Patient Case Studies

The following case studies illustrate how an integrated and comprehensive approach to health care can help individuals determine and resolve the root causes of their health issues and start enjoying better overall health.

Patient "A"

“A” presented with a diagnosis of hives after 3 recent ER visits, where “A” was given steroid medication. “A” had seen an allergist who advised that there were no tests that could be done to determine the cause of hives. "A" was prescribed 2 antihistamines, to be taken daily and indefinitely. When “A” asked me to recommend lab tests, I explained that since the hives were caused by delayed type reactions, “A” could do testing through ELISA / ACT Biotechnologies for their Lymphocyte Response Assay. The results of this testing showed “A” was having both strong reactions and moderate reactions to a number of items. I advised “A” to avoid substances identified as “strong reactive” for at least 6 months and “moderate reactive” items for at least 3 months. Most of the “reactive items” were foods “A” ate regularly.

“A” was then recommended an alkalinizing diet and certain nutritional supplements, targeted at calming the overactive immune responses and healing the leaky gut. “A” was also advised follow a rotation diet of foods that tested negative, to avoid forming new reactions. Within 3 days, “A” was able to stop taking antihistamines. Incidentally, 2 weeks later “A” had a reaction after discovering that a friend had included one of “A’s” reactive foods in her meal. After following the comprehensive program for 6 months, “A” remained symptom free, even with the reintroduction of previously reactive items.

Patient "B"

“B” first presented with “allergy” symptoms, including post nasal drip, as well as with a history of hypertension, insomnia, glaucoma, gastric reflux, chronic sinusitis, asthma, eczema and migraines. “B” brought records from an allergist, showing allergies to trees, grasses, weeds, dust mites, and molds. “B” reported that symptoms were constant, and were negatively impacting sleep.

Shortness of breath and muscle and joint pain were noted. “B” reported that antihistamines were not continuing to be effective and allergy desensitization shots were not helping. “B” was on a second round of allergy desensitization shots, after destabilizing, due to to wildfire smoke exposure. I recommended “B” purchase a HEPA air purifier and consider a comprehensive elimination diet trial, as well as nutritional status testing. Additionally, I recommended an Alkalinizing diet, to help calm allergic reactions and also advised “B” to begin to monitor urine pH. I also recommended “B” try herbs, like nettles, as well as buffered vitamin C and the bioflavonoid, Quercetin.

As “B” began an elimination diet, weaning caffeine was started, to avoid rebound headache, and “B” weaned off medication for hypertension. During the first 30 days on the elimination diet, “B” noted deeper breathing, clearer lungs, and although some sinus congestion and nasal drainage persisted, the allergy symptoms were gone. Without nighttime allergy symptoms, “B” reported improved sleep. Better energy and an ability to exercise, followed a 10 pound weight loss.

“B” had reported being significantly restricted from hiking, for the past 20 years, due to low back pain. As we worked together, additional diagnoses were uncovered: depression, vitamin D deficiency, elevated homocysteine, elevated cholesterol. Supplements to replete deficiencies, in addition to Vitamin D and sublingual B12 (as well as B12 injections) were recommended. Massage was suggested for shoulder and back issues. I recommended “B” to do a baseline test through Enterolab for gluten antibodies and continue the sublingual B12 and B12 injections.

Following these recommendations, “B” reported a slight decrease in persistent cold hands and feet. Numbness and tingling, that had been present for some time, as well as sleep, were reported as much improved. “B” had also achieved a neutral first AM urine pH, by following the Alkalinizing diet.

Enterolab testing showed positive for high gluten and TTG-autoimmune gluten reactions. Casein, from dairy and other food sensitivities were also noted as a response to food reintroduction, after the eliminations diet. L-glutamine and gamma orzynol were started to heal “leaky gut”.

At some point, while traveling, “B” was off the elimination diet and noted huge fluctuations in energy without any depression symptoms; “B” had always thought fatigue was related to depression. Sleep disturbance was noted again and allergy symptoms returned with reintroduction of wine. At that point, we discussed a trial rotation diet.

At a subsequent visit, “B” excitedly reported restoring a literal “ high point”, with the ability to climb up a local 9200 ft mountain and hike for 3 days. As “B” continued avoiding gluten, dairy, and soy, with only occasional red wine, “B” noted decreased fatigue, and only mild back pain. “B” was getting back the vitality that had been lost while suffering from underlying food sensitivities and was free of high blood pressure without the need for medication. “B” was enjoying restful sleep, normal energy and mood, and was leading an active lifestyle again.

Patient "C"

“C” came to me wanting a comprehensive functional medicine approach. A few years before we met, ”C” had been hospitalized, and was introduced to a functional medicine doctor, who was working on staff at that time. “C” had a history of Hashimoto’s hypothyroidism, profound fatigue, peripheral neuropathy, oral candidiasis, chronic back pain, seizures, palpitations, tachycardia, low body temperature, cognitive deficits, as well as an episode of jaundice. “C” had been ill for the past 3-4 years, had experienced a series of emotional traumas, and had been unable to drive for the past year. “C” had numerous medical symptoms, but the most symptomatic areas were digestive and emotional. Family history included Alzheimer’s and a brain tumor. Subsequent appointments revealed prior elevated liver function tests and “C” was found to have chronic sinus and ear infections, depression, hair loss, cold hands & feet, and irritable bowel symptoms (IBS), with belching, bloating and constipation. “C” also presented with muscle aches, rashes, dry skin, “hive-like” skin issues, and infections with Human Herpes Virus 6 and Epstein Barr virus. Previously, “C” had been very active, a healthy weight, and was self employed in a family business. “C” recalled the first symptom that presented was dizziness.

