NEW STUDY A case report of patient who was dogmatically told to lose weight, cut salt and cut calories, when he actually had a brain tumor. A male patient in his thirties, of Asian descent, had a past medical history of easy bruising, central obesity, headaches, hematuria, and hypertension and past family medical history of hypertension in his father and brother. He reported that in 2015, he was at his heaviest weight of 180 lbs. placing him in the overweight category. At that time the patient reported he was following a SAD diet but that he was active throughout the day. He ate a diet with plenty of vegetables, fruits and carbohydrates, but he was not able to lose weight. The patient stated that he switched to a LC diet, to address weight gain and hyperglycemia, and he reported that he lost approximately 35 lbs in 1.5 years His LC diet consisted of green leafy vegetables, low carb fruits, fish, poultry, beef and dairy products. The patient then later switched to a carnivore diet. He noted despite aggressively adhering to his diet, that his weight-loss had plateaued, although his waist circumference continued to decrease. The patient noted his carnivore diet consisted of eating a variety of different meats, poultry, fish and eggs. The metabolic markers were obtained after the patient had started a carnivore diet. The patient’s blood glucose levels decreased over time. But he was concerned as he still had headaches, and bruising, and he felt his weight & blood pressure were exceedingly difficult to control When the patient was consuming a SAD diet, he was not under the care of a physician and was unable to provide us with previous biomarkers but nonetheless during this period when his medically unexplained symptoms were occurring, his LC diet seemed to keep him quite healthy. Despite strict adherence to his diet and initial improvement in his weight, his blood pressure and his blood sugar levels, in October of 2021 the patient was admitted to the hospital for hypertensive urgency, with a blood pressure of 216/155. His complaints at the time were unexplained ecchymosis, hematuria and significant headaches that were resistant to Excedrin At the hospital, the patient underwent a CT Head and CXR, and both images were negative for anything acute. During his hospital admission, the patient denied any changes in vision, chest pain or edema of the legs, or any other symptoms Ultimately, the patient was told to eat a low-salt diet and to follow-up with a cardiologist. At discharge, the patient was placed on hydrochlorothiazide, labetalol, amlodipine and lisinopril. What he got was meds, meds and more meds, with a cursory dietary message. The patient was then seen by his primary care physician in November of 2021 and his urinalysis at that time had no hematuria. Given his persistently high BP, the patient's primary care physician started him on yet another drug. Of course, the primary care physician reinforced cutting out salt and limiting his calories to prevent any further weight gain, which his physician explained would contribute further to his hypertension. He was referred to hematology and oncology in November of 2021 for his symptoms of hematuria and abnormal ecchymosis to his abdomen, thighs and arms. The patient’s coagulation and platelet counts were normal, and his symptoms were noted to be improving. What’s going on? His hematuria and ecchymosis were attributed to his significant Excedrin use from the past 1–2 months and again, a low-salt, calorie-limited diet was recommended, now by his hematologist. The patient was referred to cardiology where he was evaluated for secondary hypertension, because despite his weight loss and his strict adherence to his diet, his blood pressure was still uncontrolled on multiple medications. He had a normal echocardiogram and renal ultrasound which showed no signs of renal artery stenosis bilaterally. At that time the patient’s serum renin, aldosterone and urine metanephrine levels were all normal. Still, a mystery, WHAT is going on? His cardiologist increased his lisinopril, and continued him on amlodipine, furosemide and labetalol and reinforced the recommendations of lowering his salt and preventing weight gain. MESSAGE: "more meds, less salt" Dogma at it's best. The patient first contacted our office in January of 2022. At that time his blood pressure was noted to be 180/120 despite being compliant with current blood pressure medications. The patient reported strict adherence to his carnivore diet by sharing his well-documented meals on his social media accounts. Given the persistent symptoms, despite his significant change in diet and weight loss, we were concerned that a hormonal etiology may be driving his symptoms. The patient was seen in-person, in our office, in March of 2022. At the request of the patient, we again reviewed his social media profile which documented his daily meals for the past several years. This guy ate perfectly, meat, broth, fish, vegetables, some coffee I knew then, this wasn't his diet, something else was going on While the patient was eager to show us his carnivore meals, what we incidentally noted in his photos was despite weight loss and strict diet adherence, he had developed moon facies. On the physical exam, we noted his abdominal striae A midnight salivary cortisol was ordered, with values of 0.884 ug/dL & 0.986 ug/dL which are inappropriately elevated At this point our suspicion was confirmed And I felt such anger & resentment to the medical system that repeatedly told this person to cut salt, reduce calories Based on screening tests and significant physical exam findings, we referred for a low-dose dexamethasone suppression test with a resulting high DHEA. ACTH was 27.2 and MRI showed a 4mm microadenoma of the pituitary. IPSS confirmed the diagnosis. TAKEAWAYS: It is important for clinicians to consider alternative pathology. As depicted in this case, the patient lost 35 lbs. while on a LC diet, despite having hypercortisolism, presumably for months/years prior to the diagnosis of his condition. The patient noted a tendency to gain weight, and have elevated blood sugar and blood pressure which prompted him to begin self-treatment with increasingly strict carbohydrate restriction. The patient was able to keep his symptoms of hypercortisolism managed, potentially making the diagnosis difficult for his team of clinicians. From a diagnostic perspective, it’s important to understand that strict dietary adherence can have profound impacts on even the most severe hormonal pathology. Ultimately, this case serves as a reminder of the power of nutrition to address metabolic derangements and simultaneously as a reminder to diagnosticians to never rely on lack of dietary adherence as a reason for persistent metabolic symptoms. The reflexive advice to “not gain weight” and “lower salt intake” in retrospect appears both dogmatic and careless. In this case, the patient had seen several doctors and was even hospitalized and yet his disease state remained unclear and the dietary messaging cursory. Many chronic diseases, including diabetes, hypertension and obesity, are generally thought to be caused by dietary and lifestyle choices. However, as exemplified in this report underlying medical problems, such as endocrine disorders, can be the cause of such metabolic derangements. It is critical that practitioners consider other causes of metabolic derangements, as assuming that they are due to poor dietary adherence, can allow them to go undiagnosed. While there is extensive literature on LC diets and their effect on the metabolic derangements associated with hypercortisolism, there needs to be further research on LC as an adjunctive therapy to conventional CD treatment. Ultimately, nutrition can have a powerful impact on suppressing, or even reversing metabolic disorders. As depicted in this case study, a LC diet is powerful enough to temporarily suppress symptoms of CD. https://www.mdpi.com/2218-1989/12/11/1033/htm

Posted by Doctor Tro at 2022-10-29 16:22:30 UTC