A 54-year-old man comes to the emergency department after vomiting blood. He has also had melena, fatigue, and lethargy over the last 24 hours. The patient emigrated from sub-Saharan Africa 20 years ago and occasionally returns to visit friends and family. Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, and pulse is 115/min. Abdominal palpation reveals an enlarged liver and a spleen tip below the level of the umbilicus. Laboratory results are as follows: Upper endoscopy reveals bleeding esophageal varices. Which of the following is the most likely underlying cause of this patient's symptoms?

Question

A 54-year-old man comes to the emergency department after vomiting blood.  He has also had melena, fatigue, and lethargy over the last 24 hours.  The patient emigrated from sub-Saharan Africa 20 years ago and occasionally returns to visit friends and family.  Temperature is 37.5 C (99.5 F), blood pressure is 90/60 mm Hg, and pulse is 115/min.  Abdominal palpation reveals an enlarged liver and a spleen tip below the level of the umbilicus.  Laboratory results are as follows:  Upper endoscopy reveals bleeding esophageal varices.  Which of the following is the most likely underlying cause of this patient's symptoms?

Quizplus · Accepted Answer

11ec160b_37ff_b902_9249_6dc3b38ff255_MD0001_00 Esophageal varices and splenomegaly are signs of portal hypertension, which usually indicates underlying hepatic fibrosis. Although chronic viral hepatitis and alcohol abuse are the leading causes of hepatic fibrosis in the United States, this patient's immigration/travel history and eosinophilia raise suspicion for hepatosplenic schistosomiasis, a parasitic blood fluke infection seen primarily in rural parts of sub-Saharan Africa and East Asia. Exposure to Schistosoma occurs when humans swim in freshwater contaminated by infected snails (the intermediate host). Cercariae penetrate human skin and migrate to the liver, where they mature to adult worms. Adult worms then spread through the portal circulation to the mesenteric venules or venous plexus of the bladder. Here, they release eggs into host tissue that are excreted in the feces or urine. Although many patients with schistosomiasis are asymptomatic, chronic exposure to Schistosoma eggs can activate hepatic stellate cells, leading to collagen deposition in periportal spaces and progressive periportal fibrosis. Occlusion of periportal veins eventually blocks venous outflow from abdominal organs, leading to congestive splenomegaly and gastroesophageal varices. Patients frequently have anemia from intestinal/variceal bleeding, thrombocytopenia from splenic trapping of platelets, and eosinophilia in response to adult worms. (Choice A) Cysticercosis is caused by ingestion of Taenia solium eggs from contaminated pork. Although initial infections are usually asymptomatic, patients may develop seizures years or decades later due to calcified granulomas at the site of previous brain infection. Muscle and subcutaneous tissue can also be involved, but the liver and hepatic venous system is generally not affected. (Choice B) Hookworm infection is a common cause of chronic, iron-deficiency anemia and eosinophilia, but this organism does not invade the liver or portal venous system; therefore, gastric varices and hepatosplenomegaly would be atypical. (Choice C) Malaria is common in patients who return to endemic areas (eg, sub-Saharan Africa) after being away (due to waning partial immunity). Although hepatosplenomegaly and anemia are common, most patients are acutely ill (eg, fever, chills, malaise), and portal hypertension and eosinophilia are generally not present. (Choice E) Toxoplasmosis is most common in patients with AIDS. It usually presents with meningoencephalitis (eg, confusion, headache, vomiting). Upper gastrointestinal bleeding from esophageal varices and eosinophilia would be atypical. Educational objective: Schistosomiasis, a parasitic blood fluke infection, is common in rural portions of sub-Saharan Africa. Initial infection is often asymptomatic, but some patients develop chronic hepatosplenic (eg, portal hypertension, hepatosplenomegaly, esophageal varices) or urinary (eg, bladder cancer) complications years or decades later. The presence of eosinophilia is an important diagnostic clue.

A 54-Year-Old Man Comes to the Emergency Department After Vomiting