Massive splenomegaly in rural Malawi: new wine, old wineskins and the importance of collaboration.

During a voluntary placement in rural Malawi, we assessed a 21-year-old man who presented with dyspnoea and lethargy secondary to a chronic refractory anaemia associated with massive splenomegaly. He was initially treated at the rural hospital for a presumptive diagnosis of hyper-reactive malarial syndrome (HMS) with long-term malarial prophylaxis. There was inadequate provision of blood products and the availability of suitable donors was limited by the high local prevalence of blood-borne viruses. He was transferred to the district hospital for further investigations after transfusion of three units of blood. Unfortunately, he self-discharged without receiving appropriate investigations and medical treatment. Subsequently, his family sought help from the local traditional healer who performed scarification to attempt to treat him. Further efforts to emphasise the importance of hospital-based care proved unsuccessful, and sadly this man died at his family home 3 months after his initial presentation.