I’m following up on my 57-year-old female patient with a diagnosis of fibromyalgia and a stool test showing Klebsiella overgrowth at 3+ on Doctor’s Data, confirmed by BioHealth Lab. Her main complaints are debilitating fatigue, muscle aches, and brain fog gradually worsening over the last two years. Gut symptoms were gas, bloating, and severe constipation. Gut improved with initial dietary changes to the Paleo reset. She has been on the antimicrobial protocol for 60 days with only minor changes in symptoms of fatigue and body aches. During the treatment protocol period, she has titrated off a recently prescribed antidepressant But he suffered from significant withdrawal symptoms. She also has not been strictly observing diet. Ate two gallons of ice cream in the last three weeks and admitted to a return of constipation and worsening of body aches. We are now at the re-evaluation point. Would I prescribe another 30 days of the antimicrobial protocol with best attempt at diet compliance? Is it too early to begin the gut restoration phase? When would you recommend a retest of the gut, now or after another 30 days of protocol and diet compliance?

Dr. Amy Nett: The question is how come she wasn’t compliant with the diet? That’s a pretty big variation to have two gallons of ice cream. I would have that discussion, and I would consider ordering a Cyrex Array 4 to see. Is dairy a big issue for her? Maybe it’s not. The ice cream still has sugar, so I’m not advocating it, but sometimes if someone sees that they make antibodies to a food they are a little bit better about being stricter with staying away from that food. If she makes antibodies to one of the dairy proteins, that might help, but then will she kind of “cheat” with something else? It’s kind of tricky. I don’t think—I try to tell patients the 80/20 rule is totally okay. If dairy protein is not that big of a deal for her, yes, the sugar. It depends if that was her only treat, and that actually fit into the 80/20 rule. I don’t know if that is that big of a difference, but you are saying that it seems like that sugar bolus led to a return of constipation and increasing body aches.

Three-plus Klebsiella, and you did 60 days. I would probably repeat the test, the reason being 60 days should be a good amount of time. I wonder if there is something else that is contributing to her inflammation. My preference would be to do a repeat test and just kind of keep her on a maintenance of probiotics. I wouldn’t even go to the full gut restoration phase with a lot of prebiotics until I have the test results back. If money is an issue, and the repeat tests are going to become a problem, then you could do another 30 days of the protocol and then repeat testing, but I definitely would not go more than 90 days without doing a repeat test.

I’m wondering, you mentioned her—it sounds like things improved a little bit on the treatment and then got worse after the ice cream. I also think about, of course, methylation, especially with the depression and fibromyalgia. I also think about metals. So, I don’t want you to spend too long on the gut because there could be other layers that need to be addressed. Depending on the discussion with her, 30 more days could be reasonable. Don’t do any more than 30 additional days of treatment. Then repeat the Doctor’s Data test. Consider a SIBO breath test, if that hasn’t been done already. If those come back looking okay, move on to the gut restoration phase if she is still having symptoms. Look at least at homocysteine. If homocysteine is higher than probably seven, think about methylation, support with B vitamins. Also check hemoglobin and MCV, or mean corpuscular volume, because if she has a large MCV with mild anemia, that could also be a functional B12 or folate deficiency, so you might get that on board. Then maybe metals would be something. Hopefully that gives you a couple options in terms of where to go with her.