The New England Journal of MedicineA 58-Year-Old Woman with Fatigue, Abdominal Bloating, and Eosinophilia

Unfolding a Clinical Enigma: From a Tibia Fracture in Congo to Mysterious Symptoms

A Case Challenge study of a 58-year-old female who, after sustaining a tibia fracture in the Democratic Republic of Congo (DRC), started experiencing persistent fatigue, abdominal bloating, and elevated eosinophil counts, ignites a journey into the intricacies of infectious disease diagnosis and management. After reading, what’s your diagnosis?

• The woman presented with fatigue, abdominal bloating, and eosinophilia, eight months post tibia fracture in the DRC
• The patient’s eosinophil count had escalated to 3,530 per microliter, significantly beyond the normal reference range (0-400), whereas it had been normal 18 months earlier.
• Following her leg injury, her pre-existing symptoms of weight gain and fatigue intensified; she gained 13.6 kg and started taking afternoon naps due to fatigue.
• Calcified lesions in the right lung, liver, and spleen, suggestive of granulomatous disease, were revealed in a CT scan, along with a probable hepatic cyst.
• Tests for common infections, such as syphilis, HIV, and strongyloidiasis, returned negative results.
• Blood tests for thyroid, kidney, and liver functions were within normal limits, and a test for Lyme disease was also negative.
• The patient had a history of chronic migraines and hyperlipidemia, with no significant past of fever, abdominal pain, or arthralgias.