8

Acute infections, sepsis, and septic shock

In the USA, sepsis is the second leading cause of death within noncoronary intensive care units, with increased mortality rates of between 20% for sepsis and 60% for septic shock.

S. DENK, M. PERL, AND M. HUBER-LANG,
“DAMAGE- AND PATHOGEN-ASSOCIATED
MOLECULAR PATTERNS AND ALARMINS”

A point is reached at which the severity of the disease increases. . . . Unfortunately, this critical point does not immediately appear to lend itself to definition in the individual patient. . . . These changes [in the cytokine profile] have the characteristics of a self-perpetuating and amplifying system of functional derangement.

I. A. CLARK, L. M. ALLEVA, A. C. MILLS, ET AL.,
“PATHOGENESIS OF MALARIA AND
CLINICALLY SIMILAR CONDITIONS”
 

In fatal disease in the form of toxic shock-like syndrome, uninfected hepatocytes undergo apoptosis without evidence of ehrlichial infection.

N. ISMAIL, K. C. BLOCH, AND J. W. MCBRIDE,
“HUMAN EHRLICHIOSIS AND ANAPLASMOSIS”

Whether the presence of a particular cytokine is beneficial or detrimental to the host’s protective immune response depends on several factors, such as the time during infection when it is produced, the concentration of the cytokine, and whether it is present at high levels systemically in the serum or locally in the foci of infection.

H. STEVENSON, J. M. JORDAN, Z. PEERWANI, ET AL.,
 “AN INTRADERMAL ENVIRONMENT PROMOTES A
PROTECTIVE TYPE-1 RESPONSE AGAINST LETHAL
SYSTEMIC MONOCYTOTROPIC EHRLICHIAL INFECTION”

Infections with Babesia, Anaplasma, and Ehrlichia can, under some circumstances, shift into a more acute form. Sometimes this can lead to what is called sepsis or even further into septic shock. This is caused by an extreme shift in the immune system’s cytokine response to the infections. During mild and moderate infections, and during the initial stages of all infections, the bacteria shift the body’s immune response to Th2 rather than the more effective Th1. During these more extreme infections the immune system suddenly shifts into an overreactive Th1 response.

It’s almost as if the body, in response to being artificially suppressed for so long, has slowly built up a counterresponse that, as the suppression goes on, increasingly grows in strength. Then, suddenly, the suppression of Th1 responses just ceases. What remains is a powerful, overreactive, inflammatory Th1 response that, without a counteracting downregulation, overwhelms the body.

A positive feedback process begins; inflammation spirals out of control. This is sepsis. If it deepens, the body and its organs will begin to shut down. This is what is known as septic shock.

No one knows exactly why it happens in these diseases, but there are a number of factors that have been identified as being essential to its happening.

SEPSIS

The term sepsis has been around for nearly three millennia, but until the 1990s, a concrete clinical definition of the term was hard to find. The root of the word comes from the ancient Greek and means putrefaction or decay (hence “septic” tank). Prior to its redefinition, the term was applied to any serious illness accompanied by decay or putrefaction (such as gangrene). Septicemia, a related word (theoretically no longer used), also from the Greek, means putrefied blood, in other words a serious blood infection. Sepsis (and its related conditions) now has a specific meaning (despite its etymology), which is . . .

systemic inflammation (specifically, systemic inflammatory response syndrome, SIRS) that occurs simultaneously with suspected or proven microorganism infection. Severe sepsis includes accompanying organ dysfunction while septic shock is a sepsis-induced hypotension that persists despite all interventives (such as fluid resuscitation).

It specifically refers to a small subset of those who contract microbial infections (with a variety of different organisms, including Babesia, Anaplasma, and Ehrlichia) and, despite the microbial element of the definition, it also refers to those who suffer such things as acute trauma (e.g., burns) accompanied by a hyper immune response. For these people the infection (or bodily damage) turns into sepsis, which, in some cases, leads to septic shock. It can, under some circumstances, lead to coma and death.

The sepsis process has identifiably similar dynamics whenever it occurs. This is true no matter which organism is involved or even where no organism is involved at all. In other words, sepsis and septic shock in malaria, babesiosis, ehrlichiosis, severe tissue injury, severe blood loss, and so on are nearly identical in nature. There is something occurring that is, at root, identical in all those circumstances.

Counterintuitively, during pathogen-initiated sepsis there does not seem to be any relation to parasite density and the onset of the sepsis. In other words, in some people who experience sepsis the causative organisms exist in high density throughout the body; in others the parasites, unbelievably enough, have already been eliminated from the body (usually with antibiotics); and in others the parasite density is so low as to be undetectable. As Bitsaktsis et al. (2007) comment, “Susceptibility to fatal IOE [Ixodes ovatus Ehrlichia] infection occurs within a narrow range of infectious doses, between 500 and 1000 bacteria.”

This is why death from sepsis, when it occurs, can be sudden and inexplicable to medical technicians. Routine testing shows the person clear of parasites. While for some the symptoms are clearly life-threatenting, for others medical examination finds few, and fairly minor, symptoms. To illustrate, in one instance, a 44-year-old man, an outdoor worker, from Minnesota, after experiencing a week of fever, chills, myalgia, and severe pain in his jaw, sought medical help from his physician. The physical examination revealed little; a low-grade fever was the only abnormal sign. The heart, lungs, abdomen, lymph, liver, and spleen all appeared normal. The man’s physician did not perform a blood test but rather, based on geographical area, type of work, and symptoms, diagnosed Lyme disease. He prescribed amoxicillin and sent the man home. The symptoms did not worsen, but persisted, and 19 days later death occurred. The man’s only complaint the night before was a slight shortness of breath.

At autopsy, both lungs were congested with mild to moderate hemorrhagic edema, and the pleura were inflamed. The spleen was found to be enlarged and interior examination found numerous polymorphonuclear leukocytes infiltrating septic foci in its tissue. The heart showed widespread transmural myocarditis with endocardial involvement. There were numerous areas of neutrophilic and lymphocytic infiltrates as well as scattered areas of myocardial necrosis. Cellular infiltrates were found throughout the heart’s tissue. Despite the lack of symptoms, the widespread inflammation in the organs caused the man’s body to just shut down.

