Case Series

Remission of palindromic rheumatism through ketogenic and carnivore diets: A case report

Eric C. Westman, Jessica Fischer, Amy Berger

Received: 09 Sept. 2025; Accepted: 21 Dec. 2025; Published: 28 Apr. 2026

Copyright: © 2026. The Author(s). Licensee: AOSIS.
This work is licensed under the Creative Commons Attribution 4.0 International (CC BY 4.0) license (https://creativecommons.org/licenses/by/4.0/).

Abstract

The low-carbohydrate ketogenic diet (LCKD), developed a century ago to treat epilepsy, is now commonly used as a therapeutic intervention for obesity, type 2 diabetes and other conditions associated with insulin resistance. A growing body of literature supports the use of LCKDs for conditions associated with autoimmunity and inflammation. Here we present the case report of a 61-year-old man diagnosed with palindromic rheumatism (PR) – often a precursor to rheumatoid arthritis – whose condition was considered to be in remission after he adopted an LCKD and subsequently transitioned to an even lower-carbohydrate ‘carnivore’ diet. The patient was able to discontinue all arthritis-related medications, and currently, 7 years after initially starting the LCKD, he continues to follow a carnivore diet and reports no daily pain while remaining active in endeavours that require manual dexterity, such as woodworking and playing the guitar. Through anti-inflammatory effects and the removal of dietary irritants, dietary carbohydrate restriction may have potential therapeutic benefits for PR, a condition for which effective treatments and disease-modifying strategies remain elusive.

Keywords: palindromic rheumatism; rheumatoid arthritis; ketogenic diet; carnivore diet; low-carbohydrate diet; autoimmune disease; anti-inflammatory diet; case report.

Introduction

Palindromic rheumatism (PR) is a rare type of inflammatory arthritis characterised by intermittent episodes of erythema, pain and swelling in and around the joints. Flares are typically severe and unpredictable, with frequency varying from daily to several per year. Symptoms resolve between flares and the affected joints return to normal without lasting damage.^1,2 The condition affects men and women equally, typically occurring in individuals aged 20–50 years, and about half of individuals with PR eventually develop rheumatoid arthritis (RA), which can lead to structural changes and permanent joint damage.¹ Flares have been described as ‘debilitating’ and usually last only a few days but can persist as long as 2 weeks in some cases.² Palindromic rheumatism most commonly affects the same joints as RA, including the wrists and fingers, but the shoulders and knees may also be affected.² Unlike RA, which often affects joints bilaterally, PR flares are typically mono-articular although multiple joints may be afflicted at any given time. Palindromic rheumatism is believed to be a distinct clinical entity from RA, although autoimmunity is believed to play a significant role in PR. While not all PR patients develop RA, PR has been labelled ‘clearly a pre-RA stage for most, but not all, patients’.³

The mechanisms driving PR are poorly understood, and targeted treatments are elusive. Patients with PR are often treated with disease-modifying antirheumatic drugs (DMARDs) ‘despite limited evidence and no controlled trials to support their efficacy’.² Considering the high risk of progression to RA and the subsequent risk for debility and reduction in quality of life, there is a need to explore alternative approaches not only for managing PR symptoms but also for potentially altering the course of the condition and improving long-term outcomes. This case report aims to demonstrate the effectiveness of dietary carbohydrate restriction for reducing symptoms associated with PR and to explore the mechanisms by which this approach may be exerting its effects. Although this is a single case study, it may provide valuable insights into the potential benefits of this dietary intervention for individuals living with PR.

Case presentation

This case involves a 61-year-old man with a prior diagnosis of De Quervain’s tenosynovitis who presented in November 2014 with PR and a history of labs showing positive rheumatoid factor (RF), which increases the risk for conversion of PR to RA.⁴ The information for this case report is derived from his medical records and interviews with the investigators. (He has given informed consent for the release of his personal and medical information.) The joint pain was primarily in the hands, wrists, shoulders, knees and ankles. The PR continued to progress over the following year and was unresponsive to naproxen and hydroxychloroquine. The patient reported daily pain described as ‘debilitating’ and was prescribed methotrexate in addition to having a standing order for a prednisone taper for occasional flares. By October 2016, the patient continued to take methotrexate and hydroxychloroquine as prescribed plus an over-the-counter antihistamine and ibuprofen to help with pain relief and to facilitate sleep. He reported his joint symptoms as mostly well controlled with this regimen, with pain flares commonly occurring after intense physical exertion, such as home improvement projects. The patient self-reports that before medication, flares would cause pain at a level of 7–8 (out of 10), which was reduced to 4–5 with medication.

