A Case Study Submitted By Scott Rigden, MD
This is a fascinating case study. A dermatologist referred this gentleman for evaluation and treatment of his chronic, severe eczema. As you will see, this medical condition actually was the key to understanding and helping multiple chronic illnesses, not the least of which was morbid obesity. This kind of complex case study also is a beautiful example of how the integrative approach of functional medicine with a personalized lifestyle approach can succeed, even though many specialists over forty years had not been able to understand and help this gentleman.
Case Study #7095, “John,” presented initially as a 54 year old professional engineer with chronic severe eczema as well as multiple medical problems including obesity, diabetes mellitus Type 2, hyperlipidemia, osteoporosis, S/P PTH disease and surgery, hypertension, obstructive sleep apnea with C-PAP, kidney stones, osteoarthritis, history of multiple allergies as a youth, GERD, multiple medications, low energy, elevated life stress, and diverticulitis/diverticulosis. His family history was positive for lung disease. Past medical history included parathyroid surgery in 2008, pulmonary embolism in 2003, and a tonsillectomy as a youth. His medications included Prilosec (omeperazole), Acetaminophen, Ibuprofen, Excedrin, Lotensin 20-25mg one daily, Norvasc 5 mg daily, and Fosamax (previously had been on Boniva). His physical examination was remarkable for obesity and extensive, severe atopic dermatitis/eczema on his extremities, trunk, scalp and hairline.
Tests and Measurements
Weight: 307.4 pounds Ht.: 66 inches BP 142/92. RAST IgG4 tests
showed severe 5+ reactions to casein, milk, egg whites, and egg yolks with a 3+ reaction to navy beans; 25-OH-D level 41: TSH: 2.50, Free T3 2.9, Free T4 1.1; Plasma zinc: 91; ANA negative; Cocci screen negative; anti-streptolysin antibodies negative; random glucose 179; cholesterol 231; triglycerides 303; fasting insulin 32; Apolipoprotein A1 and B negative; CRPhs 10; celiac screen negative; CBC, Vit. B12 and Folate levels normal; fasting glucose, 148; ALT 86; A1C 7.4; stool cultures show 0 growth of lactobacillus and 4+ vigorous growth of multiple pathogenic bacteria, including 2 species of Citrobacter, Hafnia pseudomonas and klebsiella.; Candida 1+, no parasites; all bacteria sensitive to Cipro
1. Type 2 Diabetes Mellitus with hyperinsulinemia and insulin resistance
2. Elevated CRPhs, confirming high levels of inflammation
4. Food hypersensitivities with a history of chronic allergic issues for his entire life with a chronic case of refractory, severe eczema
5. Intestinal dysbiosis with no lactobacillus growth, several bacterial pathogens and candida overgrowth
6. Elevated ALT with probable NASH
7. Chronic GI problems with GERD and diverticulisits/diverticulosis,; also on Prilosec for years, which may be contributing to a chronic malabsorption issue
9. Osteoporosis with a history of parathyroid disease and surgery
11. High stress
12. Obstructive sleep apnea with C-PAP
13. Borderline Vit. D levels.
14. Osteoarthritis (knees and right ankle)
15. History of kidney stones
1. Start low glycemic load diet, the modified Mediterranean diet, with 5-6 feedings per day including a specially designed medical food with select kinase response modifiers designed to normalize glucose-insulin metabolism, 2-4 scoops daily.
2. In addition to a low glycemic load diet, eliminate casein, milk, egg whites and yolks, and navy beans from his diet.
3. After 10 days of Rx Cipro, take saccharomyces boulardii supplementation for 3 weeks followed by a high potency dairy-free probiotic twice daily for an indefinite period of time.
4. EPA/DHA 2 grams twice daily, modified folic acid 400 mcg twice daily, micronutrient support for glucose/insulin metabolism (contains chromium, lipoic acid, cinnamon compounds, etc.) 1 tab twice daily, 4000 i.u. of Vit. D3 daily
5. Start two ten minute walks daily.
PROGRESS NOTES/FOLLOW-UP VISITS
2 Months Later
Patient reports improved energy, digestion and elimination, skin and musculoskeletal pain. He is more “clear-headed.” Weight is 301.6 lb., down 9 lb. BP is 122/68 (previously 142/92).
4 Months Later
Patient reports better energy, GI tract is much better and he has been able to discontinue omeperazole. Skin condition continues to improve. Blood pressure is 118/64 and weight is now 291.8 lb. (down 19 lb.).
5 Months Later
Patient reports marked improvement in skin, GI tract, and energy. Weight is now 282.2 lb., decreased from 310.2 lb., and BP is 122/78. Labs: (previous in parentheses) CRPhs 5.6 (10.0); A1C 6.9 (7.4); fasting insulin 20 (32); 25-OH-D 53 (41); cholesterol 208 (224); triglycerides 128 (163); LDL 145 (154); fasting glucose 135 (148); ALT 20 (86) We will start tapering Norvasc.
ONE Year Later
Patient is off Norvasc, weight 274.4 lb. (down 36 pounds), BP 120/80. Plan to decrease Lotensin to 10/12.5.
TWO Years Later
Feeling and functioning well. Weight is 255 lb., BP 120/78
DEXA bone density much improved, showing normal bone density in the lumbar spine, borderline normal levels in hips, with persistent osteopenia in the left forearm.
2.5 Years Later
Weight 310.1 lb. 251 lb.
BP 142/92 122/78
FBS 148 109
Fasting Insulin 32 8
A1C 7.4 6.3
Triglyc. 163 99
HDL 43 66
CRPhs 10.0 0.9
Skin( 0-10) 10 1,2
GI Sx’s (0-10) 9-10 1-2
Energy(0-100) 40-50 80-90
Mskel pain (0-10) 6-7 0-1
Conclusion: this gentleman’s chronic severe inflammatory skin condition was a marker for multiple physiological imbalances in the body that were producing inflammation that impacted multiple systems of the body, e.g., cardiovascular, glucose-insulin, musculoskeletal, bone density, GI, etc. By normalizing inflammation originating from adipocytes and the arachidonic cascade with blood sugar-insulin management, removing food triggers and GI sources of chronic inflammation, “John” has re-invented himself. He continues to work on his weight and we are hopeful some day to have a BMI closer to 30. His skin condition, ironically, was the key “clue” to help us understand and develop a successful personalized lifestyle medical program.