A Moment of Truth with My Doctor

I had my latest appointment with one of my doctors today, Dr. M.  She is my "second-string" ME/CFS doctor, but I need her for all the treatments Dr. C doesn't meddle with.

We Disagree About Whether I Have Lyme Disease

In past posts, I wrote that Dr. M believes, with "100% certainty" that I have Lyme disease.  This is based on her clinical diagnosis, an equivocal Stony Brook Western Blot test, and an IGenex Western Blot test that was positive IgM, negative IgG.  To be honest, her "100%" pronouncement was a bit of a red flag for me, as I don't think a responsible doctor should opine 100% certainty about any diagnosis, let alone something as complicated and controversial as chronic Lyme.  But on the other hand, I very much need a doctor to fill Dr. M's role, and I feel she is probably my best option right now.  I am reluctant try to find another local doctor who specialized in complex neruo-immune illnesses.

After first receiving the IGenex results, I thought I probably did have Lyme. But after reading more about Lyme and consulting other patients and doctors, I came to the belief that I probably do not have Lyme.  In my mind now, there is about a 10-20% chance I have Lyme.  Thus, I have a fundamental disagreement with my treating doctor...which can be a problem.  And so I went into this appointment intent on having a straight-talk conversation with Dr. M to determine if we should continue working together.

I explained my skepticism of the Lyme diagnosis as diplomatically as I could, trying not to make it sound as if I don't trust her experience or judgment.  Then I noted that the two main treatments she wanted me to try for Lyme would theoretically help regardless of which neuro-immune disease I have.  She has me taking Byron White's AL Complex, which is labelled first and foremost as "immune support," not necessarily a Lyme treatment.  The other treatment is Lauricidin / Monolaurin, which is supposed to be a powerful anti-bacterial, anti-viral, and anti-fungal.  So, in theory, these two treatments would help regardless of whether I have Lyme, ME/CFS, or both.  Plus, since I think there's still a small chance I might have Lyme, I want to hedge by incorporating at least one Lyme treatment into my plan, especially if that treatment helps with other conditions as well.

So I asked Dr. M, does it matter if we don't agree on exactly which disease within the neruo-immune family of diseases I have?  I said that in my estimation, it seems that about 80% of treatments overlap between Lyme and ME/CFS.  Could we simply focus on treatments that work for both?  She agreed that we could (maybe she simply wants to keep my business) and so it was settled.  

Phosphatidylcholine

I then told Dr. M about my experiment with Phosphatidylcholine (PC), a treatment she had recommended. To summarize my experience with PC: it started a major detoxification event from which I still haven't quite recovered.  I was effected badly by Herxheimer or detox symptoms: achy kidneys, crippling brain fog, muscle twitches, unquenchable thirst, urine that was a strange shade of yellow (almost brownish-yellow), and increased fatigue/inflammation.  

Dr. M echoed what I had already been thinking: that this reaction was actually a good sign. If we interpreted these symptoms correctly as the result of detoxification, then my body needs this detoxification.  I simply need to titrate more slowly.  (Dr. M pointed out that her instruction sheet from my last appointment clearly advised me to titrate slowly, which I completely overlooked.) So I'm going to try PC again, this time using the capsule form (as opposed to liquid form) so that I can more easily control the dose.  18 capsules apparently equals one tablespoon of liquid PC, so now I can start with 1/18th of the prior dose.  

Dr. M explained again that PC repairs and cleans cell walls throughout the body, which is consistent with what I had independently read. These built-up toxins (and oxidative stress?) then become merely waste in the body, existing intracellularly (between cells).  Releasing too much of this waste at once can make a person feel very badly.  I believe that's exactly what happened when I went directly to a high dose of PC; the symptoms fit.  

Hormones

I continue to believe that bringing the hormones back into something that resembles a "normal balance" is one important key (among many) to regaining health.  That's something that every ME/CFS doctor I've met with besides Dr. C has advised (Dr. C. has a laser focus on enteroviruses and related treatments, to the exclusion of most everything else).   

We also agreed that the dose of active Thyroid hormone (T3) my previous doctor had me taking was too high (75 mcg/day).  We want to go back down to 50 or less.  This has to be done very slowly and carefully because the body needs time to adjust and start increasing its own production of the thyroid hormone precursor, T4.  As a first step, we're only reducing it by 10 mcg.