Consistent with what is typically observed in PR, the patient showed no evidence of biological indicators of inflammation (such as elevated C-reactive protein [CRP] or erythrocyte sedimentation rate [ESR] – these remained normal with the exception of one instance of elevated high-sensitivity CRP in 2014) although some researchers suggest that these may be elevated during a flare but are not captured in blood tests between flares.³ Also consistent with PR, imaging studies revealed no articular damage or degenerative changes, and visualised soft tissues were unremarkable.

In addition to his rheumatologic concerns, the patient had experienced weight fluctuations over the years, from a self-reported low weight of 73 kg (160 lbs) upon his separation from military service to a high of 113 kg (250 lbs). Medical records indicate a low weight of 98 kg (216 lbs) in July 2014 and a high weight of 110 kg (243 lbs) in October 2015.

Prompted by his weight fluctuations as well as by the positive effects experienced by a family member who had adopted a ketogenic diet for its purported mental health benefits, the patient began a low-carbohydrate ketogenic diet (LCKD) in October 2017. His rheumatologist had previously recommended a Mediterranean diet, but the patient was disinclined to follow this dietary pattern, owing to his dislike for many of the foundational foods.

The patient’s LCKD included eggs, pork, beef, poultry, high-fat dairy foods, nuts and low-carbohydrate vegetables, such as broccoli, asparagus and cucumbers. Following this approach, the patient lost 36 kg (80 lbs) in less than a year and reported a dramatic improvement in symptoms although not complete resolution. By July 2018, desiring to discontinue all PR-related prescription medications, he transitioned to a ‘carnivore diet’, having learned about it from an orthopaedic surgeon with an influential social media presence. (We should note that the patient made the dietary changes reported here without recommendation by a medical or dietetics professional and without medical supervision outside of his standard physician visits.) So-called ‘carnivore’ diets may be considered a subset of LCKDs, as they exclude all major sources of dietary carbohydrate, even the non-starchy vegetables, nuts and low-sugar fruits typically permitted on an LCKD. Carnivore diets exclude all foods from the plant kingdom, though some adherents make exceptions for seasonings, coffee, tea and low-carbohydrate alcoholic beverages. The patient’s carnivore diet consisted primarily of beef, with moderate amounts of pork and poultry and occasional use of black pepper and a homemade mayonnaise consisting of eggs, vinegar, mustard and medium-chain triglyceride (MCT) oil, as well as occasional intake of luncheon meats, which included plant-derived seasonings. All dairy foods were excluded except butter.

Medical records from November 2018 indicate that the patient had decreased his methotrexate dosage from weekly to every other week and experienced joint stiffness only if he went longer than 3 weeks without taking it. He reported being ‘very happy with his progress’ and stated that joint pain, sleep, mood and energy had all improved while following the diet and that he was able to perform tasks and hobbies he enjoyed but had to curtail prior to developing arthritis.

Medical records from May 2019 indicate the patient was experiencing no active swelling, warmth, erythema or morning joint stiffness. He reported eating mainly red meat and walking 6 miles 4–5 days per week. Noted in his records is a Clinical Disease Activity Index (CDAI) score of zero, indicating remission of arthritis.⁵ He discontinued all related prescription medications that year and has maintained a near-carnivore diet since then. In addition to weight loss and remission of PR, the patient reported that within a week of adopting the LCKD, the heartburn for which he had previously used omeprazole had also resolved.

The patient attests to having been strictly compliant on the ketogenic diet. After switching to a carnivore diet and discontinuing medication, if he strayed from the diet, he experienced recurrences of joint pain, which were mild but served as motivation to return to strict adherence. He reported no adverse effects from either the ketogenic or the carnivore diet, apart from loose stools during the first 2 weeks of the carnivore diet. He denies experiencing even the adaptation symptoms that may accompany the first few weeks of a ketogenic diet, such as headaches, muscle cramps or constipation. While on the ketogenic diet, he consistently registered blood ketone concentrations of 1.5 mmol/L – 2.5 mmol/L, whereas on the carnivore diet, they were typically ≤ 0.5 mmol/L. (Low ketone concentrations are not uncommon on a carnivore diet, potentially owing to the antiketogenic nature of protein.) The subject did not track caloric intake, nor aimed to follow precisely calculated percentages of calories from carbohydrate, fat and protein (commonly referred to as ‘macros’).

