Imam Waked. M.D.

MB, BCh, MSc, MD Professor of Medicine National Liver Institute 108 Tahrir Street, Dokki, Giza 12311, Egypt iwaked@liver-eg.org Tel: +20-12-2157256

Cairo, September 14, 2011

To Whom It May Concern

Short Medical Report
Re: Ahmed Hammam EL-SAEED,

Mr. El-Saeed is a 23-year-old Egyptian accountant. He has not been feeling well for the last 6 months. In March 2011, he had an attack of 10 days fever and diarrhea. He related that to eating raw oysters, raw fish and raw pork in a Dubai hotel. He saw a doctor who ordered labs which showed: HB 16.3gm/dl, WBCs 7,100/cmm with normal differential, platelets 219,000/cmm, stool analysis showed pus cells ~70/hpf with clumps, but no parasitic ova or blood, stool culture growed normal commensals with no pathogenic bacterial growth, hemoccult negative, serum cholesterol 228 mg/dl, triglycerides 114 mg/dl/ LDL 155 mg/dl, HDL 50 mg/dl, ESR 13 mm/hr, CRP positive 17 mg/L, bilirubin 0.8 mg/dl, AST 24 U/L (normal <40), ALT 26 U/L (normal <40), creatinine 1.2 mg/dl. Ultrasound showed an enlarged smooth liver with normal echogenicity, and a slightly enlarged spleen. I saw him in late March 2011. He still had diarrhea and a low-grade fever, and some colics. A system symptom review showed no other complaints. On examination, he was in no distress, and clinical examination showed normal built, no jaundice, no pallor, no edema, normal chest and heart, lax abdomen with and no palpable organs, and slight tenderness on the left upper quadrant close to his costal margin. I prescribed ciprofloxacin and loperamide, and his fever and diarrhea improved and subsided in a few days. A repeat stool analysis showed no pus cells and no parasites. Hepatitis virus serology showed: anti HAV-IgM negative, anti-HAV total positive, HBsAg negative, anti-HBs positive, anti-HCV negative. A repeat ultrasound 2

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weeks later showed his spleen size back to normal, and a month later his liver size returned to normal. A few days later he started to complain of repeated attacks of vague dizziness, lightheadedness, and abdominal discomfort, sometimes associated with back pain and/or diffuse muscle pain, and occasionally arthralgias. They last for a few hours every few days, which made him unable to go to work on many occasions. A repeat blood count showed hemoglobin 17 gm/dl, WBCs 4,500/cmm, with 10% eosinophils, platelets 268,000/cmm. ESR 3 mm/hr, CRP negative 0.9 mg/L, INR 1.12, bilirubin 1.5 mg/dl total, 0.3 mg direct, AST 27 U/L, ALT 39 U/L, albumin 4.9 gm/dl, creatinine 1.2 mg/dl, urea 22 mg/dl, Na 140 mmol/L, K 4.6 mmol/L, TSH 1.83 uIU/ml, urine analysis normal, stool analysis normal. Repeat blood counts after 2 weeks showed that eosinophilia subsided. He saw many doctors, and did many, many investigations which were all normal. He was given by some the diagnosis as possibly having IBD or Pre IBD, celiac disease, Whipples disease, familial Mediterranean fever, ankylosing spondylitis, or an infection related to his ingestion of raw meat and fish (echinococcosis, cystecercosis, trichinosis, tapeworms). He underwent many lab tests and imaging on many occasions which showed: Blood counts, ESR, CRP and stool analysis normal repeatedly. Helicobacter pylori stool antigen negative, calprotectin negative (<20mg/l, normal up to 50mg/l), familial Mediterranean fever genetic tests negative for all tested mutations and showed normal wild-type genotype, antigliadin IgA and IgG negative, ANCA C and P negative, schistosoma serology negative, antisacharomyces cervisiae (ASCA) negative, rheumatoid factor negative, ANA negative, HLA-B27 negative, EBV VCA negative, EBV EBNA negative, HIV negative. CT of the lumbar spine and of the bony thoracic cage normal, MRI of the abdomen and pelvis normal, echocardiography normal. He was treated with several courses of different antibiotics by different physicians. He saw a gastroenterologist in France in May who diagnosed him empirically as having giardiasis, and gave him 2 weeks of oral Flagyl, with no improvement. Tests for echinococcosis, cystecercosis and trichinosis turned out negative. He took two weeks of albendazole as an anti-parasitic for tissue parasites, after which he improved for one or two weeks, then his symptoms recurred (though slightly less severe).

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His parents were very anxious at the possibility of his having IBD, and insisted he have a colonoscopy. A full colonoscopy in August was completely normal, with normal mucosa, no ulcers, polyps, or strictures. A gastroscopy showed gastric antral hyperemia which was positive for helicobacter pylori, and his duodenum was hyperemic. A duodenal biopsy showed some flattening of the villi. He took treatment for Helicobacter pylori and esomeprazole. Currently, he still gets the same attacks (though milder) every few days, during which he is not feeling well. In between the attacks he feels fine, and plays sports and uses weights in the gym. He is traveling abroad and wants to have a second opinion to reach a definite diagnosis. If I could be of any further help regarding Mr. El-Saeed, please do not hesitate to contact me.

Imam Waked, M.D.

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