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Chronic Fatigue Syndrome Case Study with Certified IFM Practitioner Alex Manos

Alex Manos is one of only a few (thirteen as of January 2017) practitioners in the UK to hold IFM certified status, and you will see his functional medicine training reflected in this case study.  Looking in depth into a client’s health journey is a crucial aspect of a functional medicine approach.  It is impossible to determine the best path forward without first fully evaluating the impact of what has come before.    In this case study, Alex outlines the contributing factors and the steps taken so far with a very recent client suffering from complex health issues including chronic fatigue syndrome.  It’s only 3 months since Alex first saw this client, which is early days for a complex case; Alex has kindly offered to update us on further progress in 3 – 6 months.  Thank you Alex for sharing your protocol as well as your incredibly valuable reflections and insights too. 

Case study at a glance

Main health concerns:
Female with CFS, IBS & depression

Main underlying causes:
Exposure to mycotoxins from living in a water-damaged environment
Work & lifestyle-related chronic stress 

Organic acids test
Mycotoxins test
Stool test

Supplements: Antioxidants, vitamin D, vitamin C, curcumin, sequestering agent, probiotic & multivitamin formula
Lifestyle: Sauna therapy, sunlight exposure, emotional & physical expression, reduce exposure to other xenobiotic compounds

Client has been following the support programme now for 3 months & is really starting to move forward.  Alex will update again in 3-6 months

Case Outline

When asked to write a brief summary of a client I had supported recover from fatigue, one client popped to mind immediately. It is a client I am in fact still supporting but I thought it would be a useful case to highlight, partly due to the underlying cause of the fatigue, which we feel is at least partly related to exposure to a water damaged building, and thus mold.  Miss E came to see me after a diagnosis of chronic fatigue syndrome. She also suffered with IBS and had been on medication for depression. As a result of her health, she had been off work for six months.

After a comprehensive investigation in to her health journey it became apparent that she had been exposed to mold in her previous home, and also had a very demanding career and social life.

Main Aims

Our immediate aims were to identify the underlying causes of her condition so we could create a targeted programme to support her back to health.

The long term aim was of course getting her back to the work she loved, while appreciating she couldn't return to her previous lifestyle which may have been involved in triggering CFS. As part of this we discussed the difference between healing and transformation. I once read a comment on social media around this concept:

Healing implies that our previous state was more desirable…and that striving for healing is to return to our previous state before the illness. Transformation is completely different - it’s shedding our old beliefs, habits, stories and scripts that kept us small.

Her previous lifestyle, we both feel, was related to beliefs that were formed early in life (as is always the case) and thus the relationship she had with success and purpose/productivity. She found the work by Robert Holden incredibly valuable here.

The other reason we felt it important not to return to the previous way of live is that the functioning of the immune system, so heavily affected by chronic stress and excess stimulus, impacts on the extent to which an individual will be affected by exposure to bacteria and endotoxins (as well as on the nature and severity of exposure and genetic makeup of the individual). As discussed by Mike Ash at an IFM Annual Conference a couple of years ago;

It is important to consider the relationship between a microbe and the host.


Based on her history and symptoms we completed an organic acid test, a stool test and a mycotoxins test.

It is worth noting here that exposure to water-damaged environments, mold and mycotoxins may result in injury to the gastrointestinal tract and thus when considering mycotoxin involvement it seems appropriate to include gastrointestinal testing also.


Exposure to mold and mold components are well known to trigger inflammation, oxidative stress, and inflammatory reactions so these mechanisms need to be considered in any programme.


 • Antioxidants
 • Vitamin D
 • Liposomal vitamin C
 • Curcumin
 • A sequestering agent - Sequestering agents refer to non-absorbable materials capable of binding toxins in the gastrointestinal tract, thus reducing enterohepatic recirculation and ultimately the body burden of toxins. These agents are not absorbed into systemic circulation.
 • A probiotic
 • A multivitamin and herbal formula to support the immune system – Optimising intake of key nutrients is important for toxin clearance and recovery. Nutrients which are commonly low include vitamin D, magnesium, zinc, coenzyme Q10, and B vitamins, all of which can adversely affect multiple pathways in the body necessary for detoxification, thereby perpetuating the effects of the toxin exposure.

Lifestyle interventions

 • Sauna therapy - The mycotoxin Ochratoxin, for example, has been found in human sweat. I am keeping my eyes out for controlled studies that have evaluated the presence of mycotoxins in sweat (let me know if you are aware of any!). However, regardless of whether mycotoxins are found, induced sweating will likely reduce the total overall body burden of toxins and support recovery in persons made ill from exposure to water damaged buildings.
 • Sunlight exposure
 • Emotional and physical expression - this can be via journalling and letter writing, and exercise such as yoga, tai chi or/and body awareness therapy respectively.

NB. My client was already living in a different building so she was no longer being exposed to the mycotoxins – however targeting this may be the first step for some people.


“Studies have shown that endotoxins act synergistically with mycotoxins to enhance the cytokine mediated inflammatory response”*. This is another reason why investigating gastrointestinal health is important in particular LPS (lipopolysaccharide).

We found numerous yeasts including candida in the stool, as well as high levels of the bacteria Citrobacter Braakii and Klebsiella Pneumoniae. There were deficiencies in magnesium, vitamins B2, B9 and B12 and the mycotoxins Ochratoxin A and Gliotoxin were present.

We are now 3 months in to the support programme and really starting to feel like we are moving forward. Working with clients on a monthly retainer means we have tweaked the programme as we have felt best - rotating between different probiotics and sequestering agents to provide the most comprehensive support we can. While we still have some way to go we are confident we are on the correct path and simply need to keep faith in the process.  I will give you a further update on this case in another 3-6 months.

Additional Notes

In addition to avoiding further exposure to the mycotoxins (by moving home), it is recommended to decrease exposure to other chemical xenobiotic agents including pesticides, heavy metals, volatile organic compounds and fragrances, vinyl chloride, plastics, perflourinates (nonstick cookware), and other toxins in an effort to reduce total load and improve the ability to detoxify from the exposure to a water-damaged environment*.

It is common for patients exposed to water damaged indoor environments to become sensitive to and avoid many chemicals, which frequently becomes noticeable after leaving the environment. It is therefore important to educate the client around this and be mindful of any changes in this aspect of health.

*Hope J (2013) A Review of the Mechanism of Injury and Treatment Approaches for Illness Resulting from Exposure to Water-Damaged Buildings, Mold, and Mycotoxins, The Scientific World Journal

About Alex Manos – Certified Functional Medicine Practitioner
Alex has a MSc in Personalised Nutrition, during which he wrote his dissertation on glucocorticoid resistance in chronic fatigue syndrome. He is one of thirteen fully certified Functional Medicine practitioners in the UK (as of January 2017), having completed his studies with The Institute For Functional Medicine (IFM). He lectures on both MSc and BSc programmes and is also currently certifying as a Life Coach and has been a personal trainer for over a decade with numerous qualifications in movement assessment, corrective exercise and performance enhancement. With this breadth of knowledge Alex is fortunate to work with a wide range of clients from professional athletes to those suffering with chronic health conditions. He has a particular interest in the gut-brain axis and PNI and loves coffee, dark chocolate and apple crumble!