Differential Diagnosis

The patient's complex presentation of chronic health issues, including gradual onset fatigue, steatorrhea, unexplained weight loss, and neurological symptoms, requires a comprehensive differential diagnosis. The following categories outline potential diagnoses:

• Single Most Likely Diagnosis
  • Chronic Parasitic Infection: The patient's history of extended travel to West Africa, south and southeast Asia, and exposure to domestic and farm animals, combined with symptoms such as steatorrhea, weight loss, and spontaneous hematoma, suggests a chronic parasitic infection. The improvement in symptoms after using wormwood, clove, and black walnut extracts, which have antiparasitic properties, further supports this diagnosis.
• Other Likely Diagnoses
  • Small Intestine Bacterial Overgrowth (SIBO): The patient's GI-MAP results show an elevated E. coli count and an abnormal Firmicutes:Bacteroidetes ratio, which may indicate SIBO. Symptoms such as steatorrhea, weight loss, and abdominal pain are consistent with SIBO.
  • Vitamin B12 Deficiency: The patient's low B12 levels, despite supplementation, and improvement in symptoms after starting IM B12 supplementation, suggest a vitamin B12 deficiency. However, the underlying cause of the deficiency needs to be investigated.
  • Malabsorption Syndrome: The patient's symptoms, such as steatorrhea, weight loss, and fatigue, may indicate a malabsorption syndrome. Further testing, such as a hydrogen breath test or intestinal biopsy, may be necessary to confirm this diagnosis.
• Do Not Miss Diagnoses
  • HIV/AIDS: Although the patient tested negative for HIV, it is essential to consider this diagnosis due to the patient's history of travel to high-risk areas and symptoms such as weight loss, fatigue, and spontaneous hematoma.
  • Lymphoma: The patient's chronic lymphopenia and elevated SHBG levels may indicate a lymphoproliferative disorder, such as lymphoma.
  • Whipple's Disease: This rare bacterial infection can cause malabsorption, weight loss, and neurological symptoms. Although unlikely, it is essential to consider this diagnosis due to the patient's chronic symptoms and exposure to rural areas.
• Rare Diagnoses
  • Tropical Sprue: This rare condition, characterized by malabsorption and chronic diarrhea, may be considered due to the patient's history of travel to tropical areas.
  • Abetalipoproteinemia: This rare genetic disorder, characterized by malabsorption of fat-soluble vitamins, may be considered due to the patient's symptoms of steatorrhea and weight loss.
  • Celiac Disease: Although the patient's upper endoscopy was unremarkable, celiac disease may still be considered due to the patient's symptoms of malabsorption and weight loss. Further testing, such as serology or intestinal biopsy, may be necessary to confirm this diagnosis.