We're also going to put me back on testosterone cream instead of the self injections.  The injections were causing me groin pain and I had to quit.  Prior to quitting, testosterone was helping substantially.  Thus, we want to add it back in, but less aggressively, and using a dosing method (cream) that doesn't lead to such extreme spikes of testosterone levels in the blood. 

So now we have a new plan... 

What Must Happen Next to Solve ME/CFS

We Need Multiple Breakthroughs Before "the Big Picture" Emerges 

The next big breakthrough in ME/CFS research...will be the first.

As sobering as that is, in 30 or 40 years of ME/CFS research, we can't point to a single discovery that truly qualifies as a "breakthrough."  I'm referring to a breakthrough on the order of the XMRV discovery.... if it had turned out to be correct.  We can't claim anything so important.  Not one.  And yet in order to truly "solve" ME/CFS, we might need dozens of such breakthroughs.

When I read accounts of the latest IACFS conference*, or the daily articles that make the rounds in our blogosphere, I have mixed feelings.  A few dozen dedicated researchers are all working on their pet theories and all seemingly churning out important findings.  It all sounds positive...we are surely making "progress."

But it raises a question: Is one of the researchers correct, and the others wrong?  Almost certainly not. There are too many confirmed physiological derangements found in ME/CFS patients that are, by now, beyond debate.  In the immune system alone, there is a constellation of problems, and that's merely one sector of the disease.  We know with absolute certainty we're dealing with a complex multi-system disorder. And so each of these dedicated ME/CFS researchers is probably focusing on what will turn out to be but a small piece of the puzzle.

When a true breakthrough finally occurs, it will look like one of two things:  Ideally someone will suddenly discover the cause--the one event that sets off the long chain of subsequent derangements.  Then we'd have a true focus for treatment research.

But barring such a "home run" discovery, true breakthroughs will begin to occur when someone with a mind toward the big picture starts making connections between the various derangements.... and proving them.  Someone has to start linking these findings in a causal chain so that we can begin to create a comprehensive model of this incredibly complex disease.

Look at the list of derangements involved with ME/CFS below and realize that nobody has yet to conclusively link even two of them together in a causal relationship.  And yet, in order to truly understand ME/CFS, we might need to figure out how they all connect:

1.  Glutathione deficiencies, methylation defects, detox mechanisms
2.  Mitochondrial dysfunction
3.  Neurological symptoms
4.  POTS/OI/tachychardia
5.  Hormone imbalances
6.  Th1/Th2 imbalance
7.  Natural Killer Cell deficiencies
8.  Pro-inflammatory cytokines
9.  Unhealthy gut biome
10.  High viral titers
11.  Cognitive dysfunction
12.  Sleep disturbances
And many more...

A note on terminology.  The list above includes symptoms, imbalances, deficiencies, dysfunctions, and pathogenic markers.  Collectively I refer to them as "derangements."

In addition to linking all these derangements together, a unified model has to explain how we can have multiple routes into ME/CFS:  gradual onset versus sudden onset; viral infection, major bodily injury, etc.  Perhaps this is the test by which all theories of ME/CFS etiology should be judged.  Does the theory explain why we have multiple routes into the same state of disease?  If it doesn't, at best, the theory only explains part of the puzzle, further downstream from the cause.

This is why I believe the theories of so many of our dedicated ME/CFS researchers will be, even if proven to be true, only part of the puzzle.  Many of the theories probably aren't broad enough to explain both sudden onset and gradual onset.  Moreover, many of the current working theories would explain only part of the disease process further downstream, not the etiological origin.

                                                            Possible Models of ME/CFS

When we are finally able to link all of the states of dysfunction together through causal connections, the model that emerges will probably look like one of the following 3 examples:

Linear chain:  Imagine all 12 of the derangements listed above tied together in a simple cause-and-effect chain, from 1 to 12.  This is the most simplistic model, and probably very unlikely to describe ME/CFS.

Hub and spokes:  This is a wheel analogy.  First, you have an axle (the original cause).  Next, the "hub" connected to the axle is a single, master derangement--one that leads to all the others.  Every other derangement stems directly from the hub but is not linked to any of the others.

