Chronic Chagas megaoesophagus — DTM&H MCQ

Correct answer: C — Chronic Chagas disease

The correct answer is C, chronic Chagas disease. The vignette gives the classic epidemiological and clinical triad: an acute febrile illness in childhood in rural Bolivia (acute Chagas infection via triatomine bug exposure), followed decades later by megaoesophagus with dysphagia, regurgitation, and a barium swallow showing a dilated oesophagus with distal tapering. Chronic infection with Trypanosoma cruzi destroys the myenteric (Auerbach) plexus of the oesophagus, producing loss of peristalsis and failure of lower oesophageal sphincter relaxation, a pattern that mimics primary achalasia radiologically but has an identifiable infective cause. Bolivia has among the highest Chagas prevalence in Latin America, making this the epidemiologically appropriate diagnosis rather than an idiopathic motility disorder. Why the other options are wrong: A. Achalasia of unknown cause: this label is reserved for primary (idiopathic) achalasia in non-endemic settings; here the antecedent febrile illness in a Chagas-endemic area identifies a specific infective aetiology, so the cause is not unknown. E. Corrosive oesophageal stricture: caustic injury produces fixed strictures at sites of maximal contact (mid or lower oesophagus) with a history of ingestion, not a bird's beak achalasia-type pattern with childhood febrile illness. D. Oesophageal carcinoma: carcinoma causes an irregular, shouldered stricture with progressive solid-food dysphagia over months in older patients, not the smooth symmetrical tapering of chagasic megaoesophagus. B. Plummer-Vinson syndrome: this comprises iron deficiency anaemia, upper oesophageal webs, and dysphagia, with no link to febrile illness or Latin American residence. Key point: megaoesophagus with an achalasia-like bird's beak appearance in a patient from rural Latin America with a prior febrile illness indicates chronic Chagas disease from T. cruzi-mediated destruction of the myenteric plexus.

Reference: GOV.UK, UK Health Security Agency, Chagas disease: migrant health guide, https://www.gov.uk/guidance/chagas-disease-migrant-health-guide