Antibiotics and autism: a case study

OK you got me.

Another case study of autism is being discussed in this post. It's not that I'm moving away from good ole' evidence-based medicine - double-blind, placebo-controlled group studies like this one if you please - but rather that as I've discussed before, there is often merit in looking at autism from the N=1 perspective. After all, it is a heterogeneous condition and we have all that 'autisms' chatter of late (see here) coupled with some elevated risk of comorbidity (see here). Indeed why else would medicine still enjoy the odd case report or two more generally?

Go fish @ Wikipedia  

The case study in this case(!) is reported by P. Lucas Ramirez and colleagues* (open-access) and concerns an interesting outcome following the use of antibiotic therapy for a young man diagnosed with autism.

I have, as it happens, covered the potentially double-edged sword that is antibiotics and autism in a previous post (see here) alongside some discussion on specific preparations with autism in mind (see here). The whole gut bacteria side of things comes into play in the Ramirez paper given the reasons why antibiotic therapy was initiated (encopresis) and the subsequent results of a stool analysis.

A few points of note:

• Whilst antibiotics were the name of the game, there is some interesting history about this particular young man with autism and his dietary history focused on the use of a gluten- and casein-free diet. Those who follow the autism research scene will probably have come across some recent interest in the whole autism-diet link as per the paper by Nga Lau and colleagues (see here) on immune reactivity to gluten (see here also). In this case, there was the 'suggestion' that diet might have impacted to some degree on various core and other facets of this chap over the years.
• So: "A ten-day course of metronidazole and a subsequent twenty-day course of ketoconazole were prescribed for management of the Clostridium spp. and G. klebahnii, respectively". Clostridia has already been talked about (quite a few times) with autism in mind. Geotrichum klebahnii is not something I'd come across before so I can't really say too much about it.
• Suffice to say that alongside some bowel-related effects, positive effects following antibiotic therapy: "Parental reports indicated that his aggressive and self-injurious behaviors significantly improved and his self-stimulatory behaviors decreased dramatically during the course of the treatment".
• Alas, the completion of the antibiotic / anti-fungal course did not herald a major permanent shift in the presentation of behaviour for this young man as per the reports of a regression in his behaviour after antibiotics had finished.

I find this to be an interesting case report. Not least that the report of 'doing well' on antibiotics / anti-fungals was followed by a return of behavioural symptoms after course completion in line with other reports of antibiotic therapy such as that of Sandler and colleagues**. You might argue that there was some kind of placebo effect from the antibiotic use but I have to say that I have some issues with the suggestion that the presentation of aggression and self-injury would be so fundamentally altered. Indeed when one hears that aggression and SIB between cycles of treatment included things like "breaking a teacher’s nose with a head butt, and breaking the rear windshield of a vehicle by head banging" I have to say that I'm not convinced that the placebo effect would be so effective as a sole explanation. Of course, if science wanted to prove me wrong, there is a placebo-controlled study waiting to be done there....

Insofar as the fungal connection and any effect this might have had with regards to symptoms, I'm not going to make too much of this at the present time. I note that Julia Rucklidge, she of the vitamins after earthquake research, has asked a similar question of late with yet another case report about whether yeast infection could "impair recovery from mental illness"***. Without trying to approximate autism with mental illness (they are not the same), the common denominator is the effect of such bacterial or fungal beasties on overt behaviour. Indeed Rucklidge presents an interesting hypothesis about how certain fungal elements might impair nutrient absorption and onwards what effect this might have on behaviour; which as far as I can see could easily also be asked about autism too.

I know that for some the report by Ramirez is going to be of little interest; a fluke and nothing more than correlation and association perhaps even with a dash of controversy around one of the authors and some previous monkey business****. So be it. What perhaps should be taken into consideration is that at least the presentation of encopresis for this young man was taken seriously and not just put down to that old chestnut - 'it's all part of the autism'. That and reiterating what effects gastrointestinal / bowel symptoms can have for a person with autism and all that potential gut-brain axis stuff that I seem to keep going on about.

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* Ramirez PL. et al. Improvements in Behavioral Symptoms following Antibiotic Therapy in a 14-Year-Old Male with Autism. Case Reports in Psychiatry. 2013: 239034.

** Sandler RH. et al. Short-term benefit from oral vancomycin treatment of regressive-onset autism. J Child Neurol. 2000 Jul;15(7):429-35.

*** Rucklidge JJ. Could yeast infections impair recovery from mental illness? A case study using micronutrients and olive leaf extract for the treatment of ADHD and depression. Adv Mind Body Med. 2013 Summer;27(3):14-8.

**** Hewitson L. et al. Influence of pediatric vaccines on amygdala growth and opioid ligand binding in rhesus macaque infants: A pilot study. Acta Neurobiol Exp (Wars). 2010;70(2):147-64.

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Ramirez, P., Barnhill, K., Gutierrez, A., Schutte, C., & Hewitson, L. (2013). Improvements in Behavioral Symptoms following Antibiotic Therapy in a 14-Year-Old Male with Autism Case Reports in Psychiatry, 2013, 1-2 DOI: 10.1155/2013/239034