A-shape waterfall:  This is a hybrid of the two models above.  The brink (the tipping point of the waterfall) is the etiologic cause of ME/CFS.  Perhaps you have a single stream leading up to the brink, but perhaps you have many tributaries (different causes) all leading up to one brink.  As the water falls over the brink (the person becomes ill), the stream becomes divided, and then further subdivided, and so forth.  A similar analogy would be the branches of a tree dividing and subdividing from the thick trunk all the way to the thinnest branches.  

I believe, almost certainly, the model will end up looking like the waterfall example above.  It is the only model that explains the variations in symptoms from one ME/CFS patient to another.  The farther the water drops from the brink, the more likely it is that rocks on the cliff (small variations in patients' body chemistries, from one person to the next) will send each molecule of water in a different direction from the one next to it.  At the top of the waterfall, the path of each patient's disease development probably looks the same, but it starts looking more and more different as we get away from the brink.

One of the implications of the waterfall model would be that the more common the derangement, the closer it would be to the brink.  If there's a derangement that nearly all patients have, that derangement, logically, would be more directly connected to the etiologic origin of ME/CFS (i.e. closer to the brink).  Less common derangements would be further down the waterfall.  This somewhat logical conclusion might provide a basis by which we might begin to construct a complete model.

The Pessimistic View

Each of the divisions in the waterfall model represents a connection that needs to be hypothesized, tested, peer-reviewed, confirmed, and ultimately accepted by consensus before we truly understand the disease process.  There are dozens of these connections that need to be made in this fashion, and we've yet to do even one.  Arguably, only when we finish this process and have a complete model of ME/CFS can we really hope to focus our search for a cure.  The treatment research should focus on putting a damn at the brink, before the water goes over the waterfall.  But if we don't know what the brink is, how can we expect to damn it.

In 30+ years of ME/CFS research, they haven't made even one conclusive causal connection.  In fact, all we're doing is finding more and more pieces that need to be connected together to explain everything.  The big picture often seems to be getting more complex, less clear.  At this rate, it's hard to image ME/CFS ever being fully understood in any of our lifetimes, let alone an approved curative treatment found.  

Further, it is notoriously difficult for scientists to reach a consensus and accept a theory as fact, even with the simplest of theories.  When we're talking about a multifactorial disease that looks something like the waterfall model, it can seem impossible that the proof would ever be strong enough for biologists and doctors to accept any one model.  Even if a model this complex could be somehow "proven," it's such a complex model, the medical community as a whole might never fully understand it.  Doctors and medical schools are accustomed to learning/teaching simple one or two step disease processes.    

                                                               The Optimistic View

Looking at the history of Epidemiology, many diseases have been solved before they were ever fully understood.  Often a drug is discovered by chance, perhaps from research into an unrelated illness, and suddenly there is a cure when nobody was expecting it.  Then it becomes quite easy for researchers to find the cause of the disease because they can simply study why the drug is effective and work backwards.  But at that point, it's all academic anyway.  Who cares exactly why it works?  By the time they've worked it out, we'd be sipping margaritas on a beach in Belize.  

Momentum can build very quickly when just one breakthrough finding is made.  Again, looking at the history of Epidemiology with respect to other diseases, often when one key connection is made, others follow rapidly afterwards.  Imagine what would have happened had XMRV been confirmed.  With a concrete, headline-making finding, research money would have poured in.  Drug companies would have been racing to beat each other to the marketplace with an XMRV anti-viral.  Our small circle of ME/CFS researchers would have likely expanded greatly as virologist and epidemiologists all over the world would have turned their attention to ME/CFS.  Progress would have accelerated exponentially. 

At any moment, we're just one breakthrough away from a rapid acceleration of progress.  The catch is, the breakthrough (whatever it is) has to be sufficiently high up on the waterfall to explain all or most of the disease process.  

Current Treatment Implications

As I look around at how different patients and doctors approach ME/CFS treatment, I see huge variations. There are those that use zero or one or two treatments, and those that take a shotgun approach with 30+ supplements and medications.  Both are valid.

Some patients find that they simply cannot tolerate most treatments.  Others report that most treatments they've tried had no noticeable affect.  Financial affordability is often a limitation too, as are risks and side effects.   

On the other hand, some patients adopt the philosophy that substantial improvements can be cobbled together with many small, sometimes imperceptible improvements, and that each treatment must be provided time to heal slowly.

