When history leads to diagnosis

A few weeks ago, Shoumen, a 7 year old charming intelligent boy and his parents came to consult me for intermittent fever. According to his mother, Shoumen was completely well 5 weeks back when he started developing fever that came twice in a day. He was apparently normal and had no history of any prior infection nor had any rash. His appetite was normal as before. Her mother took him to two doctors and got some lab investigations done. He was prescribed a course of empirical antibiotic but he did not get better.
On physical examination, he had enlarged spleen (an organ of abdomen that fights infection and anemia) lower blood hemoglobin level. There was no enlarged lymph node, liver enlargement and no rash. Blood test for malarial parasite was normal but shows lower number of all blood cells. Blood and urine culture shows no organism to cause the infection. Chest x-ray was normal. This lab picture was not saying any particular disease and diagnosis remained a dilemma.
When I reviewed and explored the history in detail, it was found that he had a travelling history from his living place Dhaka to Pabna. Then, Kala Azar, diseases prevalent in Pabna came to my mind. Kala Azar is presented with prolonged irregular bouts of fever, enlargement of spleen, anemia caused by a parasite transmitted by the bite infected female sandfly found in several districts of Bangladesh with the highest incidence in Mymensingh.
I re-examined the boy and ask for another peripheral blood film comment and rK39 test. This rK39 test was found positive, which indicates he might have Kala Azar. In order to confirm, tissue was obtained from his enlarged spleen and we found the organism that causes Kala Azar. The he was treated and cured after that.
The travelling history and prolonged fever made gave me the clue to reach final diagnosis. It is important to explore history properly while evaluating a case of prolonged fever or any complicated case.

The writer is a Professor of Paediatrics, Community Based Medical College, Mymensingh.
E-mail: mmukkhan@gmail.com