His current diet includes eggs, pork, beef, poultry, high-fat dairy foods, homemade mayonnaise, occasional luncheon meats and a commercially available electrolyte supplement. He reports no daily pain, and only occasional discomfort in both hands, specifically with stenosing tenosynovitis (‘trigger finger’) affecting the middle finger of each hand. He remains active in pursuits that require manual dexterity, such as woodworking, resistance training and playing the guitar. Owing to the dietary restriction required, ketogenic and carnivore diets may be difficult to maintain over the long term. The patient profiled here reports that after he remained pain-free for extended periods, he experimented with reintroducing higher carbohydrate foods, but he could do so for only a few days before the pain recurred. He reports that the potential for pain resurgence leads him to adhere strictly, and that he finds the diet to be sustainable when compared to the possibility of returning to a chronic disease state.

Discussion

Low-carbohydrate ketogenic diets are perhaps most widely used for weight loss, but a growing body of research supports their efficacy for putting type 2 diabetes into remission as well as for improving or putting into remission metabolic syndrome, polycystic ovarian syndrome (PCOS) and non-alcoholic fatty liver disease (NAFLD).^{6,7,8,9,10,11,12} While long thought to be potentially harmful for cardiovascular function, emerging research suggests that dietary carbohydrate restriction is beneficial for cardiovascular health via the lowering of blood glucose and insulin levels, facilitating weight loss, improving hypertension, improving atherogenic dyslipidaemia (i.e. lowering the triglyceride-to-high-density lipoprotein (HDL) ratio and shifting low-density lipoprotein (LDL) particle size from more atherogenic pattern B to less atherogenic pattern A) and through anti-inflammatory effects.^13,14,15,16 Additionally, emerging research in the field of metabolic psychiatry indicates that adherence to an LCKD has the potential to result in ‘unprecedented mental health improvements’ in those with major depressive disorder, bipolar disorder and schizoaffective disorder.¹⁷

Looking more specifically at the anti-inflammatory effects of dietary carbohydrate restriction, which may have played a role in the patient’s symptom improvement, LCKDs have been shown to put inflammatory conditions such as Crohn’s disease and colitis into remission, as well as reducing the pain associated with lipoedema and improving inflammatory conditions such as acne, psoriasis and hidradenitis suppurativa.^{18,19,20,21,22} Mechanistically, carbohydrate restriction-driven decreases in insulin and increases in glucagon and blood ketone concentration (beta-hydroxybutyrate) are associated with reduced secretion of pro-inflammatory cytokines and increased secretion of anti-inflammatory compounds.²³

The patient in this case report experienced remission of PR from a change in diet that led to substantial weight loss, opening the mechanistic question of ‘Was it the diet or was it the weight loss?’ For example, a reduction in adipose tissue (weight loss) may lead to a reduction in inflammatory cytokines. We are not aware of any other case of remission of PR from either diet change or weight loss using another treatment. Clinicians who advise patients regarding carbohydrate-restricted diets frequently encounter patients who report improvements in joint pain quickly after adopting the diet, long before significant weight loss has occurred. Moreover, while the patient reported PR flares affecting his knees and ankles, the most severely affected joints were in the hands and wrists, and compared to joints in the lower body, it is unlikely that these would be substantially affected by weight loss.

While some interventional studies call for low-calorie ketogenic diets, it should be noted that multiple beneficial effects of ketogenic diets have been documented even in the absence of clinically meaningful weight loss, including reversal of metabolic syndrome, improvement in glycaemic control in type 2 diabetes and pain reduction in lipoedema.^8,24,25 This suggests that caloric restriction may not be required in order to realise the metabolic and anti-inflammatory effects of a ketogenic diet. Compared to a low-fat diet, a low-carbohydrate diet (both ad libitum) induced greater improvements in multiple markers of inflammation in overweight men and women with atherogenic dyslipidaemia.²⁶ A phase II study of ketogenic diets in relapsing multiple sclerosis showed that an LCKD resulted in significant improvements in inflammatory markers.²⁷

Apart from remission of PR, the patient in this case report also experienced rapid resolution of heartburn. The effectiveness of carbohydrate restriction for this purpose has been established previously, including in a study in which 42 women with gastroesophageal reflux disease (GERD) had complete resolution of symptoms and discontinued all related medication usage within 10 weeks of following a low-carbohydrate diet.^28,29