I think it's safe to say that there is no single existing treatment that can build a damn at the brink of the waterfall.  If such a treatment existed, someone would have stumbled on it by now.  For that reason, my current treatment philosophy is to try to implement at least one treatment for each derangement -- even if that means sometimes merely treating the symptoms.  Since we have no idea which derangements are downstream from others, it arguably makes sense to address a little of everything.

Having said that, I'm still at a place on my disease timeline where I can tolerate most treatments that I try.  That may change.  My hope is that I can stay tolerant of these treatments long enough for a breakthrough to occur of the kind described in the Optimistic View section above (the accidental breakthrough.)  Because if we have to rely on piecing together a full model of ME/CFS before solving it, I fear the disease will far outlive me.

*I originally wrote this post after the March, 2014 IACFS/ME Conference and, for some reason, never posted it.  I found it this week sitting in my blog as a draft and decided to click "Publish." Some of the references therefore might be slightly outdated.

Check Out and [Maybe] Edit ME-pedia.org

Apparently ME/CFS has it's own wiki.  I recently found out about ME-pedia.org when a friend emailed the link.  This page shows its organizers and founders.  

I'm excited about this.  ME-pedia has the potential to revolutionize how the patient community builds its knowledge base.  One of the best ways to ensure progress is for patients to share their experiences and build collective knowledge bases.  We can't simply rely on a handful of scientists to solve everything (although I'm still holding out hope for that!)  Up until now, the process of patient-to-patient knowledge sharing has mainly played out in the message boards.  I love the message boards, but they aren't the most efficient way to collectivize knowledge.

Say you want to understand a given treatment.  First you might search the Internet generally for an article or a research paper on the topic. Those are rare and can be difficult to find.  If you can't find any articles, maybe you go to the message boards where there's often dozens of threads on a given treatment.  Within each thread, there are various digressions and irrelevant information.  Nobody is verifying that statements are supported with citations.  It's all up to the reader to divine the useful information from the "noise" and decide whether that information is supported by facts or is merely opinion.

ME-pedia has the potential to make this collective knowledge sharing process much more effective and efficient.  I assume it will work like Wikipedia, where editors check to ensure that users' edits and additions are supported by citations and are generally written in an objective, encyclopedic style. If so, this could turn into an invaluable resource.  It's already shaping up that way.

I just wish ME-pedia had been around when I first received my diagnosis.

Candida Tongue and ME/CFS

When I was diagnosed with ME/CFS in 2011, one of the first things the doctor told me was that the white film on my tongue was called "Candida" and that it was a sign of a weakened immune system.  Ever since that day, I've tried to determine if that doctor was correct.  Is the white film really a sort of barometer for how the immune system is functioning?  Here's what I've learned.

My Past History with "Candida Tongue"

I became ill with ME/CFS in the Summer of 2011, but I know I've had a white film on my tongue since at least 15 years earlier.  When I was in college, a girlfriend once mentioned the white film on my tongue and told me it was a sign I needed to brush my tongue harder.  I looked in the mirror, and it was the first time I ever recall noticing the whiteness.  If it had noticed before, I assumed it was normal.  The film was mostly confined to the back half of my tongue, exactly as it is today.  

My girlfriend's tongue was, by contrast, perfectly pinkish-red.  Not a hint of white film could be seen.  For the next few months, I brushed my tongue after every teeth washing.  It never made any difference.  I came to the conclusion that I could brush my tongue until it bled and it still wouldn't remove that film.  My girlfriend was clearly wrong about the brushing.  She simply had a pinker tongue I decided.

_______________

In 2005 (6 years before ME/CFS), I experienced a year of unexplained health problems.  Although I didn't know it at the time, it was a bit of a preview of ME/CFS.  I contracted Epstein Bar Virus (I have positive IgM blood tests from that time), I had kidney aches, and serious GI distress among other things.  All would return in 2011, along with many more.  

The GI distress eventually led me to a gastroenterologist who "scoped" my stomach via endoscopy. He found no ulcers, but he did find "candida plaques."  According to my medical records from that time (which I retrieved later after my CFS diagnosis), the doctor prescribed me 2 weeks of Diflucan.

It is said that everyone, including healthy people, has Candida yeast growing inside them, so my assumption is that what the gastroenterologist saw was more than the usual amount.  Although the "scope" report doesn't actually say Candida "overgrowth," it's doubtful the gastroenterologist would have prescribed Diflucan if he'd seen merely a normal amount.     

