2019-01-01_Discover

20 DISCOVERMAGAZINE.COM

CLOCKWISE FROM TOP LEFT: QA INTERNATIONAL/SCIENCE SOURCE; SAKURRA/SHUTTERSTOCK; STEVE GSCHMEISSNER/SCIENCE SOURCE

a sphincter, at its top and bottom.

During a swallow, these muscles relax

and contract to allow food to enter

the esophagus and exit at the bottom

into the stomach.

However, in patients with achalasia,

the nerves don’t work right. The

lower part of Richard’s esophagus

wasn’t opening, so food was piling

up and fermenting. Regurgitation,

as Richard was doing in his sleep,

cleared the passage.

Patients have several treatment

options, all designed to keep the

lower esophagus open. One involves

inserting and inating that special

hollow balloon, and another involves

injecting Botox (the same agent used

by plastic surgeons to treat skin

wrinkles) to relax the lower sphincter

so it doesn’t close. A permanent

ix is to cut the lower esophageal

sphincter muscles.

Richard was about to leave on a

weeklong business trip, so we scheduled

an appointment two weeks out to

discuss which procedure he preferred.

TAN TELLS THE TALE

When Richard arrived for the

appointment, I noticed his fresh,

dark tan. During his business trip to

Panama, he told me, he sunbathed and

took long walks on the beach. This

caught my attention.

“How often do you go to Panama?”

I asked.

“All the time,” he said. “I have a lot

of business interests down there.”

“Do you ever get a lot of bug bites

on your trips?” I asked.

“So many I stop counting,” he

said, laughing.

“Do you sleep under a net to keep

away insects at night?” I asked.

He laughed again. “Not at the cheap

hotels I stay at down there.”

“Do you at least use bug repellent?”

“Nope.”

Richard’s story took on a new

dimension. In most patients diagnosed

with achalasia, a cause is never found.

There is, however, a well-known

connection between Central America

and the disorder.

Panama, like many other parts of

Central America, is home to tropical

parasites, most notably Trypanosoma

cruzi, which causes Chagas disease.

Insects spread the disease by biting

humans. It can cause fevers and

weakness, although some people show

no symptoms. A chronic infection can

lead to deadly heart problems.

Chagas disease can also cause

achalasia by damaging nerves along

the esophagus.

I had Richard’s blood checked, and

the test came back positive for T. cruzi.

Given his many trips to Panama, he

might have been infected several times.

His complaints of weakness had

me worried he had developed heart

problems. But a cardiac ultrasound

showed his heart was healthy.

I prescribed antibiotic medicine to

treat any ongoing infection. But the

damage to his esophagus was already

done, and he still needed treatment.

Richard selected endoscopic Botox

injections, which would require

maintenance injections every few

months. Several days later, I performed

the procedure, and in less than a week,

Richard was swallowing better. His

energy was also returning, and he

began putting on weight.

Now that Richard knew the cause of

his swallowing problems, he cut back

dramatically on his trips to Central

America. When there, he used bug

spray, slept under nets and took other

preventive measures.

Most physicians advise patients not

to tan deeply, but in Richard’s case, it

led to my pinpointing the cause of his

condition. Given the disease’s ability

to eventually damage the heart, his tan

might have indirectly saved his life. D

Douglas G. Adler is a professor in the

Department of Internal Medicine at the

University of Utah School of Medicine. The

cases described in Vital Signs are real, but

names and certain details have been changed.

A number of tropical insects, including the

kissing bug above, can infect unwary tourists

with Trypanosoma cruzi, a parasite that causes

Chagas disease.

A crucial part of the digestive system is the

esophagus, which connects the throat to the

stomach. An upper and lower sphincter admit

food into and out of the esophagus, but during

achalasia the lower sphincter can remain closed,

causing discomfort and problems with nutrition.

Esophageal

achalasia

Normal

Esophagus

Detail area

Lower esophageal

sphincter

Dilated esophagus

Lower sphincter

doesn’t relax

Vital

Signs