier T. Exogenous histamine
aggravates eczema in a subgroup of patients with atopic dermatitis. Acta Derm Venereol 2009;89(1):52-56
Case Summary 6
Basic Bio: Age: 35 Sex: f Height: 5’7.5” Weight: 112 Body Type: Thin
Constitution: Vata, Melancholic
Tongue: Pink, reddish tip, small scallops, quivering
Pulse: steady, deep, weak, and strong in spleen/stomach point on right
wrist.
Energetic: Cold and dry constitution, with tension and laxness, and some
stuck liver chi
Comments: looks weak and worn out
Basic Med Hx (Physical, Psyche, Accidents, Surgeries, Diseases etc)
~ 2009- Klebsiella found in stool sample. Treated with Augmentin and
Flagyl. Client had allergic reaction to antibiotics (hives and anaphylaxis) and
developed autoimmune condition (chronic hives), which she battled for a
year.
~ 2010- Severe whiplash, subarachnoid hemorrhage.
~ 2010- Cone biopsy and DNC
~ 2011- Anemic, Gilberts syndrome (high billirubin). Lots of food
intolerances (which she removed from diet).
~ 2012- Rib pain from boxing, put on Baclofen for muscle spasms.
~ 2012- Lost 40 pounds over the year. Test shows high pancreatic enzyme
count. Sent to ER where did colonoscopy (test results normal).
~ 2012- Reintroduced some foods to diet and gained back 12 pounds but
liver/gallbladder hurt.
~ 2013- Foods that were previously ok now causing reactions (hives, rashes,
fatigue, diarrhea). Also becoming reactive to smells and chemicals, face
flushing (relieved by antihistamines). Feels jittery all the time.
~ 2013- Received microcurrent treatment. After treatment, migraines
worse, with numbness in head and arm, really high blood pressure spikes.
Baclofen no longer working for muscle spasms.
~ 2014- Can only eat beef and rice waffles without getting reaction. Liver
feels like a brick under the ribs. Thyroid test comes back underactive.
Sympathetic nervous system feels jacked up all the time.
Family Med history (esp if related to current presenting or secondary
concerns)
Mother: high blood pressure.
Father:
Sister:
Grandfather: cancer, diverticulitis
Grandmother: pancreatic cancer, high blood pressure
Other Practitioner Involvement:
~ Acupuncturist: Dr. Yea
Primary care: Dr. Foly
Diagnoses, Lab Results
~Whiplash
~High blood pressure
~Gilberts syndrome
~Klebsiella in GI tract
~Hypothyroid
Medications, Herb, Supplements (include dosage)
Histaminum hydrochloricum 6c: homeopathic, 2-6 pills whenever she eats
Baclofen: 20mg, 3x per day
Tylenol: 325mg, 2x per week
Ativan: .5mg, 2x per month
Magnesium: 1 pill, 1x per week
Sea Salt: .5tsp, 2x per month
Apple cider vinegar: .5tsp, 1x per month
Vitamin D: 1000 IU, 3x per month
Lifestyle:
~ Client no longer works or exercises much. She lives at home with her
mother and her sister who had a stroke a few years ago. There are always
caretakers in the house so there is little privacy. When client was feeling
better she did some gardening, but now stays inside most of the time and
doesn’t exercise at all because she feels to weak and bad most of the time.
She has few friends and no partner so she spends most of her time on her
own or occasionally with her mom. She enjoys cooking and will cook for
others sometimes though she can’t eat the food herself without reacting.
She smokes cigarettes a few times a day.
Diet:
~ Client used to eat a variety of food including microwave dinners and some
fast food before she developed intolerances and reactivity. She now only
eats ground beef burgers made from pasture raised beef and gluten free
and dairy free rice flour waffles. These are the only foods that she seems to
be able to tolerate beyond occasional small portions of white rice, chicken,
carrots, zucchini, squash, and potatoes. She also eats candied ginger on a
regular basis. She is intolerant of almost everything, but has strong
reactions to dairy and gluten as well as foods high in histamines. She eats
small helping of burgers and waffles (3 palm size hamburgers and waffles)
throughout the day adding up to 1 pound of beef per day. Her body has
trouble digesting if the servings of food are too large. She craves sweets,
breads, and baked goods but cannot eat them. If she doesn’t eat
throughout the day then she gets shaky and anxious. Foods that stimulate
bile flow cause liver pain. She has gone on paleo and gaps diets before
after she got sick. Paleo diet caused migraines, fatigue, and stomach pain
when she first started. Gaps diet caused constipation, low blood sugar, and
anger. She is constipated most of the time (bowel movement every 4-5
days), but if she eats an aggravating food then she has diarrhea. She drinks
about 1.5 liters of water per day.
Bad days include:
~ Same diet on good and bad days. Rice waffles and burger patties with
some candied ginger as a snack.
Good days include:
~ Same diet on good and bad days. Rice waffles and burger patties with
some candied ginger as a snack.