                                                                   _______________

These incidents from my pre-ME/CFS past suggested two possibilities:  Either (1) the white film on my tongue is not unusual and not indicative of weak immune system, or (2) I've had a weak immune system since well before ME/CFS.  In this latter scenario, perhaps a weak immune system made me pre-disposed to ME/CFS; in effect, I was perhaps a "ticking time bomb" waiting for my viral and/or toxin load to reach a critical mass.  

So which one is it?

Test Results

When I eventually received my CFS diagnosis, one of the first blood panels showed that my candida antibodies were very high.  Using a reference range of <1.0, my results were:

IgG  1.3

IgA  3.7

IgM 1.4

They were all high, but the IgA results particularly were off the proverbial charts.  Subsequent courses of oral Nystatin brought the numbers down slightly, but IgA never fell below 2.4.  (I didn't tolerate Diflucan well this time--it made my kidneys ache.)

On the other hand, dozens of non-CFS doctors and dentists have looked in my mouth over the years and none have said anything about an excess amount of Candida.  That tells me, if the Candida levels in my mouth are excessive, it is not shockingly obvious.  

                                                             My Amateur "Investigations"

After the blood test results, I began to wonder about Candida overgrowth and, for a period of time in my first year with ME/CFS, I naively thought that treating it might be a key to recovery. (How little I knew.)  I read The Yeast Syndrome, by John Trowbridge and Morton Walker.  I changed my diet, first to an anti-Candida diet for about 90 days, and then to a Paleo diet for "maintenance."  

All the while, the white film on my tongue remained mostly unchanged, although for brief periods of time while on Nystatin, the film was slightly reduced.  Even when I wasn't taking Nystatin, every once in a while the film would nearly disappear for a day or two, for no apparent reason, only to return.  It's truly bizarre how it can come and go, and yet, when it's there, it feels so utterly permanent--incapable of being brushed away.  How can that be explained?  

Then, as the years passed, I began occasionally asking friends and family to show me their tongues..."for science!"  They all had some degree of white film, although none quite as thick as mine.  (I never again saw a perfectly clear tongue like that of the old college girlfriend, and so I realized that either (1) she must have had an abnormally strong immune system, or (2) she was a space alien.)  

So I knew that measuring the strength of someone's immune system wasn't as simple as looking inside someone's mouth to see if they had a white film.  Nearly everyone has it to some extent.  Yet I also knew that the white film had at least some correlation to the health of one's immune system.  How?  Search Google Images for "oral thrush" (a severe form of candida overgrowth in the mouths of people with very severe immune deficiencies, such as those with HIV or certain cancer treatments.) But for godssakes, don't look if you are squeamish or eating.  (Click here if brave or crazy)

Now that we know what a severely immune deficient person's tongue looks like, it's logical to conclude that lesser degrees of immune deficiency would result in a lesser degrees of white film on the tongue.  But where is the line between a healthy amount of Candida on the tongue and Candida overgrowth?  Excluding cases of severe oral thrush, can one determine how healthy someone is by looking in their mouth?  Could ME/CFS patients possibly use it as a barometer to track the effectiveness of treatments?  Having compared my tongue to the tongue of healthy friends and family, I believe the answer is this:

My Conclusions

There's no criteria to determine when a normal amount of Candida on the tongue crosses over into Candida "overgrowth."  As far as I know, it's a judgment call by doctors.  They just "know it when they see it," and probably 10 different doctors would have 10 different opinions.

But I've noticed that while a healthy person's tongue often has some degree of white film, it is spotty and thin, covering 10 to 60% of the back half of the tongue.  When most of the back half of the tongue and even some of the front half of the tongue are covered with white film, the person may be immune deficient.  Obviously I'm not a doctor, but that's what I've observed.  

Where Did It Go?  

Now get this: In the last three weeks when I look in the mirror, the white film has been gone.  No trace of it.  My tongue looks as pink and clean as that old college girlfriend's.  Cleaner than those of my friends and family.  It is utterly confounding.  As far as I know, this is the first time since at least 1998 that I've had a consistently Candida-free tongue.  Nothing, not even Nystatin or Diflucan has been able to achieve this before.