ACUTE BABESIOSIS, ANAPLASMOSIS, AND EHRLICHIOSIS: THE INITIAL STAGE OF SEPSIS

During acute episodes of these coinfections, the immune response and cytokine profiles are quite different than during milder forms of the disease. Such episodes, while they can occur in younger, immunocompetent people (usually children), most often occur in those without a spleen, those on immunosuppressive drugs, those with diseases affecting immune function (such as HIV), or the old (usually over 50) who are experiencing age-related low immune function. There is also some evidence, at least in babesiosis, that less common forms of the protozoa may lead more easily to septic conditions. Babesia duncani, formerly B. WA1, is an example.

During the initial stages of infection the process is not unlike the milder forms of the diseases: IL-10 is upregulated and suppresses the Th1 immune response. However, at a certain point, the infection, rather than resolving or becoming intermittent, moves rather rapidly into an acute phase in which the immune system suddenly, and inexplicably, shifts to a very strong Th1 response. The cytokine profile alters accordingly. As Shaio and Lin (1998) comment about babesiosis:

Of the cytokines tested, levels of TNF-α, IFN-γ, IL-2, and IL-6 were high in the acute phase. . . . Neither IL-4 nor IL-10 were detectable throughout the course of the illness. Concentrations of E-selectin, VCAM-1, and ICAM-1 were also markedly increased as much as six-fold. . . . This study has demonstrated systemic elevation of levels of TNF-α, IFN-γ, and IL-2, but not of IL-4 or IL-10 in the acute phase of human babesiosis. In addition to the increase in NK cells, CD8+ T cells were predominant over CD4+ T cells during the acute phase.

This same cytokine profile is identical with that found in other mammals (cows, sheep, mice, and so on) that have developed acute forms of babesiosis. It is also very similar to that which occurs during acute anaplasmosis and ehrlichiosis.

The spleen appears to be the initial site of the Th1 cytokine shift but once the inflammatory cascade reaches a certain point, many of the body’s organs also begin producing the same cytokines in copious amounts. The spleen, liver, lungs, heart, kidneys, and brain are generally the most strongly involved.

The immune movement into a powerful Th1 dynamic is often enough to, finally, eliminate the organisms and their effects from the body. Once the infection is dealt with, the body begins producing more IL-10, the inflammation begins to subside, the body returns to normal. However, in some circumstances, the immune system dysregulates. A hyper immune response with unusual qualities occurs. Sepsis begins. As Anaplasma researcher Stephen Dumler (2012) observes:

When the typical homeostatic mechanism of inflammatory dampening occurs after the inflammatory stimulus has been controlled and reduced in quantity, inflammatory signaling ceases and the underlying pathologic processes are altered to that of repair and reconstitution of function. However, significant and unremitting inflammatory injury occurs [under certain circumstances. This] . . . permits an unrestrained amplifying proinflammtory response without benefit of cytolytic homeostatic resolution. The result is a poorly controlled, in cases, relentless downward spiral of inflammatory injury and severe or fatal disease.

 

Treating Acute Babesiosis, Ehrlichiosis, and Anaplasmosis

Treatment of acute forms of these coinfections would be identical to treatment for the mild to moderate forms of the diseases with one exception: the substitution of Scutellaria baicalensis tincture for Withania somnifera. Dosage would be ½–1 teaspoon of the tincture 3–6x daily. Rather than downregulating IL-10, this would modulate its levels, that is, normalize its actions, lowering it if it is too high, raising if it is too low. There are a number of other herbs good for this, many of which are already in the protocols: Cordyceps, Glycyrrhiza, Houttuynia, Poria cocos (a.k.a. Wolfiporia extensa, a.k.a. fu ling), and Sambucus. Withania itself does act as a modulator (though I tend to think of it more as a dampening agent) but in this instance, I prefer the Scutellaria. Dosages for the other herbs and supplements in the protocol might have to be increased depending on how acute the conditions become.

 

COINFECTION-INITIATED SEPSIS AND ITS CYTOKINE CASCADE

Examination of tissues after septic shock episodes has found that the affected organs experience a range of impacts. Hypertrophy of the organs’ endothelial cells as well as intravascular aggregates of large mononuclear inflammatory cells are common. This can lead to occlusion of medium veins, thrombosis, and multifocal coagulative necrosis. Again, these impacts have been reported even when levels of peripheral parasitemia remain very low; research commonly finds no relation between parasite density and the hyper immune response that occurs. In the liver, acute inflammation is present in the complete absence of babesial parasites in the affected locations.

During sepsis, the liver’s production of cytochrome P450 3A (CYP3A) is significantly inhibited by the high levels of IFN-γ, TNF-α, nuclear factor kappa-B (NF-κB), and nitric oxide (NO) that are being produced by the liver’s macrophages and Kupffer cells. (CYP3A, by the way, is responsible for the metabolism of some 50 percent of pharmaceutical drugs including chindamycin and quinine, one of two primary treatments for babesiosis. In consequence the drugs may never reach the levels necessary for successful treatment of babesial infection.) Under the impact of the continual, massive cytokine production the liver’s tissue structure alters. The hepatic sinusoids dilate and begin to fill with macrophages and infected red blood cells. There is an increase in inflammatory cellular infiltrations, glutathione and catalase levels fall, nitric oxide and malondialdehyde levels significantly increase; there are increased levels of lactate dehydrogenase and protein carbonyl content. Hypertrophy of the endothelial cells occurs with accompanying occlusion in the veins. Necrosis develops and the tissue begins to crumble.

In the lungs pulmonary edema and phlebitis are common with reduced oxygenation of the blood and resultant shortness of breath. Endothelial cell activation is high with accompanying hypertropy of the endothelial cells. Intercellular adhesion molecule 1 (ICAM-1) is strongly upregulated. Intravascular margination of leukocytes accompanied by prominent lesions occurs in the lung tissue. Generally, there is reduced oxygen saturation and pH along with increased carbonic acid and accompanying hypoxia and respiratory acidosis.

In the spleen significant red pulp hyperplasia may occur. The splenic tissue contains large numbers of plasma cells, lymphocytes, and immunoblasts and large numbers of histiocytes exhibiting erythrophagocytic activity (that is, they consume red blood cells). The parenchyma is highly abnormal with severe integrity degradation. There are large multiple infarcts in the tissue, sometimes leading to rupture. (Again, because babesial infection can recur in endemic areas, procedures to salvage the spleen, if at all possible, should be pursued. There are cases, in the medical literature, where spontaneous splenic rupture has been successfully treated by physicians without splenectomy.)

