Practitioner Case Study – September 2017

Patient Info:

• Anna, 76yo female
• Previous Dx: IBS
• Rx: N/A
• Chief complaints
  • Diarrhea, 9-INT
  • Stomach Ache, 5-INT
  • Bloating, 8-CO
  • Reflux, 6-INT
  • Weakness/Fatigue, 5-CO
  • Joint Pain, 8-CO
  • Belching, nausea, mucus in throat
  • **You will notice we are now tracking severity (on a 1-10 scale) and frequency (as occasional, intermittent, or constant). I used to ask this during exams, but it has been much easier to have this in writing.

Visit 1 (day 1) – History and Exam:

Anna Marie presents as a pleasant 76yo female who is on a limited diet, inactive due to leg cramping/weakness, but has a great demeanor. She has done a lot of health research and I fear her eagerness has been exploited by other providers.

She has been Dx with IBS and is on no Rx. Her CCs seems to have started after food poisoning in ’85 and persisted somewhat ever since. She has not done any FM work; her conventional workups have come back normal.

Her presentation is highly consistent with PI-IBS, SIBO, and histamine intolerance. Other ddx are possible, including high acid/ulcer or Hg tissue burden.

Acid lowering supplements have helped, while probiotics may cause diarrhea. Low FODMAP/SCD diet food list resonates with what she notices she can eat.

We will work through standard GI model. Since she has done no FM GI work there is much potential. Long course of illness may be poor prognostic indicator. Prognosis fair to good.

Initial impression

• Anna is a great example of a patient who would do anything (highly motivated), and sadly her binder of frivolous tests and her thinking that she had 10 different diagnoses was a testament to how damaging some CAM and functional medicine can be. She had spent a lot of money, felt no better, but was convinced a lot was wrong with her – all thanks to her other providers.
• Her case should be relatively straightforward, but there are a few unusual observations. She is elderly and this population is at highest risk for low stomach acid, however she feels better on supplements that decrease stomach acid. She also may have a negative reaction to probiotics.

Visit 2 (a few days later) – Testing and Initial Recommendations

Testing

• Tests ordered
  • Aerodiagnostics GLUCOSE SIBO breath test
  • Doctors Data Comp. Stool w/ Para 3x
  • Diagnostechs GI-15 stool/saliva test
  • Custom blood panel at LabCorp
    • CBC w/ Diff & platelet count
    • Metabolic Panel, Comprehensive
    • Lipid Panel
    • Iron Panel: Iron, TIBC, Iron Sat., Ferritin
    • Sed Rate (ESR), Westergren
    • Insulin, fasting
    • Hemoglobin (HGB) A1c
    • C-Reactive Protein (CRP) Quant.
    • T-4, Free (Thyroxine, Free)
    • Thyroid-Stimulating Hormone (TSH)
• Testing Rationale
  • We of course want to rule out SIBO; she was very reactive to FODMAPs, so lactulose may have flared here, hence the decision to use glucose.
  • Additionally, since this all started after food poisoning, a good evaluation of parasitology is indicated.
  • If I could run this again I would have added HP breath and AB testing at LabCorp.
  • The blood panel will assess for any common metabolic imbalances: diabetes, hypothyroid, anemia, etc.…

Recommendations

• Continue with your previous personalized elimination diet
• Do your best to start walking – start slowly and gradually
• See local therapist for help with legs/cramping – consider someone who practices ART (active release technique)
• Do your best to be in bed before midnight

• Dietary
  • Please perform the Modified Fast for 2-4 days (see website for PDF), then
  • Resume your normal diet for 2-4 days. Then,
  • Try the Semi-elemental diet for 2-4 days (see website PDF Elemental Diet Patient Handout for more).
• Supplemental
  • GI: Enzyme/bile formula, HCl formula, S. boulardii
  • Continue your magnesium
• Recommendation Rationale
  • Her diet was already restrictive and based on elimination-reintro, so not much change was needed there.
  • I did want to eval the effect of fasting and perform a short trial of an elemental formula.
  • Even though she noted she had responded well to acid lowering supplements, I wanted to eval if she should be aided by using HCl, hence the trial here.
  • I also decided to try S. bouldardii alone since she had reacted to probios previously, knowing boulardii can be helpful with diarrhea.

Visit 3 (day 30) – Lab Interpretation and Treatment Evaluation

Lab interpretation:

Aerodiagnostics GLUCOSE SIBO breath test

H2 4, CH4 3, combo 7

Doctors Data Comp. Stool w/ Para 3x

3 commensals overgrown. Candida +1. Yeast: many, 3x.

