I have a tough case of a 23-year-old obesity outpatient with recurrent pineal cysts, which started after trauma to the sacral area. And even after multiple surgeries and acne, she has very mild gut issues if any. She’s borderline anemic, low normal MCH, MCV, MCHC, hematocrit, and RBC. Her HbA1c was low at 4.3. Should be high with iron-deficiency anemia (although I have seen a lot of variation with HbA1c in anemias and that’s one of the problems with that marker). And low ferritin at 19. Considering Medihoney for the cysts and a Paleo diet with A, D, and K2 supplementation. All other tests normal, B12, hormones. TSH, fasting glucose normal, kidney function good. She can’t afford testing yet, but I was wondering if you could provide direction on this presentation. Looking forward to your thoughts.

Chris Kresser:  Yeah, that is a difficult case. Let me see if anything springs to mind just after first glance. I’m wondering about the gut, but both because of the anemia, I mean what’s not clear is this, if this anemia is nutritional, which it may be. You say you’re considering starting her on a Paleo-type of diet, which suggests that maybe she wasn’t doing that before and may have been on a different kind of diet that could be contributing to the anemia. You said you’ve got ferritin that’s low, which is supportive of iron-deficiency anemia. So that’s something obviously that would need to be corrected right away. Iron deficiency anemia can cause a whole bunch of issues. The acne to me and the possible anemia if she’s eating sufficient amounts of iron in the diet do point to gut issues.

When you said she has mild gut issues, I assume you mean symptoms because you said she hasn’t done any testing yet, and as you know from the gut unit, many patients without gut symptoms can still have gut problems that can interfere with nutrient absorption, cause acne. In fact, the first thing that I do when I see someone with skin issues, whether it’s acne or something else, is to test their gut. As you know, we talked about that in the gut section because I’ve seen such a strong correlation between gut issues and skin problems, even when the patient doesn’t have gut symptoms. So given the symptom picture here, I would definitely test for, run the gut panel once she can afford testing if she can. I might even consider a therapeutic trial of the antimicrobial gut protocol and just bypass the testing if she’s not able to afford the testing. I would use some of the supplements or dietary interventions we talked about for correcting iron-deficiency anemia. And I would focus on weight loss because, as you know, overweight can contribute to insulin resistance and that can interfere with hormone balance, and I think that’s, even though her hormone levels are normal here, that’s likely to be involved in this kind of symptom presentation as well. So hopefully that gets you started.