Increasingly sophisticated examination of the cytokine cascade that occurs during sepsis has found it to be very unusual. IL-10 levels begin to substantially rise, just as should occur during the final stages of acute episodes. However, instead of lowering the inflammation in the body, counterintuitively the inflammation becomes worse, significantly so. Deeper analysis of the interleukin-10 molecules in play have found that the IL-10 itself dysregulates and these dysregulated forms, once circulating in the body, begin to substantially increase inflammation. They downregulate some cytokines but increase the presence of others. A very unusual cytokine cascade develops.

During HME-initiated sepsis and septic shock, for example, the cytokine profile finds increased levels of IL-10 and IL-13 (both antiinflammatory cytokines) as well as increased levels of pro-inflammatory mediators TNF-α, IL-1α, IL-1β, IL-6, IL-8, MCP-1, MIP-1α, MIP-1β, G-CSF, TLR-2, and TLR-4, as well as increased levels of macrophages, neutrophils, T cells, and NK cells throughout the affected organs. IFN-γ and IL-2 levels are low, as are CD4+ T cell counts. CD4+ T cells are in fact stimulated to die by the unique cytokine cascade in play. There are accompanying high levels of CD8+ T cells as well as increased ferritin. The cytokine dynamics in play cause massive inflammation throughout the organs, leading to massive cellular infiltration and damage.

The organs’ production of granulocyte colony-stimulating factor (G-CSF), for instance, leads to massive neutrophil infiltration. IL-8, also in high levels, stimulates similarly, recruiting neutrophils and T cells to the site of its production. During septic episodes, neutrophil levels in the blood remain low despite the massive increase in neutrophil production. These additional neutrophils instead cluster in the organs, at the sites of cytokine production, where they begin to destroy organ integrity.

MCP-1 (a.k.a. CCL2) recruits monocytes, T cells, and dendritic cells to specific sites where they stimulate massive inflammation. MIP-1α (a.k.a. CCL3) is strongly involved in acute inflammatory states and recruits and activates polymorphonuclear leukocytes (neutrophils, eosinophils, and basophils) at the sites of its expression. MIP-1β (a.k.a. CCL4) is a chemoattractant for NK cells, monocytes, as well as polymorphonuclear leukocytes. Once activated, CCL3 and 4 induce the expression of IL-1α and IL-1β, IL-6, and TNF-α. TNF-α levels become extremely high during sepsis and especially so during septic shock.

TNF-α induces fever, apoptotic cell death, widespread inflammation, loss of weight, muscle atrophy, fatigue, weakness, loss of appetite. TNF-α stimulates the production of NF-κB, which is involved in inflammatory and immune responses, cytokine production, cell survival, dysregulation of Bax/Bcl-2, and initiation of septic shock. It also upregulates p38 MAPK, which stimulates cellular death among other things.

Again, all this leads to massive inflammation and cellular infiltration in the organs expressing these mediators. Local pockets of cellular death (focal necrosis) in the organs begin to occur. As the condition continues, these spread, leading to organ failure.

The increased IL-10 levels should, under normal circumstances, act to reduce the inflammation but they do not; they make it worse. As Shu et al. (2003) observe:

In critically ill patients, including those with sepsis, IL-10 is increased in circulation and the raised plasma levels of IL-10 have been reported to correlate with the severity and mortality in the pathological inflammatory response.

Studies have found that IL-10 undergoes polymorphic alterations just prior to sepsis. In other words a slightly different molecular form of IL-10 is generated than is usually present in the body. This unique IL-10 still downregulates some cytokines, specifically IFN-γ and IL-2, but it upregulates others that it normally downregulates, TNF-α for example. In every instance of severe sepsis and septic shock caused by these coinfections IL-10 has been found to be excessively high. The higher the levels, the more serious the condition.

However, studies have found that reducing sepsis by inhibiting IL-10 requires very sophisticated timing. Done too soon, it allows acute conditions to continue unabated. In other words, at the end of healthy and normal acute episodes, IL-10 production rises and reduces inflammation, and the healing process moves into repair and regeneration. Inhibiting IL-10 in these situations stops that progression. In situations progressing from acute to septic, IL-10 needs to be inhibited after sepsis has begun. Speficially, just after the hyperinflammatory process has begun. Studies have found that the inhibition of IL-10 during the hyperinflammatory stage reverses sepsis and septic shock. (It also has a significant and important inhibiting impact on myeloperoxidase levels, discussed in the next section.) This is where the use of Withania somnifera and other herbs such as Glycyrrhiza are exceptionally useful.

In addition to IL-10, importantly, during septic shock the levels of TLR-2 and TLR-4 increase as well. They rise to a minimum of two times higher than during non-shock infections. Toll-like receptors are a special form of pattern recognition receptor (PRR) molecules that are essential in innate immune responses to pathogens. Normally they respond to certain compounds (lipopolysaccharides) in the cellular walls of Gram-negative bacteria. However, Ehrlichia and Anaplasma bacteria don’t have lipopolysaccharides in their membranes. Upregulation occurs through another mechanism entirely: they are responding to the production of another substance called HMGB1. And HMGB1 is a very potent cytokine indeed. We’ll talk more about it in a moment.

THE CAUSES OF SEPSIS AND SEPTIC SHOCK

A cytokine cascade occurs in all people during these types of infections, but for some this progresses to what is more properly called a cytokine storm. It is this storm that leads to sepsis. While it is not known why certain people (and not others) develop sepsis, the initiating factor in all circumstances is the release of what are called damage-associated molecular pattern (DAMP) molecules.

Though, of course, to make things more difficult, they are sometimes also called alarmins or even pathogen-associated molecular pattern (PAMP) molecules.

PAMPs, to get a bit deeper into it, tend to be molecules located on the cellular surface of invading pathogens. DAMPs tend to be molecules that the body’s cells release when they are damaged. Both activate an immune response once they are detected by pattern recognition receptors (PRRs) on the surface of immune cells. (TLRs are a specific form of PRRs.)

The innate immune system, over long evolutionary time, developed, and programmed in, an awareness and memory of certain molecular patterns that are potentially dangerous when they are found in the body. The various parts of the circulating innate immune system, whenever they encounter one of those patterns, initiate specific kinds of immune responses. Because both PAMPs and DAMPs activate the innate immune response some authors refer to both of these molecular signals as alarmins (as in burglar alarm, which, in this instance, calls the immune police). Other researchers insist that alarmins are only those signals that occur from damage and are never from those initiated by pathogens. (Others say, well, it involves their opponents’ mothers somehow; feelings run rather high.) It makes more sense I think (I will probably be attacked on the playground for this) to consider them all as alarmins—PAMPs as exogenous (outside the body) alarmins and DAMPs as endogenous (inside) alarmins. (For reasons that will be clear in a moment, the inside/outside split may not ultimately be useful.)

