Free Practitioner Case Study – July 2017

Dr. Michael Ruscio’s Monthly – Future of Functional Medicine Review Clinical Newsletter

Practical Solutions for Practitioners

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Case Study

Patient Info:

  • Jeffery, 26yo male
  • Dx: N/A
  • Rx: Zyrtec
  • Chief complaints:
    • Brain fog; decreased intelligence, memory issues
    • Brain/head pain, feels like pressure and pinching pain
    • Fatigue
    • Sleep disturbances; wakeful
    • IBS: (bloating, diarrhea, poor bowel consistency)
    • Lower back/spinal cord pain

Visit 1 (10/12/16) – History and Exam:

Jeff presents as a generally healthy 26yo male with an okay diet and good lifestyle. He might be a bit overzealous with self dx and experimentation. Has many symptoms, but all started with IBS and all get worse when does not sleep well.

Has not done much in the way of FM care, but has responded to diet, digestive enzymes, and Chinese herbs. But also appears sensitive to supplements.

I’d like to start with standard approach of GI, adrenal support, nutritional support, and diet and see how he does. Also have him check in with GP for eval b/c of neuro symptoms.

I suspect improving GI can help with all other SS, but mind other ddx like metals, although not highly supported. Prognosis good to excellent.

Initial impression

  • Jeff’s case appears straightforward and he will likely do well with standard GI care. However, being mindful of overzealousness regarding self-diagnosis may be important and managing this could help prevent him from ‘getting in his own way.’

Visit 2 (10/19/16) – Testing and Initial Recommendations

Testing

  • Aerodiagnostics Lactulose SIBO breath test
  • Doctors Data Comp. Stool w/ Para 3x
  • Quest basic blood panel
CBC / Differential & Platelet Count
Phosphorus, Serum
GGT
T-4
Iron
TSH
Lipid Panel
T3 Uptake
Magnesium
Uric Acid
Metabolic Panel, Comprehensive
Urinalysis
Insulin
25-Hydroxy Vitamin D Calcitriol (1,25 di-OH Vitamin D)
HbA1c
TIBC & %Iron Saturation
Ferritin
C-Reactive Protein (HS)
ESR
Fibrinogen
Homocysteine
  • Quest GI panel
 Stool Culture, complete
Clostridium difficile Toxins A and B, EIA
H. pylori stool antigen
H. pylori Breath Test
Yersinia Enterocolitis IgM, IgG, IgA
Yersinia Stool Culture
Ova and Parasites 3x Examination w/o Giardia
Giardia and Cryptosporidum Ag
Yeast Only, Culture w Reflex to ID (stool)
Candida Antibodies, IgA, IgG, IgM, ELISA
Toxoplasma gondii Antibodies, IgG
Toxoplasma gondii Antibodies, Quantitation, IgM
Toxoplasma gondii, PCR (whole blood)
E. histolytica, Amebic Antibodies
Trichinella (Tissue Worm) Ab, SIgA
Ascaris (Roundworm) Ab, IgE
T. solium (Tapeworm) Ab, serum (aka Cysticercus Ab, serum)
Indicans, Urine Qualitative
Eosinophil Cationic Protein ( Eos. protein X)
White Blood Cells (WBC), Stool
Fecal fat, Quantitative
CRP (C-reactive protein) (non-HS)
Calprotectin, Fecal
ESR (Sedimentation Rate, Modified Westergren)
Lactoferrin, Quantitative, Stool
Occult Blood, Fecal, Immunoassay
Parietal cell ABs (APCA)
Inflammatory Bowel Disease (IBD) Expanded Profile; ACCA, ALCA, AMCA, gASCA, pANCA.
  • Rationale
    • We want to screen for SIBO and also perform an assessment for other dysbiosis and/or pathogens. Given Jeffery’s mild presentation, we could have used only one test for dysbiosis/pathogens, but he wanted to be aggressive and we had insurance coverage so we elected to be a bit more robust in our analysis.
    • We also want to perform a standard eval for things like hypothyroid, low vitamin D, anemia, etc., which the basic blood panel covers.

