The Art and Science of CIRS Medicine

As teachers and long-time proponents of Chronic Inflammatory Response Syndrome (CIRS), we felt that a compendium of current educational and scientific materials on the Chronic Inflammatory Response Syndrome (CIRS) had a place in the approach to the CIRS patient. In our existing training courses, the basics of CIRS medicine is the source of our curriculum. Call the current courses CIRS 101 and CIRS 201, if you will. Fundamental to our courses is student participation in discussion of published papers, often leading to deeper questions regarding the art of CIRS practice. The growing course work, and level of student engagement show us that students want – and need – greater exploration of the topic, access to the primary literature and opportunities to demonstrate mastery of the subject. What we have put together are informal chapters regarding opinions of skilled practitioners based both on published data and on bedside experience that should help guide new CIRS practitioners through the complex maze of treating this unique patient population. These chapters show the art of CIRS Medicine used by the authors. We cover the subtleties and nuances of exposures, symptoms, labs, physical exam, ancillary studies, use of medications and some of the cutting edge science, transcriptomics, that are brought to bear on the fundamental question, "How can we help the CIRS trainee become an expert?" We will also feature new dynamic published papers that impact our current thinking about inflammation in CIRS, namely (i) metabolism; and (ii) mycotoxin measurements in urine. We include eight demonstrative cases written up by members of the Surviving Mold CIRS Academy. We are grateful for permission provided by each of these authors (see below) to use their excellent studies for educational experiences. Here we see a merging of art and science of CIRS Medicine that translates into an answer to the question, "How do I sort out differential diagnosis and quickly identify the right approach to helping complicated patients?" Finally, we include published papers that serve as a journal club for our students. Here are the scientific foundations of CIRS Medicine. Sample teaching questions range from the obvious (what is the study design?) to the essence of science (based on these data, how can you logically apply them to patient care?). We all have our dreams for the future, like hopes and fears all rolled up into one package. We have asked Drs. Shoemaker, McMahon and Heyman to share with us their ideas on the expansion of CIRS Medicine-what is possible now and what will be possible in the future. To help on this quest, we have included a research module based on the work of Ken Hudnell PhD and Ritchie Shoemaker MD that forms a starting point for good scientific studies. Finally, the advances in transcriptomics tell us far more about metabolism and inflammation than any writings published to date. These are exciting times! Taken together, the chapters, papers and sidebars of The Art and Science of CIRS Medicine are part of the ever-expanding extrapolation of CIRS to medicine in general.

Ritchie Shoemaker, M. D., is a recognized leader in patient care, research and education pioneer in the field of biotoxin related illness. While illness acquired following exposure to the interior environment of water-damaged buildings (WDB) comprises the bulk of Shoemaker's daily practice, other illnesses caused by exposure to biologically produced toxins are quite similar in their "final common pathway." What this means is that while the illness might begin acutely with exposure to fungi, spirochetes, apicomplexans, dinoflagellates and cyanobacteria, for example, in its chronic form, each of these illnesses has similar symptoms, lab findings and Visual Contrast Sensitivity findings. Taken together the inflammatory illness from each of these diverse sources is known as a Chronic Inflammatory Response Syndrome. The few sentences above might make one think that the path of discovery of the complex abnormalities of innate immune physiology now confirmed to be present was simple. Frankly, none of the "players," as one might call C4a, TGF beta-1 and MMP9 or the genetic susceptibility from the immune response genes HLA DR, was known in 1997, the first year of Shoemaker's odyssey into the world of unusual diseases. Beginning with Pfiesteria, a dinoflagellate that killed fish and sickened over 300 people along the estuaries of the Chesapeake Bay from 1997-2001, Shoemaker has looked at multisystem, multisymptom illness with an environmental source as his "Holy Grail." Indeed, finding the answers to countless questions raised by biotoxin illnesses has provided help, and for some, cure, with illnesses defined by symptoms alone such as fibromyalgia and Chronic Fatigue Syndrome. Shoemaker says, "I suspect that the next textbook of autoimmunity and rheumatology will be one dedicated to treating high TGF beta-1 and restoring control of T-regulatory cells. Similarly, no one will be seen for neurological deficits and pulmonary problems without consideration of nerves and lungs as targets of innate immune responses gone haywire. As it is now we see unusual cases of multiple sclerosis, idiopathic juvenile arthritis, interstitial lung disease and many others unveiled as treatable conditions where the therapeutic target is lack of regulation of innate immune inflammation. Dr. Shoemaker has dedicated his life and career to uncovering the link between the toxic stew found in many of our buildings and homes, and the vast amount of misdiagnosed and catch-all ailments physicians often assign patients for whom they cannot offer any real treatment. By uncovering the real science behind these illnesses, and attacking the problem with clinical studies and sound research techniques, Dr. Shoemaker leads the way in not only identifying the true cause of these afflictions, but also in curing those whom the medical community deemed incurable. He truly feels it is imperative patients educate themselves, and has committed his time and resources to providing them with the tools they need for their survival. Dr. Shoemaker graduated from Duke University where he received honors in undergraduate and medical degrees. He is a practicing physician in Pocomoke City, MD, and conducts research with collaborators on an international basis. His dedication to his patients and his advancement of medicine through research has been recognized often, including receipt of the Maryland Academy of Family Practice Physician of the Year 2000 award, which was followed by an award as a finalist in the National competition for 2002. Shoemaker is asked to lecture to academic and lay audiences alike, with addresses to the US House of Representative and Senate. Dr. Shoemaker has published eight books, the newest being Surviving Mold, and has numerous publications in scientific research journals, on audio and video tapes and in newspapers. He has made many presentations at scientific meetings, and has frequently appeared on television.