I initially recommended a low carb diet and probiotics and herbs to decrease candida, and also recommended “C” have a brain MRI. I recommended herbs and supplements (olive leaf extract, colostrum, vitamin c), use of a “neti-pot", and steam inhalation. Lab work was ordered, to include ANA, and cortisol, in addition to my basic testing panel. We discussed doing a trial of betaine hydrochloride, a trial of an antiviral medication, and referral to an endocrinologist. I recommended “C” start taking saccharomyces boulaardi, an oral probiotic yeast supplement, to remedy low SIgA. As “C” began to work with diet changes, I recommended supplements including chelation for previously diagnosed heavy metals issues. “C” had multiple chelation therapies and noted improvement with head pressure, hand tremors and burning pain.

“C” brought up a history of psoriasis, and was also noted to have elevated salivary testosterone. Due to the elevated testosterone, I ordered a 24 hour urine comprehensive hormone panel from Rhein Laboratories. In addition, I ordered a comprehensive profile, called the ION (Individual Optimal Nutrition). I recommended zinc and a prescription medication for skin treatment. As lab results returned, “C” was found to be vitamin D deficient, with mildly elevated homocysteine, elevated cholesterol and triglycerides, and positive for inflammation, based on hs-CRP (high sensitivity C-Reactive Protein). “C” was advised to increase vitamin D, to achieve more optimal levels and B vitamins were added to improve homocysteine for better liver detox. Thyroid Stimulating Hormone (TSH) reflected under treatment of low thyroid function and autoimmune thyroid antibodies were noted to be elevated, with slightly elevated liver function tests.

Based on nutritional testing, a compounded custom amino acid formula was ordered. I also recommended increasing selenium for thyroid and mercury toxicity issues and due to sensitivity to fish oil, “C” was advised to seek out Omega 3 Fatty Acid supplement from non-fish sources. Future visits focused on pre-existing adrenal insufficiency, abnormal hormones, a new photosensitivity skin rash, excessive urination, a sleep disorder, and an increase in exercise. “C” described fatigue as 20% of normal energy.

At one point, “C” discovered that the water supply at a prior residence had been contaminated with jet fuel, causing perchlorate poisoning, which reduces iodine uptake, subsequently damaging the thyroid gland. With an increased thyroid dose, “C” noted improved GI symptoms and a small improvement in energy. As we continued working together, “C” described fatigue as improved to 60% of normal energy, and noted some weight loss; as “C” had gained 100 pounds since becoming ill.

“C” was diagnosed with Lyme disease, which helped to explain the Multiple Sclerosis type symptoms “C” had been experiencing. “C” then consulted with a doctor specializing in Lyme disease, who diagnosed “C” as having Lyme disease with neurotoxicity. In light of this, “C” made plans to restart IV chelation for heavy metals issues. During this time period, as systemic candida had been diagnosed, I also ordered mold testing. I recommended supplements that can help immune dysfunction and nourish the pituitary gland, which has regulatory function over many systems. I recommended “C” start taking high dose phytonutrients to enhance immune function through nutrition. “C” noted rapid improvement in energy, with fatigue reported as improving to 70-80% of normal energy. We had found that “C” was sensitized to mold toxins, so we focused on neurotoxin elimination protocol for mold. As “C” started a cholestyramine protocol, thyroid antibodies began to decrease. At a specialty clinic, “C” had two weeks of inpatient IV antibiotic treatments, and another 2 weeks of treatments as an outpatient, but in general, the Lyme specialist recommended other treatment modalities, reserving antibiotics for severe symptom flares.

After recommending we move to genetic testing to further assess why “C” was having so much difficulty with detoxification and clearing these chronic infections, we discovered antioxidant impairment. With recommendation from the Lyme specialist, “C” began having IV glutathione treatment. Very quickly and despite new stressors, “C” noted a sudden increase in energy, varying from 50% - 95% of normal. “C” began to increase exercise and noted almost near resolution of fatigue, although some GI and skin issues persisted along with the elevated hs-CRP. Although “C” had improved energy, symptoms of swelling, numbness, redness, and abnormal skin temperature of lower legs became a concern. As “C’s” concurrent symptom list included chest pain, heart attack was ruled out. As some prior symptoms had returned, it was found that “C” had been infected with Babesia and Bartonella, along with Lyme. “C” was seen by a conventional infectious disease specialist who did not offer any treatment program. I continued focusing on supporting liver detox with herbal tinctures, as well as retesting “C’s” nutritional status and supporting “C” with targeted supplements. I also began supplying “C” with a very potent enzyme, that was recommended by the Lyme specialist to help with the circulatory issues related to Babesia.

As “C” had decreased gluten intake and tried an Elimination Diet, but didn't see changes related to skin issues, we began to look for other markers for gluten sensitivity. “C” was found to have a positive anti-gliadin antibody and multiple genes positive for gluten sensitivity, and was therefore, advised to follow a 100% gluten free diet. With ongoing abdominal pain, testing revealed small intestinal bacterial overgrowth (SIBO) and systemic inflammation, prompting me to order a GI Effects test, for a more comprehensive digestive and stool analysis. This test revealed fungal growth, a parasite, an opportunistic bacterial overgrowth, along with maldigestion. Digestive enzymes, targeted probiotics, and caprylic acid were recommended. In addition, a 10 day course of antibiotics was recommended (to treat one specific infection), following the capryllic acid.

After almost 2 years of working together, “C” reported being able to work the first full week in 5 years, with energy returning to 95% of normal. Within a couple of months, titers for Babesia had returned to normal and most symptoms of lower legs resolved. Three years from “Cs” initial consultation with me, vitamin D levels, hs-CRP, and elevated fibrinogen were slowly improving. By this time, “C” was able to return to a normal work schedule and we began dealing more with common health issues. After many years of being ill, “C” finally celebrated being well.