Hyperreactive malarial splenomegaly — DTM&H MCQ
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Correct answer: B — Hyperreactive malarial splenomegaly
The most likely diagnosis is hyperreactive malarial splenomegaly. This is a chronic immunological complication of repeated malaria exposure in endemic regions and classically presents with massive splenomegaly, hypersplenism with anaemia, markedly raised polyclonal IgM, high antimalarial antibody titres and absent or very low parasitaemia, so repeated blood films may be negative. Clinical improvement with antimalarial therapy is a key supportive feature. The alternatives do not fit as well: schistosomal periportal fibrosis causes portal hypertension rather than raised malarial antibodies; CLL would show clonal lymphocytosis; brucellosis causes systemic febrile illness; and visceral leishmaniasis can cause massive splenomegaly and cytopenias but is not characterised by high malaria antibody titres or response to antimalarial therapy.
Reference: CDC Yellow Book 2026, International Adoption — Malaria section: notes that asymptomatic patients with splenomegaly from malaria-endemic areas may have hyperreactive malarial splenomegaly, with high malaria antibody titres but negative smears. https://www.cdc.gov/yellow-book/hcp/refugees-immigrants-migrants/international-adoption.html