ENDOGENOUS ALARMINS

There are a number of endogenous alarmins that have been associated with acute conditions leading to sepsis and septic shock, specifically: nucleophosmin, mitochondria, adenosine triphosphate (ATP), DNA, histones, neutrophil extracellular traps (NETs), and HMGB1. These are generally released in the body during nonprogrammed cell death (trauma or infection) and by immune cells using specialized secretion processes during damage or infection.

(As an initial note, the inhibition of NETs, HMGB1, and macrophage migration inhibitory factor, a.k.a. MIF, has been found to negate the cytokine dynamics that create sepsis and septic shock. This can reverse the conditions.)

Nucleophosmin (NPM)

NPM is a phosphoprotein primarily localized in a part of the nucleus of cells called the nucleolus. When cells are broken apart by invading pathogens or when the immune system is stimulated in certain ways, nucleophosmin can be released extracellularly, into the body. NPM release triggers a response release of a number of molecularly active compounds including intercellular adhesion molecule 1 (ICAM-1), TNF-α, IL-6, and monocyte chemoattractant protein 1 (MCP-1, a.k.a. CCL2).

ICAM-1, once produced in enough quantities, can act via a positive feedback loop, creating even more ICAM-1, with deleterious effects on tissues. It acts as a proinflammatory protein on the body’s tissues when released. ICAM-1 initiates leukocyte binding to endothelial cells, more porous junctions between the cells, and transmigration of leukocytes into tissues.

TNF-α is a major proinflammatory cytokine that is closely linked with many autoimmune diseases. High levels of TNF-α can, by them selves, induce septic shock–like symptoms.

MCP-1 recruits monocytes, T cells, and dendritic cells to sites of inflammation in the body. MCP-1 is involved in conditions accompanied by monocytic infiltrates, neuroinflammatory conditions in the central nervous system and brain, and a number of autoimmune conditions. (IL-6 is covered in the DNA section; see page 180.)

Mitochondria

Mitochondria are also released into circulation when cells are killed or are broken apart by pathogens. Mitochondria are formerly free-living bacteria that, billions of years ago, were incorporated into cells through symbiogenesis. They act as the power factories of our cells. Mitochondria that are released into the body are identified by pattern receptors on innate immune cells as foreign bodies, as bacteria, because they aren’t supposed to be free in the body. They are supposed to be sequestered inside other cells. In consequence, mitochondrial release is accompanied by systemic inflammation. People with major trauma to their body accompanied by severe inflammation have plasma levels of mitochondrial DNA at concentrations several thousand times higher than in people who are healthy.

Adenosine Triphosphate (ATP)

ATP transports chemical energy within cells, powering metabolism. It is used by cells as a coenzyme for a wide variety of processes. During cellular damage, ATP is released from cells into the extracellular environment. Further, a number of secretory organelles in cells store large amounts of ATP that they release as a danger or alarm signal. The release of ATP triggers neutrophils, macrophages, and dendritic cells to activate IL-1β and IL-18 (and the subsequent release of IL-1α). All are involved in the production of inflammation processes in the body.

DNA

DNA is normally held inside cells; it is not (generally) supposed to exist free in the body. In consequence, when it is, the innate immune system experiences it as an alarmin, signaling damage to cellular tissues (hence DAMP). (DNA can, of course, be an exogenous alarmin or PAMP when it is released from killed microorganisms such as babesial protozoa.) Immune mononuclear cells, when they encounter free DNA, immediately bind with it. This stimulates the release of significant amounts of IL-6 in the body, from both bound mononuclear cells and the spleen. The more free DNA in the serum, the more IL-6 that is produced. Overproduction of IL-6 is involved in a number of pathologic conditions in the body such as autoimmune, inflammatory, and lymphoproliferative disorders. Some of the conditions that occur are plasmacytosis, rheumatoid arthritis, encephalomyelitis, glomerulonephritis, dysregulation of new blood cell formation, and general inflammation and cellular dysregulation of bodily tissues, including the organs. Among the severely ill, those in whom sepsis occurs have been found to have significantly higher levels of free DNA (and IL-6) in their serum than those who did not develop sepsis.

Histones

Histones are highly alkaline proteins that exist inside the nuclei of cells. They package and order the DNA into specific structural units (nucleosomes). In essence they are a kind of spool around which DNA winds.

As an aside, each cell contains nearly six feet (two meters) of DNA. Wound around a histone protein spool this length is reduced significantly, to around 90 micrometers (0.09 μm), allowing it to fit inside the cell.

When cells are damaged, for whatever reason, histones, like the DNA that winds around them, are released into the body. Extracellular his-tones stimulate abnormal endothelial cell activity, neutrophil margination and accumulation, and intra-alveolar hemorrhage.

All these molecules, when released from cells, significantly contribute to inflammation processes in the body and a number of autoimmune conditions; all are involved to differing extents in sepsis. However none are more potent stimulators of sepsis than NETs and HMGB1.

Neutrophil Extracellular Traps (NETs)

Neutrophils freely circulate in the blood vessels and are called to sites of inflammation during microbial infections. For a very long time, neutrophils were viewed through a fairly simplistic (i.e., stupid) lens as being nothing more than dumb killers of pathogens. Specifically, they simply enveloped (phagocytosed) pathogens and killed them. However, this view, in the past decade or so, has come under increasing scrutiny; it is in fact wrong. Neutrophils orchestrate an extremely complex response to microbial pathogens. Among them is the recently discovered capacity to create neutrophil extracellular traps or NETs for trapping and killing microbes.

NETs are formed by neutrophils on contact with many microbes (including a large variety of protozoa), as well as activated platelets and a number of inflammatory stimuli. Once stimulated by this contact a major alteration in the structure of the neutrophil cells occurs. The cells begin to unwind and then extrude their DNA and histones (and a few other substances) to form a kind of net or spiderweb or cage that traps pathogens within it. In essence, the DNA is unspooled and used, along with the histones, to create a webwork to entrap pathogens. NETs are able to trap nearly all types of pathogens, including those too large to phagocytose, among them Gram-negative and Gram-positive bacteria, viruses, protozoa, and yeasts.

