Chris: No problem. No problem. So let’s dig into this a little bit. “A 32-year-old male, history of anorexia nervosa, stable BMI, hypothyroidism, ablation, scalp rash, abdominal cramping, pain worse with high-FODMAP food. Avoids dairy and gluten, tolerates eggs, low-FODMAP diet, significantly improve symptoms. Functionally, high TSH of 3, free T4 perfectly good at 1.6, CBC and CMP normal, A1c 5.3 normal, CRP 1.29 kind of slightly above the functional range and lipids of 51, and then the SIBO breath test was max at 13 ppm for hydrogen and max of 5 ppm for methane.”
Yes. It looks normal for SIBO at least according to the breath test unless we consider sulfur as you mentioned which is possible, but right now, you don’t really have any way of knowing that, and oftentimes with sulfur, you do see the zeros. There’s a lower amount. So yes, that’s an interesting case, and sometimes in this situation, I mean, there are a couple different possibilities. One is that it’s not SIBO. I mean, we I think there’s a tendency for us always to assume that it’s SIBO even when it’s not. It could be just a disrupted gut microbiome. Have you done stool testing with her yet?
Dr Dani: No. That would be my next step. I’m trying to do one thing at a time. She does not want to spend too much money essentially right up front.
Chris: Understood. Another possibility is that she has a parasite infection or fungal overgrowth that will show up on the stool test. She could have had SIFO, which we don’t unfortunately have a way of testing for yet, small intestinal fungal overgrowth. There are two or three studies now in the literature documenting it. But we don’t have a SIFO breath test yet. Sometimes you need to treat that somewhat empirically if you suspect that. I had a patient the other last week who came in, and she was convinced she had SIBO, just absolutely certain from everything that she’d read online and all the symptoms lined up, FODMAP intolerance, etc.. We tested her, and she didn’t have SIBO, but she did have Blastocystis hominis. As you know from the course, this is a controversial pathogen. It’s not always even a pathogen, which is what makes it controversial. Sometimes it can be present and not really cause symptoms, and other times it very much does cause symptoms. She just came last week, so I don’t know what will happen in her case, but we definitely have people who have all of the signs and symptoms of what you would suspect would be SIBO, but it ends up being a parasite or even just a pretty disrupted gut microbiome.
Dr. Dani: Got it. Okay.
Chris: And then the thyroid, when the TSH is 3 like that, and you would get this in the blood chemistry section, but often just a mildly elevated TSH can be a result of a deeper problem like a gut issue because if T4 is converted into T3 in the gut among other places like the liver and her T4 is obviously perfectly good, so that indicates that her thyroid gland is functioning normally, so what often happens in these situations is—
Dr. Dani: Well, she’s on Synthroid I think.
Chris: Oh okay, right, because of the ablation, yes. But even there, that has to be converted into T4 to T3 if she’s not on any T3 additionally inside and that conversion happens outside of the thyroid gland. It happens in the peripheral tissues, in the liver, and in the gut. If someone is experiencing a lot of GI issues, then oftentimes fixing those can just normalize without any change in medication or even switching to no MDT.
Dr. Dani: Sure, sure. Great.
Chris: Alright. I hope that helps.
Dr. Dani: Thanks so much. I appreciate it.