Differential Diagnosis

The patient's complex presentation of chronic health issues, including gradual onset fatigue, steatorrhea, unexplained weight loss, and neurological symptoms, alongside a history of travel to endemic areas and response to certain treatments, suggests a multifaceted differential diagnosis. The following categories outline potential diagnoses:

• Single Most Likely Diagnosis
  • Chronic Parasitic Infection (e.g., Giardiasis, Hookworm, or other intestinal parasites): The patient's history of travel to West Africa, South Asia, and the presence of domestic and farm animals, combined with symptoms like steatorrhea, weight loss, and response to antiparasitic treatments (wormwood, clove, black walnut extracts), strongly suggests a chronic parasitic infection. The improvement in symptoms and eGFR rebound after using these extracts further supports this diagnosis.
• Other Likely Diagnoses
  • Vitamin B12 Deficiency: Although the patient's B12 level is 166 pmol/L, which is within the normal range, the improvement in vision, mental clarity, mood, and exercise recovery after starting B12 IM EOD supplementation suggests that the patient may have a functional B12 deficiency or a high demand for B12 due to underlying conditions.
  • Zinc Deficiency: The patient's consistently low zinc levels despite supplementation could contribute to immune dysfunction, wound healing issues (spontaneous hematoma), and other symptoms.
  • Thyroid Dysfunction: Elevated RT3 and SHBG levels may indicate thyroid hormone imbalance or resistance, which could contribute to fatigue, weight loss, and other symptoms.
• Do Not Miss Diagnoses
  • HIV/AIDS: Given the patient's history of travel to high-prevalence areas and symptoms like weight loss, fatigue, and chronic infections, HIV/AIDS must be considered, despite the patient's reported lack of high-risk behaviors.
  • Tuberculosis: The patient's travel history, chronic symptoms, and unremarkable blood markers (except for mild elevations in homocysteine and low WBC) make TB a diagnosis that should not be missed, especially given its potential for severe consequences if untreated.
• Rare Diagnoses
  • Whipple's Disease: A rare, systemic bacterial infection that can cause malabsorption, weight loss, and neurological symptoms, which might be considered given the patient's chronic diarrhea, weight loss, and arthralgias.
  • Chagas Disease: Although less likely given the patient's travel history, Chagas disease, caused by Trypanosoma cruzi, can lead to chronic gastrointestinal and cardiac symptoms and should be considered in the differential diagnosis of a patient with a history of travel to endemic areas.

Each of these diagnoses requires careful consideration of the patient's complex clinical presentation, travel history, and response to treatments. A comprehensive diagnostic approach, including further laboratory testing and potentially specialty consultations, is necessary to determine the underlying cause(s) of the patient's symptoms.