I wish I could pinpoint exactly what made the Candida go away, but I'm not one of those people who possesses the discipline to implement only one treatment at a time.  About  4 to 6 weeks ago, I began adding a number of supplements to my routine in rapid succession.  Since most of the supplements I added were repetitions of past treatments, I can narrow the likely cause to supplements that are new.  

The new supplements I added are Oregano Oil (181 mg./day), Monolaurin /Lauricidin (only 3 to 8 pellets per day), and then there was a one week experiment with Phosphatidylcholine.  I also stopped taking D-Ribose, which is a type of sugar and may or may not feed Candida (this is debated).  I've also picked up the habit of just eating a spoonful of extra virgin coconut oil occasionally.  Coconut oil  is an anti fungal.  

My guess is that it is was a combination of the Oregano Oil, Monolaurin and Coconut Oil, both of which have anti-yeast properties. 

It's still too early to tell if this glorious Candida-free state will last, or if it will help in my overall battle with ME/CFS.  So far I don't feel any different.  But damn it feels good to look in the mirror and see a clear tongue.  To quote Jason Mraz in his song I'm Yours:

"I've been spending way too long checking my tongue in the mirror

And bending over backwards just to try to see it clearer"

Book Review: Why Can't I Get Better?, by Dr. Richard Horowitz

[Note:  This review can also be found on my Book Review Page.]

Why Can't I Get Better? by Richard Horowitz

Before I get into the details of this book, I want to mention that this review is written from the perspective of an ME/CFS patient reading a book that is primarily about chronic Lyme disease. The book overall has excellent reviews on Amazon  and it actually reached the New York Times Best Sellers list, which is remarkable for a specialty health book.  Clearly, Dr. Horowitz did something right here.  

I read this book for two reasons.  I had recently received a questionable Lyme disease diagnosis, and I wanted to read a book about Lyme to see if it would help me decide whether I truly have Lyme or, if not, what else I could do to shed more light on this murky topic.  The second reason was that ME/CFS and Lyme seem to have a large amount of overlap in symptoms, test abnormalities, and treatments.  A Lyme book could be valuable reading for an ME/CFS patient.  

At times I found this book to be a bona fide page turner; I was learning new things on nearly every page. Mind you, if you've been an ME/CFS patient for any period of time, you probably won't learn anything new on a "macro level"—that is, you won't discover any new concepts or treatments.  But the book offers a deeper understanding of many of these old concepts, like mitochondrial dysfunction, the HPA axis, immune dysfunction and others.  Dr. Horowitz views Lyme, ME/CFS, Fibromyalgia, autoimmune diseases, and other neuro-immune illnesses as being part of a spectrum he terms MSIDS (more on that later...), so it's relevant regardless of which neuro-immune disease one might have.

Usually when I read a health book, I'm constantly assessing how I might rate the book.  For over 400 pages, I had this book pegged as a solid 4 stars, despite its flaws.  Then on page 437 I came across this (in Chapter 19, called "Lyme and Exercise"):

"Patients with Lyme disease, fibromyalgia, and chronic fatigue syndrome (myalgic enchephalomyelitis) find their fatigue and pain syndromes improve with increased exercise, independently of other changes in their medical regimens."

Uh oh!  It gets worse. Later, he says:

"Aerobic exercise has been shown to be effective in reducing fatigue among adults with chronic autoimmune conditions, as well as those with depression, cancer, multiple sclerosis, and chronic fatigue syndrome."

Later he recommends "a graded exercise program."  In the span of two pages, the book went from a 4 to a 1 star.  I was left wondering, how could someone who purports to be an expert on, among other things, ME/CFS be unaware of all of the studies showing that exercise makes ME/CFS patients worse—that it is, in fact, dangerous?  The book has a copyright date of 2013; two years before the Institute of Medicine (IOM), in conjunction with the National Institute of Health issued its report which attempted to rename the disease SEID, or systemic exertion intolerance disease. One wonders if Dr. Horowitz took note of the IOM report when it was published and if future editions of the book might contain a revised Chapter 19.

But let's not allow the review of a 532 page book to be about 3 sentences.  Although I probably risk being ostracized from the ME/CFS community for saying this, the rest of the book does have some value.