Sleep
~ Client sleeps 4-5 hours per night and then gets a few more hours during
the day. She is awake from 1-6am every night at which point she feels
awake and energized/agitated. She does not feel rested when she wakes
up and doesn’t ever catch up on her sleep. She has nightmares on a regular
basis and sleeps with the light on. She doesn’t seem to have any trouble
falling asleep when she first goes to bed around 8 or 9pm. Client is aware
of times of the night coinciding with Chinese organs and says she always is
awake for “liver time”.
Psycho-Social Review
Stress Level: high
Relationships: client has a somewhat stressful relationship with her mother
and sister and does not have a partner. She also doesn’t have many
friends.
Her outlook on life seems better now, but still poor with lots of anger and
frustration over her situation.
Intake/Interview Summary:
Chief Concern summary:
~ Client is experiencing reactivity to foods and smells. Symptoms include:
hives/rashes, migraines, diarrhea, wheezing, fatigue, liver pain, jittery
feelings.
Tx to date with outcomes:
Paleo and Gaps diets along with elimination of food intolerances.
Eliminating intolerances helped with symptoms initially, but then they
came back. Antihistamines and Alca seltzer used to make reactions better.
Secondary Concerns summary:
Tx to date with outcomes:
Assessment:
~ Client appeared a bit weak, worn out, and slightly anxious. She has been
dealing with fairly intense health problems for around four years now and
has gotten worn down. She is a fighter and used to taking care of herself
and others so being stuck in a situation where she can’t find a solution has
been hard. Her body is displaying overall tension and weakness/laxness.
There are signs of stuck liver chi including cold hands and feet, allergies,
headaches, and flushing in face. Her food intolerances and reactivity began
with her allergic reaction to antibiotics and there is a possible link between
a damaged gut biome and food reactivity. She has also had some trauma in
her life and there is a strong mental emotional component to her case. She
has had a poor relationship with her body for many years and has trouble
opening up to people due to the trauma in her past. Her liver is also
playing a role here with its pain and trouble processing food and toxins.
She experiences a lot of anger, which she associates with her liver. She is
very motivated to get well but she has thus far focused mainly on the
physical aspects of her problems and ignored the mental/emotional. When
she was in the hospital for high blood pressure (fluctuating between 160
and 200 during the afternoon of some days) she was very angry with the
doctor for suggesting that there could be a mental aspect to what she was
experiencing. She seems more willing to embrace the idea that there are
some mental factors at play now than in the past few months. Her
energetic work with her acupuncturist (he can’t use needles on her due to
her high sensitivity) has helped bring her blood pressure down and give her
some vitality back. As she has worked through moving her blood and
energy she has started to feel a bit better.
Protocol:
Herbal ~ Aloe, Ginger, Marshmallow, Milk Thistle
Food intolerances/reactivity: soothing demulcents, immunomodulators,
anti-inflammatories
Liver support: hepatoprotectives
Mild weakness (in the whole body): tonic adaptogens ?
Aloe: as an anti-inflammatory and demulcent. To heal any damage in the
digestive tract. As a mild laxative.
Ginger: as an anti-inflammatory and as a carminative for digestion. For its
anti-nausea properties and to aid with the absorption of other herbs. As a
warming circulatory stimulant.
Marshmallow: as an anti-inflammatory and demulcent. To heal any
damage in the digestive tract.
Milk Thistle: as a hepatoprotective and for its ability to heal damage to the
liver.
Formulas
Tea:
Marshmallow 50%
Ginger 30%
Milk thistle 20%
1 tsp of blend per 8 oz of boiling water.
Take Aloe as a liquid gel mixed with some water.
1-2 oz per day mixed with enough water to make it palatable.
Supplements:
Consider taking some probiotics or eating more fermented foods to build
up the gut flora, which will help with digestion and immune function. In
particular, I would suggest trying saurkraut juice as a probiotic drink.
Also consider taking the magnesium supplement more often if it is well
tolerated.
Regimen
Sleep
~ Client could try taking melatonin before bed and see if that might help in
getting a full nights sleep. Also soaking feet in a tub of hot water and
Epsom salts with a cold cloth over the forehead may also help in relaxing
the body and aid in getting back to sleep.
Exercise
~ Increase exercise: Client could try some gentle stretching and strength
building exercises as part of a daily routine. This along with a mild walk
might not over tax the body and even provide some added vitality and
better sleep.
Anxiety/Stress
~ Client could try journaling and meditating. Breathing or guided
meditations might be a nice place to start, though journaling is perhaps a
better choice given the client’s habit of thinking through problems and
trying to come to some understanding.
Diet
~ Client has introduced some new foods into her diet in the past month
including zucchini and potatoes. Even though she continues to be reactive
to most things, I think experimenting a little with more variety is a good
thing. She is still underweight and isn’t getting all the nutrition she needs.
Her liver problems make it hard to introduce any fats into her diet. She
does well with some proteins and some starches and carbs, but it will be
hard for her to get enough nutrition until her intolerances and immune
system become less reactive. Healing the gut and introducing new
probiotics seems like a good place to start.