To generate NET formation, a number of enzymes, held in special granules in the neutrophils, are, at the moment of contact with a pathogen, released. Neutrophil elastase (NE) and myeloperoxidase (MPO) are two of the most crucial. They break apart the DNA/histone formation and initiate their extrusion into the extracellular space. Once the NET forms, a number of compounds—NE, MPO, cathepsin G, proteinase 3, lactoferrin, calprotectin, and numerous antimicrobial peptides—are also released into the extracellular space. These act to kill the pathogens held inside the NETs. The histones integrated into the NET webs disintegrate the pathogen cell wall membranes, making them more susceptible to these microbial-killing compounds. Unfortunately, once stimulated, under some circumstances NETs continue to form throughout the body and organs, despite microbial clearance.

The continued presence of NETs creates an ongoing inflammation process in the body. Much of this comes from the massive amounts of DNA and histones that remain in circulation. This has been linked to a number of chronic inflammatory and autoimmune diseases such as vasculitis, thrombosis, acute lung injury, and even cancer. DNA, histones, MPO, NE, and cathepsin G are strongly involved in the tissue destruction that occurs in various organs and tissue types, especially endothelial and epithelial cells. NETs are a major factor in the acute conditions that can occur during coinfections, and are participants in both sepsis and septic shock.

Neutrophils that accumulate in specific locations, such as the lungs or brain, can cause serious damage when NET formation becomes self-generating. IFN-γ levels increase substantially in those locations (not in serum) and can cause, as an example, the kinds of problems seen in the neurological manifestations of malaria and babesiosis.

Inhibitors of NET formation can significantly reduce the impacts on organs and cellular tissues. (Some general NET inhibitors found to be effective are EGCG, rutin, vitamin C, and N-acetylcysteine). Inhibiting NE and MPO will stop NET formation entirely. There are a number of plants and isolated constituents/supplements that are very good for this.

Neutrophil Elastase (NE) Inhibitors

The seeds of Caesalpinia echinata (brazilwood) inhibit NE (as well as cathepsin G, proteinase 3, and NF-κB). They have been found to directly reduce organ injury caused by NETs, especially in the lungs. (This herb is not generally available, nevertheless it is specific for this.)

Other NE inhibitors, in no particular order, include the traditional Chinese herb Spatholobus suberectus (millettia) stems, Erythrina velutina seeds (a.k.a. mulungu, which also inhibits TNF-α and leukocyte migration and stimulates IFN-α and IL-12), Semiaquilegia adoxoides (tiankuizi), Thymus vulgaris (thyme), Tamarindus indica (tamarind) seeds, Galium aparine (cleavers), Arctium lappa (burdock) root, Fucus vesiculosus (bladderwrack), Pimpinella anisum (anise) seed, Angelica sinensis, Harpagophytum procumbens (devil’s claw) root, Actaea racemosa (black cohosh) root, Oenothera biennis (evening primrose) oil, Nigella sativa (black cumin) seed, oleic acid (olive leaf–infused oil), quercetin (also inhibits lactoferrin), heparin, resveratrol (from Polygonum cuspidatum), and genistein. The research on natural inhibitors of NE is fairly deep; this is just a look at some of the more prominent ones.

The strongest inhibitors, in my opinion, are Angelica sinensis, Caesalpinia echinata seeds, Erythrina velutina seeds, Nigella sativa, Spatholobus subererectus, and the constituents/supplements oleic acid (olive leaf–infused oil), resveratrol, quercetin, EGCG, rutin, N-acetylcysteine, and genistein.

Myeloperoxidase (MPO) Inhibitors

The research on MPO inhibitors is much less deep than for NE; nevertheless the inhibitors include Amburana cearensis, Baccharis spp., Bauhinia forficata, Cissus sicyoides, Glycyrrhiza spp., Oenothera paradoxa (evening primrose) oil, Paeonia lactiflora, Punica granatum (pomegranate), Scutellaria baicalensis, and the isolated constituents/supplements myricitrin, quercetin, resveratrol, and silymarin (milk thistle seed). The strongest appear to be Scutellaria baicalensis, Oenothera paradoxa (evening primrose) oil, quercetin, rutin, resveratrol, and silymarin.

HMGB1

High-mobility group protein B1 (HMGB1) is a nuclear binding protein. It works to facilitate gene transcription, stabilizing nucleosome formation in the cell. In essence, it is a guardian of the genome, protecting it from oxidant injury while promoting healthy genome formation and function. It is commonly found inside the nucleus and in the cytosol—the fluid inside the cell. It is also secreted from mature dendritic cells, leukocytes, and natural killer cells when they encounter alarmins. Damaged or necrotic cells (including red blood cells) release massive quantities of HMGB1 as they break apart.

HMGB1 is one of the most potent cytokine inducers known. During the early stages of infection, HMGB1 is a powerful, and benign, part of the innate immune response. The cytokines it induces do clear infections. Because it is so potent, HMGB1 stimulates the immune system to respond to and detect extremely low levels of parasite infestation. It also calls stem cells to damaged cellular sites, simulating tissue regeneration. The problem occurs when the immune system dysregulates, a postive feedback loop is generated, and HMGB1 levels do not subsequently decrease.

Interestingly, the molecular form of released HMGB1 is somewhat different depending on the site that releases it. Immune cells release one form, damaged or necrotic cells another. Each type of HMGB1 stimulates slightly different cytokine cascades. During inflammatory episodes as well as bacterial infestations of cells the more cells that are damaged, killed, and broken apart, the more HMGB1 they release. This initiates a powerful storm of cytokines throughout the body.

HMGB1 evokes an extremely potent innate immune response when it interacts with cellular surface receptors. Once HMGB1 is released from damaged cells it binds to specific cell surface receptors such as RAGE (receptor for advanced glycation end-products) and TLR-4. This combination stimulates the production of NF-κB (and its pathway), which then stimulates the production of TNF-α, IL-1β, and IL-6.

Most cytokines have a short life span. TNF-α, for example, only lasts around 90 minutes once its production is stimulated. HMGB1, on the other hand, lasts some 18 hours. During its life span it continues to stimulate the production of other cytokines. It is also a delayed immune stimulant; it generally begins to be released much later than other immune cytokines, anywhere from 8 to 48 hours later, depending on circumstances. This is why sepsis occurs later during infections. (HMGB1 is released more quickly—within two hours—during burns or trauma, but during infections it is slower.) Once initiated, HMGB1 levels tend to remain high. A reduced form with high chemoattractant properties occurs during the first three weeks of infection, then a strongly inflammatory form presents for the next four to eight weeks. And levels remain high, for up to two months after the septic condition appears to have passed.