The Good.  To build on something I said above, Horowitz does an excellent job of taking the reader on a wide ranging, comprehensive tour of the various systemic failures and corresponding treatment options for patients with chronic neuro-immune diseases.  A brief scan of the chapter headings for chapters 5 through 18 gives an idea of the breadth of this book:  Immune Dysfunction, Inflammation, Environmental Toxins, Functional Medicine and Nutritional Therapies, Mitochondrial Dysfunction, Hormones, the Brain, Sleep Disorders, Autonomic Nervous System Dysfunction/POTS, Allergies, Gastrointestinal Health, Liver Dysfunction, and Pain.

Despite having read extensively about most of these topics in the past, many of them were explained in a more clear, logical way than I'd previously encountered. For that reason alone, I'm glad I read the book and I'm glad I have it in my library as a reference source, despite the glaring flaw regarding the "e" word.

The Bad.  Besides the exercise disaster mentioned above:

1)  Dr. Horowitz tries to coin a new term: MSIDS, which stands for Multiple Systemic Infectious Disease Syndrome.  This is meant to be a sort of overarching spectrum upon which the various neuro-immune diseases fall.  The problem is, we don't need another acronym. This is obviously not a term that will catch on in the larger medical community.  The goal of a book like this should be to make the subject less esoteric, not more.

2)  Similar to the above, Dr. Horowitz proposes an MSIDS diagnostic algorithm amusingly called "The Horowitz Sixteen-Point Differential Diagnostic Map."  Every time he refers to it throughout the book, which is often, he repeats the full 7-word eponymous title.  I pictured the author in an infomercial, and whenever he says "...the Horowitz Sixteen-Point Differential Diagnostic Map" we hear the chime of a spoon against a crystal glass as a cartoonish gleam flashes on the doctor's smarmy grin.  A voice-over adds "TM."

Things like this make me question an author's motive.  Is he a true scientist at heart, nobly trying to expand the knowledge base and heal people in the process, or is he trying to become the next celebrity doctor, ala Dr. Oz?  I don't want to be questioning this when I'm simply here to find some answers to my health problem.  It makes me want to say:  "It's not about you, doctor. It's about the patients."

3)  Each chapter follows roughly the same format: There is an explanation of the scientific evidence regarding the topic of the chapter, be it Immune Dysfunction, Inflammation, etc., and a review of various treatment options.  This is often done quite masterfully.

Then each chapter concludes with an anecdote or case study, lasting anywhere from 2 to 6 pages. These quickly become tedious and formulaic.  A patient comes to Dr. Horowitz very sick and desperate.  Dr. H applies The Horowitz Sixteen-Point Differential Diagnostic Map* (TM) and this results in him trying one or two treatments.  The patient returns a few months later still feeling miserable.  Dr. H digs deep inside himself and has a brainstorm.  He adds another treatment.  The patient returns a few months later smiling and singing. They hug. The end.

These anecdotes add very little except unnecessary length to an already long book.  The book would have been better without them.  They also serve as the vehicle for some eye-rollingly corny jokes.

4)  Dr. Horowitz struggles with objectivity at times.  He mentions that he has treated thousands of "MSIDS" patients but we are rarely let in on the big picture. What percentage are recovering fully?  Are they staying recovered?  Instead, the aforementioned anecdotes leave the reader with the impression that Dr. H is a kind of miracle healer.  It makes one want to run out and immediately board a plane to New York to track him down.  It is, of course, acceptable to use anecdotes to make a medical book more engaging, and naturally, the successes make for the best stories.  But the author should take care to emphasize that the results in the anecdotes are not typical, and that many patients (presumably) remain ill despite using the very same treatments described in the anecdotes.

The same goes for Dr. H's coverage of controversial testing and treatment procedures. It is OK for the author to pick a side on these controversies, but he should first explain both sides and then explain why he picked his side.  For instance, in the Allergies chapter, he discusses so-called IgG allergy testing and comes out heavily in favor of it.  There is very little credible evidence that IgG allergy testing is valid, and in fact, the weight of the evidence seems to suggest it is probably not effective. At the very least, it is highly debatable.  But you wouldn't know this by reading WCIGB.

Another example is Dr. H's reliance on controversial Lyme testing laboratories and other laboratories that test for metals and environmental toxins.  They are all controversial in their own way.  Dr. H should explain both sides of the controversy before choosing a side, so that patients can make their own informed decision.

Despite these flaws, I would have still rated this book fairly high if it wasn't for the melt-down in Chapter 19.  As an ME/CFS patient, I can't in good conscience give it anything other than a 1 star (★)