Safety concerns about dietary carbohydrate restriction are mostly unfounded. When implemented correctly, low-carbohydrate and ketogenic diets are nutritionally adequate and do not result in ketoacidosis (except when paired with sodium-glucose cotransporter-2 (SGLT2) inhibitor medications, which may cause euglycaemic ketoacidosis even in those not following a ketogenic diet).^30,31 A recent review by Teicholz et al.³² included evidence showing that low-carbohydrate diets are replete in all essential vitamins and minerals and are safe for individuals with cardiovascular disease (CVD) and chronic kidney disease. There is concern about the potential for an elevation of low-density lipoprotein cholesterol (LDL-C) among those who follow low-carbohydrate diets, but a growing body of research calls into question the utility of LDL-C as a reliable, independent predictor of cardiovascular risk, particularly in the context of primary prevention and a zero coronary artery calcium score.^33,34,35 Moreover, the response to carbohydrate restriction with regard to the lipid profile is variable. Most individuals who adopt an LCKD experience a decrease in LDL-C, but a small subset may experience a substantial increase. These individuals are typically lean, and the increased LDL-C occurs alongside low triglycerides and higher high-density lipoprotein cholesterol (HDL-C), with this ratio being a stronger indicator of cardiovascular status compared to LDL-C.³⁶ In fact, a study of high-risk patients determined that this ratio is ‘the single most powerful predictor of extensive coronary heart disease’ among all lipid variables examined, and the strength of this association holds even after ‘aggressive lowering’ of LDL-C.^37,38 Overall, the well-recognised beneficial effects of carbohydrate restriction – weight loss, improvement of glycaemic control and insulin sensitivity, reduced inflammation and improvement of atherogenic dyslipidaemia – may reduce risk for CVD even in the context of increased LDL-C.¹⁶

It is noteworthy that the patient experienced improvement in his symptoms after adopting an LCKD but that reducing carbohydrate even further and eliminating all dietary fibre through adopting a carnivore diet resulted in further improvement, facilitating cessation of all arthritis-related medications. While LCKDs have been studied for decades, to date, there is less published research regarding the carnivore approach. In a 2020 survey of self-identified carnivore dieters with over 2000 respondents, nearly 70% reported experiencing an improvement in chronic disease and 95% reported better overall health.³⁹ Among total respondents, 18% reported having an autoimmune condition. Among this subset, 53% reported experiencing an improvement in their condition and 36% reported total resolution. Twenty-five per cent of total respondents reported having musculoskeletal issues, with 54% and 42% reporting improvement or resolution, respectively. A meat-only diet is a subtype of an LCKD, which has substantial research to support its use.⁴⁰ However, until more research has been done to determine the safety of a carnivore diet, we would not recommend its use without medical supervision.

A case series of individuals with inflammatory bowel disease showed that carbohydrate restriction resulted in significant improvements in symptoms and quality of life, with some patients reporting further improvements after transitioning from an LCKD to a fully carnivorous diet or an LCKD with only minimal plant foods.²⁰ A more recent case report highlights the experience of a patient with obsessive-compulsive disorder (OCD) who adopted a ketogenic diet for weight loss and mental health purposes and experienced unexpected remission of ulcerative colitis within 3 weeks and clearance of psoriatic plaques after 8 weeks.⁴¹

The mechanisms primarily responsible for improvements in, or complete remission of inflammatory conditions have yet to be identified for certain. Potential explanations include maintenance of normal blood glucose and insulin levels, changes in the gut microbiome, anti-inflammatory effects of ketone bodies and the removal of dietary irritants that may be provoking an inflammatory or immune response.

Conclusion

We report the apparent resolution of symptoms of PR, a condition that often progresses to RA, after following therapeutic carbohydrate restriction. The patient was able to discontinue all arthritis-related medications, and the arthritis is considered to be in remission after 7 years.

Limitations

One case report limits the generalisability of this patient’s experience. Furthermore, the dietary information is self-reported.

Acknowledgements

The author, Eric C. Westman, serves as an editorial board member of this journal. Eric C. Westman has an ownership stake in a company that provides online education about ketogenic diets. Jessica Fischer and Amy Berger declare no conflicts of interest.

Eric C. Westman: Conceptualisation, Writing – review & editing. Jessica Fischer: Writing – review & editing. Amy Berger: Writing – original draft, Writing – review & editing. All authors reviewed the article, contributed to the discussion of results, approved the final version for submission and publication and take responsibility for the integrity of its findings.

Written informed consent was obtained from all individual participants involved in the study.

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

The authors declare that all data that support this research article and findings are available in the article and its references.

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings, and content.

References