Lacto/Calpro – wnl

Diagnostechs GI-15

Ascaris lumbricoides, Entamoeba histolytica Ab

PCO

Lipid Panel Cholesterol 248-H, LDL 156-H

Hemoglobin (HGB) A1c  6-H

Thyroid-Stimulating Hormone (TSH)  5.150-H

• Summary
  • Methane producer. Candida/yeast. Age normal SCH (subclinical hypothyroid). Potential Ascaris, E. histo. Mildly elevated cholesterol.
  • SIBO is essentially negative. Candida/yeast appears main issue/imbalance. I had a suspicion the Ascaris and E. histo were false positives, but the herbal candida treatment will act against these also. We will include these both in our retesting to be sure.
  • TSH is normal given her age. A1c elevated in isolation is less suggestive of a problem. Cholesterol is normal given age.

Subjective Assessment:

• She is feeling better after discontinuing the handfuls of supplements she was previously taking (Reminder: I ask all new patients to stop all supplements when we start our work together)
• She did not perform the modified fast or elemental diet
• Felt the supplement program was helping her
• Improved:
  • All digestive symptoms
• Same:
  • Joint pain
• Worse:
  • N/A

Impression:

• We are off to a good start with Anna. She was over supplementing and this appeared to be causing much of her symptoms.
• When seeing her high TSH, she informed me that this was found a year ago by her Naturopath and that her ND aggressively recommended starting on thyroid Rx. Anna complied and noticed her fatigue became much worse after doing so. But shhh, don’t tell this to the thyroid fanatics. ☺
• I told Anna that I think the best approach right now would be ‘wait and see,’ since nearly all of her symptoms had improved. However, Anna really wanted to address her GI findings, so I agreed to start her on herbal antimicrobials.

Recommendations:

• Continue previous
  • Continue with your previous personalized elimination diet
  • Do your best to start walking – start slowly and gradually
  • See local therapist for help with legs/cramping – consider someone who practices ART (active release technique)
  • Do your best to be in bed before midnight
  • Supplemental
    • GI: Enzyme/bile formula, HCl formula, S. boulardii
    • Continue your magnesium
• Now start
  • GI: Oregano, antimicrobial blend formula, Artemisinin
• Recommendation Rationale
  • We will evaluate if any additional benefit can be achieved with herbal antimicrobials

Visit 4 (day 60)

Subjective Assessment:

• Anna felt about the same, except for the following reactions:
  • Heat/flushing, fatigue, sore throat, nausea, stomach ache

Impression:

• Given the fact that the reaction lasted longer than a week, it is likely an allergic-like or irritation reaction. This is good support for acting conservative.

Recommendations:

• Discontinue the herbal antimicrobials, continue with all other previous recommendations.
• Retesting
  • Previous finding from Doctors Data and DiagnosTechs

Visit 5 (day 90)

Lab interpretation:

Doctors Data

2 commensals overgrown. Yeast: many, 1x.

Diagnostechs

Negative

• Summary
  • Doctors Data profile has greatly improved. Since Anna is now asymptomatic, these findings are inconsequential.
  • Ascaris and E. histo could have been cleared or may have been false+, either way we are in good shape now.

Subjective Assessment:

• Flare has subsided, all GI symptoms are significantly improved.
• Joint pain is still present, but Anna feels it is improving from her work with her therapist.

Impression:

• Anna’s GI is in good shape. Since GI improvement did not result in improved joint pain, the pain is more likely structural than internally (GI) driven.

Recommendations:

• Experiment with coming off the supplements in your program. If a symptom regresses when coming off something, go back on. If nothing happens, then discontinue. Do this for 2 months and then follow up. At your next visit we will work to broaden your diet. Keep up the good work!

Dr. Ruscio’s Comments

Anna’s case is a good example of how overzealousness in FM can be problematic. She had spent a lot of money and performed much testing and treatment prior to seeing me. She did not feel any better from this, perhaps because she is somewhat reactive to supplements, which no other provider caught – likely because they were distracted by overtesting and treatment. She was also over treated for SCH, which was normal given her age.

She responded well to some basic therapies. When we attempted more aggressive treatments based upon her labs (herbal antimicrobials), she started to feel worse. An important lesson here is to remember that if what you have already done is working, don’t feel pressure to do more. There is nothing wrong with waiting and seeing, and you can always do more later.