Internet Medical Journal

Contemporary Australian General Practice Research: Case Reports

A number of patients with characteristic specific symptoms and signs have been identified in a general practice clinic. These cases are all associated with a characteristic pattern of medical symptoms and signs, as well as a characteristic pattern of blood tests findings. The “symptom and blood test” patterns were identified through longitudinal case control observations of patients in general practice.

The basic symptoms form a distinct reliably recognisable “syndrome” description. Illness appears over a very long time and very gradually. The symptom cluster is associated with a characteristic profile of pathology blood test results. This syndrome description has been named Paill Spectrum.
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Cases A, B, C form a subset of this case description, in that they all demonstrate thought disorder.

Case A showed a disorganized type of thought disorder, with inability to answer questions logically. This changed rapidly on treatment, with return of normal thought processes.

Case B was fixated on a single illogical thought that was stated as “no bones.” All questions to the patient were answered with disorganised versions of this statement. The symptoms of thought disorder improved rapidly on treatment.

Cases A & B were acute illnesses with symptoms less than six months old.

Case C was able to speak coherently but was experiencing auditory hallucinations. The voices had prompted him to jump out of a moving car and to stab himself with a knife on several occasions. The auditory hallucinations disappeared on treatment. The deliberate self-harm and other risky behaviours eased considerably on treatment.

The basic symptom cluster of the Paill Spectrum Syndrome found “variably” in all these patients includes:

• Chronic Fatigue or Tiredness,

• Sweaty hands,

• Abdominal Tenderness in para-aortic regions

• Loss of Balance.

• A characteristic learning disability (dyslexia like), may be present.

• The behavioural component of the symptom cluster includes: irritability and mood

swings, aggression and proneness to violence, loss of short-term memory or forgetfulness, impulsiveness, and small episodes of panics or jitters.

There are blood tests measuring nutrition and inflammation status in Paill Spectrum Syndrome:

• Identified nutritional abnormalities include: borderline or deficient B12/ folate status, antigliaden antibodies greater than 25% reference range as calibrated for endoscopically proven Celiac disease, and low normal zinc levels.

• Identified inflammatory abnormalities include a total quantified antibody level (GAM) greater than 11, occasional appearance of low C3 and minor elevations of ANF. FBC is characteristically normal.

While the EPP Gamma has been used as an assessment for initial cases, it has been replaced by a quantitation of IgG+IgA+IgM. When the calculation IgG+IgA+IgM-1.0 g/l is used, the resulting number is called the “GAM1“.

This figure allows comparison of quantitated total immunoglobulin levels (IgG+IgA+IgM) with the EPP Gamma (semi-quantitative) assay, by allowing for an characteristically average migration of 1.0 g/l of IgA immunoglobulin in the Beta band of the EPP. The actual amount of IgA migrating in the Beta band of the EPP is quite variable, so direct measurement of immunoglobulin is preferable in assessment.

Case A:

• EPP Gamma Quantitated at 15, equivalent to an approximate GAM 16 g/l on average, (allowing for the usual average of 1.0 g/l immunoglobulin IgA type, migrating in the Beta band)

• Zinc 11.0 microM (RR 12.0-29.0)

• Antigliaden IgG 0.45 (RR <1.00)

• Antigliaden IgA 0.27 (RR <1.00)

Case A: Comment

EPP is high

Serum Zinc level is low

Antigliaden antibodies at greater than 20% reference suggest that a trial of dietary therapy may have a symptomatic benefit.

Case B:

• GAM Total 15.17 (GAM1= 14.17)

• Serum Zinc 13.1 (RR 12.0-28.0)

• Antigliaden IgG 0.79 (RR<1.00)

• Antigliaden IgA 0.28 (RR <1.00)

Case B: Comment

EPP is high

Serum Zinc level is low-normal

Antigliaden antibodies at greater than 20% reference suggest that a trial of dietary therapy may have a symptomatic benefit.

Case C:

• GAM Total 11.58 (GAM1=10.58)

• Zinc 12 microM (RR 12-28)

• Antigliaden IgA: 0.06 (negative, RR <1.00)

• Antigliaden IgG: 0.23 (negative, RR <1.00)

• Deficient RBC Folate: 197 nM, 25% below quoted reference range.

Case C: Comment

EPP is above diagnostic threshold, though lower than the other results of Case A and Case B.

Serum Zinc level is low-normal

Antigliaden antibodies at greater than 20% reference suggest that a trial of dietary therapy may have a symptomatic benefit. This result is “borderline” for probability of success of trial of “gluten avoiding” dietary therapy.

Treatments instituted for the Paill Spectrum Syndrome were:

• Daily multivitamin supplement

• 44 mg elemental zinc daily

• Antibiotics: Minocycline 100 mg daily for a minimum of three months

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Results: in all cases:

Improvement or Resolution of the thought disorder becomes obvious from within two weeks. Substantial obvious mood improvement in terms of reduced irritability and reduced anger were also noticed within two weeks. Changes were obvious to the patient, their relatives and their carers. Treatment achieves a plateau of mood improvement and thought disorder improvement, within about three months.

Dr. Andrew Pluta (Contact via quizdoc.com)

Note from the Editor: this “Letter to the Editor” has not been peer-reviewed.

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