HMGB1 tends to be much more potent in its effects if there is extracellular DNA present. Thus the more cellular debris there is, the more potent its impacts on the body. Once HMGB1 encounters DNA, it strongly binds to it, producing synergistic impacts throughout the body.

HMGB1 strongly suppresses normal IL-10 production but is involved in the expression of the altered IL-10 that is present during septic episodes. As well, HMGB1 activates specific pattern recognition receptors called toll-like receptors (TLRs) that exist on the surface of sentinel immune cells. It specifically activates TLR-2, TLR-4, and TLR-9 as well as RAGE. (TLR-4 on the other hand, once upregulated, itself stimulates the release of HMGB1, creating a self-reinforcing pattern.) The TLRs strongly upregulate a number of other, very potent cytokines, contributing to the cytokine storm. To make things worse, HMGB1 is strongly synergistic with these cytokines—that is, it amplifies their effects.

Levels of NF-κB, TNF-α, RANTES, IL-6, MIF, IL-12, and IFN-γ, in pretty much that order, are stimulated. The amount of cytokine production is directly proportional to the amount of HMGB1 being produced. The more that is released, the higher cytokine levels go. (And these HMGB1 levels are tiny; only microgram quantities are necessary to produce extremely potent effects.) The levels of IL-6, for example, are four times higher, IL-8 three times higher, and IFN-γ two times higher during severe, HMGB1-accompanied infections than the levels in milder cases. The higher the cytokine levels go, the more cells that are damaged by inflammation. As damaged and necrotic cells proliferate, more HMGB1 is released. A positive feedback loop is created. The inflammation becomes self-sustaining. Other cytokines (chemokines) begin to be produced, such as CXCL12, IL-8, MCP-1, and MIP-1 and MIP-2. And still other actors come into play.

Platelets can also express HMGB1; they export it to their cellular surfaces when activated by cytokines. (And the specific spectrum of cytokines we’re talking about here does in fact cause them to express HMGB1.) The upregulation of HMGB1 on platelets stimulates the production of RAGE, a.k.a. the receptor for advanced glycation end-products, by endothelial cells. Once RAGE is upregulated, the endothelial cells increase their expression of vascular cell adhesion molecule 1 (VCAM-1) and intercellular adhesion molecule 1 (ICAM-1). These compounds increase the permeability of the endothelial cells and inhibit their binding to each other, permitting infiltrate movement through the endothelium deeper into the body. Infiltrates can include microbial pathogens, immune cells, and cytokines. This is a source of the infiltrates that occur in damaged organs and the increased inflammation and edema that they experience.

HMGB1 levels tend to be very high in the serum of the acutely ill, especially those with sepsis and septic shock. The higher the levels are, the worse the prognosis. Anemia is common and worsens the higher the levels become. Cytokines such as TNF-α, MIF, IL-12, and IL-10 and babesial protozoal factors such as lysate and hemozin inhibit effective red blood cell production (erythropoiesis), creating anemia.

HMGB1 and NE are, unsurprisingly, synergistic with each other. HMGB1 stimulates the release of myeloperoxidase (MPO), leading to more production of NETs, while neutrophil elastase (NE) stimulates the release of HMGB1, leading to more production of MPO, which leads to more production of NETs, which leads to . . .

HMGB1 also stimulates NET formation because it inhibits the macrophage engulfment of dying neutrophils. NETs formation is a kind of cellular death (called NETosis by some). At a certain point in time, to reduce their presence and impacts on the body, NETs are engulfed (phagocytosed) by macrophages, removing them from the system. HMGB1 inhibits this process, thus the NETs remain in circulation longer and continue to generate more impacts, more HMGB1, and so on.

Increased levels of HMGB1 cause many of the symptoms of sepsis including fever, dysregulation of intestinal barrier function, tissue injury, massive accumulation of infiltrates in organs such as the liver and kidneys, accumulation of proinflammatory cytokines in the brain, and neutrophil infiltration and acute injury in the lungs.

The spleen’s splenocytes are particularly activated by HMGB1 and show strongly enhanced cytokine release. In other words they become hyperactive in their release of inflammatory cytokines. The spleen becomes enlarged, leukocyte numbers substantially increase (leukocytosis), and the spleen tissue begins to experience inflammatory damage accompanied by large numbers of infiltrates. Anti-HMGB1 compounds reverse this and reverse splenomegaly.

The impacts of HMGB1 on the liver are similar, producing the physiological alterations in its tissue that have been found during septic events. Again, anti-HMGB1 reduces all those parameters, protecting the liver’s cellular structures and restoring it to normal functioning.

If the infections do affect the brain, the damaged astrocytes and microglia begin to synthesize and release HMGB1 and IL-1β. A rapid release of HMGB1 from the neurons occurs. This process tends to be self-maintaining. Extracellular HMGB1 initiates inflammation through cytokine production and release and the inflammatory mediators then act on the neurocytes, causing more release of HMGB1. At best there is cognitive impairment, at worst epileptic seizures begin to occur. If the brain is subjected to increased levels of HMGB1 over time, cognitive impairment can take a year or more to correct. Again, anti-HMGB1 compounds reverse the process, reducing impairment and alleviating epileptic episodes. Anti-TLR-4 compounds are also effective; reducing IL-1β helps as well. Inhibiting TLR-4 significantly reduces the impacts of HMGB1 on the body as HMGB1 impacts that TLR directly, stimulating cytokine release. (Some useful TLR-4 inhibitors, in no particular order, are resveratrol, artesenuate, guggul, Panax ginseng, curcumin, Astragalus spp., Zingiber officinalis, Polygonum cuspidatum, Lycium chinese root bark, Glycyrrhiza spp., Codonopsis lanceolata, Ginkgo biloba, Scutellaria baicalensis, Salvia miltiorrhiza, and Sparganium stoloniferum.)

Interestingly, both malarial and babesial protozoa contain HMGB-like proteins that they release during infection. They use this, along with other interventions, to stimulate the particular cytokine response they need in order to facilitate infection. During acute infections with either organism, blood levels of HMGB1 are very high. Part of this occurs from the organisms’ damage to red blood cells, which release large quantities of HMGB1.

A number of pharmaceuticals have been found useful for reducing both NETs and HMGB1 levels. Of specific note are minocycline (reduces HMGB1), sivelestat (reduces NE and HMGB1 expression and levels), cisplatin (reduces HMGB1), and heparin. Heparin is a rather potent anti-inflammatory, reducing a number of inflammatory cytokines and processes, including HMGB1.

