Chronic illness after parasite study in Africa

[sarikate]

I am a 28-year-old medical student who traveled abroad for four months East Africa in 2000, where I was studying wildlife conservation and did a field study in wildlife parasitology.  While there I contracted giardia and amoebiasis (according to a local physician there).  Upon returning to the U.S. I had repeated episodes of high fever, profuse watery diarrhea (up to 30 episodes per day), severe abdominal cramping, and weight loss.  Most tests - EGD, colonoscopy, stool cultures/O&Px3, blood smear, etc. - were negative, although I had recurring fecal leukocytosis and fecal occult blood.  I was treated with Flagyl and Cipro and improved.

However, over the past three years I have had profuse, watery diarrhea up to 20 episodes per day (can be as few as 5).  I have lost 50 pounds over the course of the past three years (BMI is now just under 20).  I baffle myself and my physicians.  My GI has ruled out IBD based on the biopsy results from a balloon enteroscopy and colonoscopy.  However, I continue to be quite ill on occasion and have required occasional hospitalization or ER visits due to hypovolemia and electrolyte abnormalities.  

Just to complicate matters, I was diagnosed with Grave's disease last year and am being treated with PTU.  My TSH has been within the normal range since I became euthyroid about one month after starting treatment.  I also have developed persistent proteinuria (3+ on every urinalysis that's been done in the past six months) that is being worked up by a nephrologist.  Somehow I wonder sometimes if all of this is connected somehow, or if it's a coincidence that I have such severe post-infectious IBS and seem to be developing a bunch of rare autoimmune conditions over the past year and a half.  Any thoughts?  I know this is a nightmare case and, of course, being a medical student, my doctors think I have oodles of time to be spending on researching my own problems, which unfortunately I don't (although I do my best).  Thanks for your help.

[Philip Parks, MD]

Hello. As you described in your posting, you have experienced quite a protracted illness. I'd be happy to have a dialogue with you regarding your illness / symptoms.

As you have discovered through your research, there are well-documented descriptions of IBS and IBS-like symptoms that follow infectious diarrhea (viral, bacterial, or parasitic).

What is your current "working" diagnosis? Is it IBS?

Does your nephrologist think that you have nephrotic syndrome?

Has gluten-sensitive enteropathy (Celiac Disease) been ruled out?

How much time passed after your symptoms began in 2000 until when you were treated with flagyl and ciprofloxacin? What dosage and treatment regimen did you complete (how much flagyl for how long)? Did you undergo multiple rounds of flagyl?

You stated in your posting that for the last three years you have had profuse watery diarrhea. Does that mean that from ~ 2000-2005 that you did not have significant symptoms?

I hope this is helpful and I look forward to seeing your response to the questions.

~•~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[sarikate]

Thank you, Dr. Parks!  To answer your questions:
1) My current working diagnosis...that's a good question.  I don't think my current GI has an "official" diagnosis at this point.  All of my paperwork says "chronic diarrhea." I've had lots of conflicting opinions on the diagnosis because most of the doctors believe IBS cannot present with such profound morbidity (including weight loss, nocturnal symptoms, leukocytosis and melena, etc.) but then again, the symptomatology does not fit "nicely" within any other disease parameters either.

2) My nephrologist has not ventured a guess about the proteinuria, although he ran through a laundry list of potential causes, including glomerulonephritis, etc. He mentioned the possibility of doing a renal biopsy; I will be seeing him next week and will know more then.

FYI, I had a random urinary creatinine done in the hospital (208 mg/dL) but there is no reference range listed on the lab report so I am clueless as to how to interpret.  Also, I noticed on my CMP that my serum protein level was low (5.7 g/dL with a reference range of 6.0-8.2).  

3) Celiac disease has been ruled out by multiple biopsies and I also had the Prometheus celiac and IBD blood panels done; both were negative.  

4) I was treated twice with oral Flagyl and Cipro in Africa.  This was because my symptoms kept returning while I was there.  Once I got back to the U.S., I received IV treatments of both and felt better for a while.  However, I was intermittently symptomatic for the next 2-3 years (i.e. I would have some days where I would be in the bathroom 15-20 times a day with watery diarrhea; these days occurred 4-5 times a month.)

Another important tidbit is that I traveled to Ecuador, Peru, and Bolivia in early 2003.  When I was in rural Bolivia, the diarrhea became more acute, usually between 15-30 times a day, and this continued every day for four weeks.  I had no pain or fevers at that time, however.  A local doctor there treated me again with Flagyl/Cipro, again I noticed improvement, and upon returning home the cycle started again.  Intermittently severe symptoms, followed by brief remissions, etc.

