A 44-year-old female treated some time ago for dysbiosis unsuccessfully; less experience and knowledge then. She presented to me with severe depression which began after a horrific treatment for intractable acne in her teens, had loads of antibiotics but also Accutane which seemed to be the trigger for her mental health decline. I. Her CSA showed no growth of Lactobacilli, 4+ E. coli, 2+ Bifidobacterium, 4+ alpha hemolytic strep, 2+ coag negative staph it looks like, 4+ pseudomonas. No growth for yeast. No parasites. On the PCR she had—and I’m uncertain how to interpret the significance given the material discussed—she had high Barnesialla, Odoribacter, Pseudoflavonifractor, and E. coli. Lowest butyrate SIgA of 289 and evidence of fat malabsorption. Sensitivities for botanicals showed best for plant tannins and uva ursi, slightly less for oregano. Already gluten-free. Tried all sorts of diets including anti-Candida diet. Organic acids showed every single marker grossly elevated for dysbiosis. Started her micronutrients including B vitamins, probiotics enzymes, and botanical protocol, which is a hybrid of yours, but not using the same products as access to them in the U.K. was tricky. We’d like to repeat her CSA with the Doctor’ Data as the year has elapsed since she has massive bloating with the same issues. Never tested her for SIBO. I also plan to do that if she is game along with the Cyrex panels, then I’ll be following your protocols to the letter. Any insights into the aftermath of Accutane? What are risks of using a course in metronidazole followed by botanical protocol Paleo diet, pre and probiotics, and gut healing nutrients? Do you have any insights on pseudomonas in particular? I’m familiar with its love of biofilm but wonder if there are any other considerations.

Chris Kresser: I’m sure many of you know about the sometimes devastating side effects of Accutane has been associated with causing IBD or actually established I think as a causative factor for IBD. There was a class action lawsuit in the U.S. about that, and it can cause a lot of nasty long-term effects. A lot to unpack here, but in general, I would say the main focus here is obviously on dysbiosis—insufficiency dysbiosis and pathogenic dysbiosis. You got the low levels of Lactobacilli and Bifidobacterium, then the 4+ for pseudomonas, and then the low butyrate. Butyrate is extremely important. The more I learn about it, the more I’m focusing on this in my work with patients. It’s anti-inflammatory. It’s immunoregulatory. There is actually some very interesting research now suggesting that in kids with autism spectrum disorders and ADHD. They often suffer from an excess of propionic acid related to butyrate, and if you infuse probiotic acid into the brains of rats, they start to exhibit behavior that looks a whole lot like autism spectrum disorders. Using butyrate in these animals basically turns them back to normal. It’s a very fascinating area of investigation, and it should remind us that as David Quigg said in the interview, “Insufficiency, this dysbiosis is no joke.” I think there might be a tendency for all of us to think about parasites, yeast, and other pathogens as being more serious, and to some extent, they can be or in certain situations. But if you see a stool test and everything is normal but there is significant insufficiency dysbiosis, SIgA, and low butyrate, that is enough to cause a lot of symptoms and problems. In that situation, especially if there is a pathogen, I would do the core antimicrobial protocol, and then I would follow up with definitely strong support with probiotics and especially prebiotics because that’s what’s going to increase the production of good bacteria like Bifidobacterium that in turn produce butyrate. There’s also a new micronized of butyrate that’s coming out shortly that I’m very excited about. It was created by Al Czap, who was the founder of Thorne actually. I think he sold Thorne a while back and went off and started as a new company tessmed.com, and it’s a micronized form of—he’s created a whole new delivery system not just for butyrate but for other nutraceuticals. It’s a trapped form where the nutrient is trapped inside. I think a nanosphere or molecule that then is released at any given time, in this case, in the colon where it’s needed most. It’s not available to the public yet. It will be probably in a couple of weeks if not sooner, but I have heard some very exciting anecdotal reports from people who have tried it with patients and patients who’ve taken butyrate salts or even done butyrate enemas but have gotten a way better response with this. Something like that form of butyrate might be a really good option here. Definitely with these symptoms and especially with the bloating, you’ve got to check for SIBO because, as you know, that’s quite prevalent. Given the dysbiosis and other issues, I wouldn’t at all be surprised if she’s got SIBO.