Recommendations

  • Please perform the Modified Fast (see website for PDF), then
  • Start on the paleo low FODMAP diet.
  • After a few weeks on whole foods, try the Semi-elemental diet as Absorb Plus or Physicians Elemental for 2-4 days (see website PDF Elemental Diet Patient Handout for more). If you do not tolerate this version, we’ll consider experimenting with the others listed.
  • Try to slowly work into exercise plan where you break a sweat 3 days per week.
  • Follow up with your primary care for neurological symptom evaluation.
  • Work onto program slowly and one at a time
  • NRT: Omega 3, 6, 9 blend
  • Adrenal: Preg, DHEA
  • GI: probios1 (lacto/bifido blend), probios2 (S. boulardii), probios3 (soil-based organism), digestive enzyme/acid/bile blend
  • Rationale
    • Fasting will tell us if he can benefit from periodic fasting or intermittent fasting
    • Exercise may be only treatment needed for neuro symptoms, hopefully
    • Adrenal support may aid with sleep, fatigue, and brain fog
    • GI support may aid with GI symptoms

Visit 3 (12/7/16) – Lab Interpretation and Treatment Evaluation

Lab interpretation:

  • Summary
    • Moderate H2 predominant SIBO. HP, Yersinia. Potential: candida, dysbiosis, fat malabsorption, GI AI.
    • Here is the big take-home with this case: a good functional medicine lab missed some significant findings, which were detected via a standard insurance lab. This is part of the reason why I say ‘the belief that insurance labs don’t offer good GI testing is a misnomer.’
    • Finding the HP, Yersinia, and potential candida are very meaningful, whereas the Doctors Data ‘commensal bacteria overgrowths’ is much less meaningful, in my opinion.

Subjective Assessment:

  • Jeffery did not perform the modified fast nor the trial of the elemental diet.
  • He was exercising regularly, which he felt to be helpful.
  • He was also on all the recommended supplements and felt like these were helping also.
  • Jeff felt globally improved, but most of his symptoms were still present, just less severe.
    • Improved
      • Brain fog; Decreased intelligence, memory issues
      • Brain/head pain, feels like pressure and pinching pain
      • Fatigue
      • IBS (bloating, diarrhea, poor bowel consistency)
    • Same
      • Sleep disturbances; wakeful
      • Lower back/spinal cord pain
    • Worse
      • N/A

Impression:

  • We are on the right track with diet, exercise, and supplement plan. Everything was well tolerated. However, today’s lab findings might account for his incomplete improvement from initial program, so treatment of today’s findings are highly justifiable.

Recommendations:

  • Continue previous program
  • Starting
    • Broad spectrum herbal antimicrobial blend (2 formulas), herbal blend including Mastica (for HP); 2 month protocol
    • Follow up in 4-5 weeks

Visit 4 (1/6/17)

Subjective Assessment:

  • At his follow up, all of Jeff’s symptoms had improved and improved to the point where he was fully satisfied with his results.

Dr. Ruscio’s Comments

I recommended Jeff to follow up again at the end of the antimicrobial protocol. However, Jeff let the office know he was feeling well and did not feel the need to follow up. This is a good problem to have! If he had, we would have retested the Quest findings, and also worked to first reintroduce foods to expand dietary boundaries, then again shortly after to reduce/eliminate the supplements in his program.

The major item I wanted to showcase here was:

  1. The value of running tandem/overlapping GI analyses and
  2. That the insurance labs like Quest/LabCorp do offer quality testing.

We also see a living example of what is reflected in the research literature: SIBO and HP tend to co-occur. The test results also helped us personalize the antimicrobial therapy and, if we used pharmaceuticals, could have helped with selecting the ideal agents.

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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