Of note: Corticosteroids (e.g., dexamethasone and cortisone) as well as aspirin, ibuprofen, and indomethacin, even at superpharmacological concentrations, have no effect on HMGB1 levels. They can exacerbate the condition by delaying appropriate intervention. They do not provide any useful anti-inflammatory actions during sepsis or septic shock.

There are a number of plants and natural substances that have been found to reduce HMGB1 levels and subsequently reduce or eliminate the acute symptoms of infection, sepsis, and septic shock. Aqueous extracts of green tea (Camellia sinensis), Angelica sinensis, and Salvia miltiorrhiza are all effective. All are dose dependent. The compounds EGCG, choline, and nicotine are also effective.

Angelica, dose-dependently, inhibits HMGB1 release and stops the progression of lethal sepsis. Both green tea and EGCG act similarly. They prevent HMGB1 release, attenuate HMGB1-mediated NO (nitric oxide) release, stop the accumulation of exogenous HMGB1 on macrophage cell surfaces, and provide a dose-dependent protection against lethal sepsis, even 24 hours after onset. Circulating levels of HMGB1 are reduced, as are levels of IL-6. Angelica shows similar activity while also inhibiting the endothelial cell permeability that HMGB1 causes.

Both Salvia miltiorrhiza and its tanshinone constituents dose-dependently reduce circulating HMGB1 levels and protect against lethal sepsis. The herb/compound also reduces levels of RAGE, TLR-4, and NF-κB. Neurological deficits in the brain (for instance) are alleviated, inflammation decreases, function is normalized. Claudin-5, a protein, is strongly upregulated. Claudin-5 is an integral membrane protein that serves to create tight junction strands in epithelial and endothelial cell sheets. This prevents the migration of infiltrates through the epithelial and endothelial barriers deeper into organ tissues.

Licorice (Glycyrrhiza glabra) and its constituent glycyrrhizin are important adjuncts in treating HMGB1-related sepsis. The plant and its compound reduce the release of HMGB1 and, at the same time, through a number of mechanisms, strongly bind to the HMGB1 molecule. Thus, through two mechanisms, they reduce the amount of circulating HMGB1 in the system. Licorice (and glycyrrhizin) has been found to inhibit SIRS, the systemic inflammatory response syndrome, which is an essential component of sepsis. It also normalizes splenocyte function in the spleen, reducing its hyperactivity, primarily from its effects on HMGB1 and a number of the involved cytokines. Licorice (and glycyrrhizin) has similar impacts on the liver if used during sepsis. It attenuates histological hepatic alterations, significantly reducing ALT and AST levels as well as lactate dehydrogenase. Hepatocyte apoptosis, a major element in organ failure and death in severe sepsis, is significantly inhibited by the herb/compound. This is partly due to its impacts on the mitochondria in liver cells; it inhibits the release of the proapoptotic mitochondrial cytochrome C from those cells, especially the Kupffer cells, the primary cells that experience massive die-offs during sepsis. The herb/compound also upregulates expression of proliferating cell nuclear antigen, promoting regeneration of the liver, and confers neuroprotection, reducing HMGB1 levels in the brain and reducing inflammatory damage and epileptic episodes. In addition to its impacts on HMGB1, the herb/compound stimulates the production of normal IL-10 molecules and inhibits a wide range of inflammatory cytokines, chemokines, and adhesion molecules, specifically IFN-γ, TNF-α, CCL2, VCAM-1, E-selectin, caspase-3, MPO, and NF-κB.

Three other important plants that have been found to reduce HMGB1 levels are Forsythia suspensa (one of the 50 fundamental herbs in Chinese medicine; it also downregulates TNF-α, IL-6, MPO, and NF-κB and reduces infiltration of leukocytes), Withania somnifera (which also reduces leukocyte migration and infiltration, reduces endothelial cell permeability, and inhibits ICAM-1, VCAM-1, IL-6, TNF-α, and NF-κB), and Paeonia lactiflora (white peony root, which also down-regulates MPO and inhibits RAGE and TLRs 2 and 4).

Others plants of note are Cannabis and its constituent cannabidiol, Rosmarinus officinalis (rosemary, which also reduces endothelial permeability and leukocyte migration), Prunella vulgaris (self-heal), Cyperus rotundus, and oleanolic acid (from olive oil/leaf, which also inhibits NF-κB and TNF-α).

Other effective compounds are choline, acetylcholine, nicotine, quercetin (and quercitrin), lycopene, rutin (which also inhibits TNF-α, NF-κB, ICAM-1, VCAM-1, vascular permeability, and the adhesion and migration of leukocytes), emodin, curcumin, berberine (note: plants containing berberine are not systemic enough to counter HMGB1 in sepsis or acute conditions), ethyl pyruvate, and ethyl caffeate.

All are dose dependent.

NATURAL TREATMENT OF SEPSIS DURING COINFECTIONS

The treatment rationale for sepsis during acute infection with babesia, ehrlichia, or anaplasma is as follows:

1. Inhibit the release and production of HMGB1 while binding free HMGB1 to reduce levels already in the system.
2. Inhibit and reduce NETs formation by inhibiting NE and MPO.
3. Downregulate IFN-γ, NO, TNF-α, NF-κB, IL-1β, IL-2, IL-6, IL-12, ICAM-1, VCAM-1, and E-selectin.
4. Protect and enhance the function of the organs affected by the specific organisms. Specifically, protection of the spleen and liver is crucial.

Specific Herbs and Isolated Constituents

The specific herbs and isolated constituents (some of which have been detailed earlier in this chapter) are as follows:

HMGB1-inhibitors (primary): Angelica sinensis, Astragalus spp., Camellia sinensis, Forsythia suspensa, Glycyrrhiza spp., Paeonia lactiflora, Salvia miltiorrhiza, Withania somnifera, and the constituents acetylcholine, berberine, choline, curcumin, EGCG, emodin, ethyl caffeate, ethyl pyruvate, lycopene, nicotine, quercetin, quercitrin, and rutin. Note: Plants containing berberine are not systemic enough to counter HMGB1 in sepsis or acute conditions.

TLR-4 inhibitors: Astragalus spp., Codonopsis lanceolata, Ginkgo biloba, Glycyrrhiza spp., Lycium chinense root bark, Panax ginseng, Salvia miltiorrhiza, Scutellaria baicalensis, Sparganium stoloniferum, Zingiber officinale, and the isolated constituents artesenuate, cur-cumin, guggul, and resveratrol.

