Practitioner Case Study – April 2017

Patient Info:

• Patricia, 60yo female
• Previous dx
  • Thyroid nodule
  • High cholesterol
  • Uterine fibroid
• Rx: N/A
• Chief complaints
  • Swelling in throat
  • Overweight
  • High blood glucose, cholesterol
  • Energy & stamina

Visit 1 (day 1 – 4/16/14) – History and Exam:

Patricia presents as a 60yo female who could improve her diet and lifestyle; poor diet, lots of stress, no exercise.

Her CCs are metabolic in nature (BS, cholesterol, energy, weight) but has also recently been suffering with a swelling feeling in throat, which might be coming from a recently dx thyroid nodule.  She also exhibits many signs of female hormone decline/menopause.

Most of her CCs started after a prolonged period of Abx use (1 year), followed by stress and poor dietary and lifestyle choices.

She has done no other treatment, but has noticed that her throat feels better when she eats less gluten, but it also feels worse when she eats low carb.  Probiotics also appear generally helpful.

Physical exams reveals slight swelling predominantly on right lobe of thyroid.

Initial impression:

• Since Patricia has not addressed some foundational aspects of health, like diet and lifestyle, I anticipate she may respond well to attention here. She will likely see her metabolic complaints improve solely by improved diet/lifestyle.
• Her throat is a different issue. The nodule could be caused by thyroid autoimmunity or from iodine deficiency. These have nearly opposite treatments, so we will start with ruling out thyroid AI. For more on iodine and nodules, search either term in our homepage search box.
• Her female hormone related symptoms should respond well to herbal treatment.

Visit 2 (a few days later – 4/18/14) – Testing and Initial Recommendations

Testing:

• Blood panel, see details at next visit

Recommendations:

• Diet & Lifestyle
  • Autoimmune Paleo Diet, keeping daily carbs generally below 100g
  • Sleep more, 7 hrs/night goal
  • Exercise at least 2x per week
• Supplemental
  • General: Multi, vitamin D, Omega-3
  • Hormonal: bioidentical estrogen/progesterone cream
• Follow up 4 weeks

Visit 3 (5/16/14) – Lab Interpretation and Treatment Evaluation

Lab Interpretation:

• Blood panel:
  • High glucose, cholesterol, mild/managed thyroid AI, low vitamin D – see below.
• Note: I could have ordered a LOT more testing than I did: female hormones, iodine, selenium, H. Pylori/GI workup, viral titers (EBV can cause swelling in throat)… But because she had not yet addressed foundational items like diet and lifestyle, I was reserved because many/most findings here will likely improve from addressing these. If I was seeing her today, I likely wouldn’t even order the expanded thyroid hormone markers (fT3, rT3) because they are simply noise this early in the process.

Subjective Assessment:

Improved:

• Swelling in neck, gone completely
• Energy
• Mood
• loss, roughly 8 lbs

Impression:

• As expected, she has responded very well to implementing some basic changes. No more improvement was needed at this point, so we will continue with current plan and follow up in another 4 weeks to make sure improvements are maintained and/or to work to reduce program and expand diet.

Recommendations:

• Continue previous plan
  • Diet & Lifestyle
    • Autoimmune Paleo Diet, keeping daily carbs generally below 100g
    • Sleep more, 7 hrs/night goal
    • Exercise at least 2x per week
  • Supplemental
    • General: Multi, vitamin D, Omega-3
    • Hormonal: bioidentical estrogen/progesterone cream
  • Follow up 4 weeks

Visit 4 (6/20/14)

Subjective Assessment:

• All previous improvements have been maintained

Impression:

• Patricia continues to do great. She is likely ready to come off her supplemental support program and proceed into a dietary reintroduction.

Recommendations:

• Continue previous
  • Lifestyle
    • Sleep more, 7 hrs/night goal
    • Exercise at least 2x per week
  • Discontinue
    • Supplemental
      • General: Multi, vitamin D, Omega-3
      • Hormonal: bioidentical estrogen/progesterone cream
    • Start to gradually add in foods you had cut out previously
    • Follow up 3-4 months or as needed

Dr. Ruscio’s Comments

Patricia was a great example of when we should do less testing. Since she did not have her diet and lifestyle in order, we should be reserved with our testing because many of the “positive” findings will likely be noise.  If she did not respond well to diet/lifestyle changes, then testing based upon her non-responsive symptoms would make sense.

The metabolic response to a lower carb paleo-like diet is not surprising; weight loss, better energy, and, if we retested, likely improved glucose and cholesterol. However, how do we account for such rapid improvements in her thyroid?  Thyroid AI may cause thyroid nodules, although the data here are far from conclusive.  What’s interesting is her thyroid AI was almost nonexistent; she was nearly in the normal range for TPO and TG was normal. It is possible that reducing this small amount of immune-mediated inflammation in the gland reduced swelling, but not likely in my opinion.

What I think may have been more likely, especially due to the rapid response and because she reported that foods seemed to have an impact almost immediately, is eosinophilic esophagitis (EoE).  This can cause dysphagia and a feeling like something is stuck in the throat.  Admittedly, her presentation does not fit the classical presentation of EoE, but I’m suspicious of it nonetheless.  She had seen an EENT who might have missed this during his exam, or it may have required biopsy to have been fully identified.  When avoiding allergenic foods, EoE can respond rapidly.  Nodules, however, don’t tend to respond near immediately, which is why I think EoE has more plausibility.  In any case, the reduction of allergenic foods was likely the main reason for the improvement in her throat swelling, whether it was from a nodule or from EoE.

What about her comment of ‘her throat feeling worse when she eats low carb?’ Could this be ‘low carb damaging her thyroid?’ Note: there is an erroneous belief that low carb somehow damages thyroid – we covered in a previous edition how low carb may actually help stop autoimmune thyroid damage.  My thinking is when she previously ate low carb, she was inadvertently eating more allergens.  The autoimmune paleo diet (AIP) is very similar to a 6 or 8 food elimination diet, which has shown impressive results for EoE quite simply because they reduce dietary allergens.  We had her eat a low carb AIP and her throat swelling improved, so it must not have been the carbs themselves that were the culprit.

Overall, Patricia did great, and more importantly did so without spending a lot, without being fear-mongered regarding ‘having thyroid autoimmunity,’ and without being instructed that she needed to follow a rigorous supplement program or restrictive diet in the long term to maintain her results.

I’d like to hear your thoughts or questions regarding any of the above information. Please leave comments or questions below – it might become our next practitioner question of the month.

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