S2747 A Detailed Travel History Solved a Medical Mystery

Abstract

INTRODUCTION: Taking a detailed history is often a clinical challenge. Asking the right question related to the presenting symptoms in the key. At the Minneapolis VA, we have encountered an asymptomatic patient who had incidental finding of “portal hypertension” on imaging. Yet, he had an extensive negative workup. At the time of his EGD, a more detailed history was taken during medical records review, the his own history finally solved the mystery. CASE DESCRIPTION/METHODS: 66 y/o male with incidental findings of “portal hypertension” from a CT scan presented for a diagnostic EGD. A recent radiology report described a cluster of varices near the gastric fundus and a spleen size of 15 cm. Subsequent evaluation by the GI specialty clinic failed to identify a cause; the workup included alcohol use history, medication review, autoimmune markers, viral serologies, genetic testing, metabolic markers, lipid studies, iron studies, tumor markers, liver function tests, clotting factors, and fibroscan. Just prior to EGD, a detailed history revealed a Vietnam deployment in 1970. The patient further described a life threatening event. He was sick for almost a year. The upper endoscopy subsequently showed no varices and no gastropathy. DISCUSSION: Falciparum malaria is the most severe form of malarial disease caused by plasmodium falciparum. This disease is responsible for over 400,000 death globally in 2018. Over 228 MILLION cases of malaria were reported by the WORLD HEALTH ORGANIZATION (WHO) in 2018. Plasmodium falciparum is classified as Group 2A carcinogen by the WHO. This organism is transmitted by infected female anopheline mosquitos. The eventual multiple organ failure and death is caused by the obstruction of the body’s microcirculation by the organism particles. In this case, the CT findings were caused by temporary pre-sinusoidal portal hypertension until the malaria was cured several months later. As a result, permanent enlarged spleen and permanent dilated veins were discovered on the CT scan several decades later. The primary disease was cured 40 years ago. It is imperative to understand the history, pathophysiology, and the clinical sequelae of common tropical diseases when taking care of patients that travel throughout the world. In today’s western medical practice, we frequently forget the old diseases that still cause wide range of destruction in other parts of the world. We can avoid wasting medical resources by asking the right question.