NE inhibitors: Actaea racemosa (black cohosh) root, Angelica sinensis, Arctium lappa (burdock) root, Caesalpinia echinata (brazilwood) seeds, Erythrina velutina (mulungu) seeds, Fucus vesiculosus (bladderwrack), Galium aparine (cleavers), Harpagophytum procumbens (devil’s claw) root, Nigella sativa (black cumin) seed, Oenothera biennis (evening primrose) oil, Pimpinella anisum (anise) seed, Semiaquilegia adoxoides (tiankuizi), Spatholobus suberectus (millettia) stems, Tamarindus indica (tamarind) seeds, Thymus vulgaris (thyme), the isolated constituents genistein, quercetin, oleic acid (olive leaf–infused oil), and resveratrol, and the pharmaceutical heparin. The research on natural inhibitors of NE is fairly deep; this is just a look at some of the more prominent inhibitors.
    The strongest inhibitors, in my opinion, are Angelica sinensis, Caesalpinia echinata seeds, Erythrina velutina seeds, Nigella sativa, Spatholobus subererectus, and the constituents/supplements oleic acid (olive leaf–infused oil), resveratrol, quercetin, EGCG, rutin, NAC, and genistein.

MPO inhibitors: Amburana cearensis, Baccharis spp., Bauhinia forficata, Cissus sicyoides, Forsythia suspensa, Glycyrrhiza spp., Oenothera paradoxa (evening primrose) oil, Paeonia lactiflora, Punica granatum (pomegranate), Scutellaria baicalensis, and the isolated constituents/supplements myricitrin, quercetin, resveratrol, rutin, and silymarin (milk thistle seed). The strongest appear to be Scutellaria baicalensis, Oenothera paradoxa (evening primrose) oil, Paeonia lactiflora, quercetin, rutin, resveratrol, and silymarin.

IL-12 inhibitors: Cordyceps spp., Salvia miltiorrhiza.

IFN-γ inhibitors: Chelidonium majus (greater celandine), Cordyceps spp., Glycyrrhiza spp. (licorice), Morinda citrifolia (noni), Paeonia lactiflora, Sambucus spp. (elder), Scutellaria baicalensis root. Note: Elder and licorice are IFN-γ modulators—they raise it if necessary, lower it when needed.

Nitric oxide inhibitors: Cordyceps spp., Eupatorium perfoliatum (boneset), Hericium erinaceus (lion’s mane mushroom), Houttuynia spp., Morinda citrifolia (noni), Polygala tenuifolia (Chinese senega) root, Scutellaria baicalensis root.

TNF-α inhibitors: Angelica sinensis, Cordyceps spp., Erythrina velutina (mulungu) seeds, Eupatorium perfoliatum (boneset), Forsythia suspensa, Ginkgo biloba, Glycyrrhiza spp., Houttuynia spp., Paeonia lactiflora, Polygala tenuifolia (Chinese senega) root, Pueraria lobata, Sambucus spp., Scutellaria baicalensis root, Withania somnifera, Zingiber officinalis, and the constituents quercetin and EGCG.

IL-1β inhibitors: Astragalus spp., Cordyceps spp., Eupatorium perfoliatum (boneset), Polygala tenuifolia (Chinese senega) root, Polygonum cuspidatum (Japanese knotweed) root, Pueraria lobata (kudzu), Scutellaria baicalensis root.

IL-6 inhibitors: Forsythia suspensa, Isatis spp., Paeonia lactiflora, Pueraria lobata (kudzu), Scutellaria baicalensis root, Withania somnifera.

ICAM-1 inhibitors: Cordyceps spp., Paeonia lactiflora, Polygonum cuspidatum (Japanese knotweed), Sambucus spp., Withania somnifera.

VCAM-1 inhibitors: Glycyrrhiza spp., Polygonum cuspidatum, Pueraria lobata (kudzu), Sambucus spp., Scutellaria baicalensis root, Withania somnifera.

E-selectin inhibitors: Glycyrrhiza spp., Paeonia lactiflora, Polygonum cuspidatum, Pueraria lobata (kudzu).

IL-2 inhibitors: Commiphora mukul (myrrh), Scutellaria baicalensis root.

NF-κB inhibitors: Astragalus spp., Eupatorium perfoliatum (boneset), Forsythia suspensa, Glycyrrhiza spp., Houttuynia spp., Paeonia lactiflora, Polygala tenuifolia (Chinese senega) root, Pueraria lobata, Salvia miltiorrhiza, Scutellaria baicalensis root, Withania somnifera, Zingiber officinalis.

Suggested Pharmaceutical Support

Heparin: Because heparin has been found so effective across such a wide range in septic conditions, in truly serious conditions it makes sense to use it. It specifically inhibits neutrophil elastase–induced HMGB1 release and inhibits NE activity in the body. (If its anticoagulant properties are a problem a desulfated heparin can be used instead.) Its actions are particularly effective in alleviating HMGB1-related lung injury.

SUGGESTED PROTOCOL FOR SEPSIS

As you can see from a review of the active herbs, the ones that cover the most areas are Angelica sinensis, Astragalus spp., Cordyceps spp., Forsythia suspensa, Glycyrrhiza spp., Pueraria lobata, Salvia miltiorrhiza, Scutellaria baicalensis, and Withania somnifera. Thus . . .

1. Tincture combination of Angelica sinensis and Astragalus spp. (equal parts of each), 1 tablespoon each hour.
2. Tincture of Salvia miltiorrhiza, 1 tablespoon each hour.
3. Tincture combination of Pueraria lobata and Cordyceps spp. (equal parts of each), 1 tablespoon each hour.
4. Tincture combination of Glycyrrhiza spp. and Scutellaria baicalensis (equal parts of each), 1 tablespoon each hour.
5. Spleen protection is provided by the Salvia miltiorrhiza. This will also protect the liver to some extent, as will the licorice. The use of high-dose standardized silymarin compounds is highly suggested to protect the liver’s Kupffer cells from apoptosis. (Dosage: milk thistle, standardized tincture, 1 teaspoon 6x daily.)

The tinctures may be mixed together in any liquid (pomegranate suggested) and should be taken until sepsis ameliorates. Note: Such high doses of licorice (Glycyrrhiza spp.) are strongly contraindicated for long-term use. This is a short-term, acute condition intervention only.