In 2005 I started losing weight very rapidly and that was what prompted me to see a GI and start the whole work-up.  Since I started medical school in September, I've lost a good 20 pounds more.  However, I have maintained my weight between 115-118 pounds for the past couple of weeks and that is heartening!

Thanks so much for your help, I know this is a lot of information to keep straight!

[Philip Parks, MD]

Sarikate,

I am happy to hear that you have been able to keep your weight steady over the last several weeks. What is your strategy at this point? What types of foods result in the fewest amount of symptoms?

Have you had a 24-hour urine test? (like you mentioned above, difficult to interpret a spot/random creatinine)

You mentioned your total protein...what was the value for albumin on your CMP?

Are you anemic? If so, what type of anemia (mixed, microcytic, macrocytic)?

What is the differential pattern with your "leukocytosis" when your white count is elevated (eosinophils, neutrophils, etc)?

What "nocturnal symptoms" are you experiencing?

The reason why I asked about the specific dosage and regimen for your treatments with Flagyl (in my previous postin) is because it is well-known that in certain parts of Africa and India, there is partial resistance of giardia to flagyl. So, giardiasis can become chronic if definitive high-dose Flagyl is not initiated. And, based on your history that you describe, you did improve with IV therapy of Cipro and Flagyl...curious!?

Even so, as you mention, this probably would not explain the protracted course of your illness and the significant morbidity that you describe.

You're welcome for the dialogue. Keep the conversation going if you like.

~•~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[sarikate]

Hi Doc,
As far as nutritional strategies go, I am essentially just trying to pack as much nutritional punch as I can.  I eat things like oatmeal. lactose-free milk. peanut butter, basmati rice, steamed veggies, berries, bananas, salmon, whole grains.  I don't notice that any foods make the symptoms better or worse.  I will have the diarrhea even during periods of fasting or low intake, although stimulating the gastrocolic reflex is well-known to "set me off."

Have not had a 24-hour urine; I've been hearing that a random P:C ratio is just as good and have gotten mixed messages about whether I actually need to have this test done.  I will ask about it next week.

I don't have my results on me right now, but if I recall correctly my albumin was borderline low, but I think still WNL.  No anemia, and ferritin levels are good.  The only thing I can think of is that my mean platelet volume (MPV) was slightly low.

I had fecal leukocytosis and and occult blood on several occasions but most recently, in the past couple of months, this test has been normal (always a bonus).  The most CBCs have shown that my white count has not been recently elevated, and there's been no eosinophilia throughout the years (I remember looking closely at that because of the relationship of eosinophilia to things like Strongyloides stercoralis, which I came into contact with in Africa).  I think my neutrophils have been a little whacky on occasion, but nothing has been consistent or evidently troubling to my physicians on the CBC.

Nocturnal symptoms were watery diarrhea and abdominal pain.  Again, comes and goes.

I've wondered about asking for a BOLUS of IV Flagyl/Cipro, I am that desperate.  I have been taking VSL#3, a fancy new probiotic (FDA approved for treatment of UC/IBS, although I'm sure you know that already)!  It was after starting this that I noticed my weight stabilized.  Not sure if those two events are related, but it's worth a shot.

[Philip Parks, MD]

Dear Sarikate:

Thanks for providing the additional details.

Please keep me informed as more testing comes in from your treating physicians and as things change or improve with your symptoms.

Are there any specific questions that I can try to answer for you at this time?

~•~ Dr. Parks

This answer is not intended as and does not substitute for medical advice. The information presented in this posting is for patients’ education only. As always, I encourage you to see your personal physician for further evaluation of your individual case.

[sarikate]

Thanks for your support.  A couple questions before I see the docs this week: I hate to bring up every little symptom because it just makes me feel like an alien, but it is hard to figure out where these things are coming from.  For instance, the rashes I had this week, which have since resolved.  Secondly, the fact that I have been having night sweats a couple nights a week.  If these were "true" night sweats or at least clinically relevant, wouldn't they happen every night?  

One more thing, do you know how to test for vitamin K deficiency?  I have serious bruising issues; I will bruise in odd places like my chest and back.  I had a PTT and PT and bleeding time done and all were normal, so could this be another manifestation of malnourishment?

I appreciate your help!

[Philip Parks, MD]

My advice is for you to explain exactly what is going on with regard to the "night sweats" and the dermatologic eruptions or "rashes."

With regard to periodicity of the night sweats, it real