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Tropical Sprue Differential Diagnoses

  • Author: Rohan C Clarke, MD; Chief Editor: Julian Katz, MD  more...
 
Updated: Dec 15, 2014
 
 

Diagnostic Considerations

Brown et al compared the histologic changes found in tropical sprue with those occurring in gluten-sensitive enteropathy, a condition for which tropical sprue is often mistaken. The study, which involved 12 patients with tropical sprue and 150 cases of gluten-sensitive enteropathy, identified no complete villous blunting in the duodenal mucosa of the tropical sprue patients, although partial blunting occurred in 75% of them. In contrast, complete villous blunting was identified in 25% of gluten-sensitive enteropathy patients. The investigators also found that in the appropriate clinical context, tropical sprue is indicated by involvement of the terminal ileum, with greater inflammation and villous blunting than in the duodenum, and by the presence, in the lamina propria, of a conspicuous eosinophil infiltrate.[5]

A study of Indian adults by Ghoshal et al indicated that, in comparison with patients with tropical sprue, those with celiac disease tended to be younger (< 35 years), have a longer duration of diarrhea and a higher platelet count, and more often demonstrate villous atrophy (subtotal or partial).[6]

Diseases of general fat malabsorption to consider include the following:

  • Bacterial overgrowth
  • Ileal diseases
  • Pancreatic disorders

Mucosal diseases leading to malabsorption to consider include the following:

  • AIDS enteropathy
  • Celiac sprue
  • Cryptosporidia
  • Giardiasis
  • Infectious causes
  • Nonspecific enteropathy
  • Norwalk virus
  • Radiation enteropathy
  • Intestinal lymphoma

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Rohan C Clarke, MD Director, Department of Gastroenterology, JPS Health Systems Hospital

Rohan C Clarke, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Cubist; <br/>Received reimbursement from Boston Scientific for learning observership for eus; Received honoraria from Optimer pharmaceutical for speaking and teaching.

Coauthor(s)

Oluyinka S Adediji, MD, MBBS Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama

Oluyinka S Adediji, MD, MBBS is a member of the following medical societies: American College of Physicians, American Medical Association

Disclosure: Nothing to disclose.

Lisa Anne Ozick, MD Attending Gastroenterologist, Leumit Health Clinic, Israel

Lisa Anne Ozick, MD is a member of the following medical societies: American College of Gastroenterology, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Sabo B Tanimu, MD Fellow, Department of Medicine, Division of Gastroenterology, Harlem Hospital Center

Disclosure: Nothing to disclose.

Rachael M Ferraro, DO Internal Medicine Hospitalist, Torrance Memorial Medical Center, Little Company of Mary Hospital

Rachael M Ferraro, DO is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, American Osteopathic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Noel Williams, MD, FRCPC FACP, MACG, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Manoop S Bhutani, MD Professor, Co-Director, Center for Endoscopic Research, Training and Innovation (CERTAIN), Director, Center for Endoscopic Ultrasound, Department of Medicine, Division of Gastroenterology, University of Texas Medical Branch; Director, Endoscopic Research and Development, The University of Texas MD Anderson Cancer Center

Manoop S Bhutani, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Institute of Ultrasound in Medicine, American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

References
  1. Gray, GM. Tropical Sprue. Blaser,MJ, Smith, PD, Ravdin, JI. Infections of the Gastrointestinal Tract. New York: Raven Press; 1995. 333.

  2. Klipstein, FA. Tropical Sprue. Gastroenterology. 1968. 54:275.

  3. Gorbach, SL, Banwell, JG, Jacobs, B, et al. Tropical Sprue and Malnutrition in West Bengal. I. Intestinal microflora and absorption. American Journal of Clinical Nutrition. 1970. 23:1545.

  4. Klipstein, FA, Holdeman, LV, Corcino, JJ, et al. Enterotoxigenic intestinal bacteria in tropical sprue. Annals of Internal Medicine. 1973. 79:632.

  5. Brown IS, Bettington A, Bettington M, et al. Tropical sprue: revisiting an underrecognized disease. Am J Surg Pathol. 2014 May. 38(5):666-72. [Medline].

  6. Ghoshal UC, Mehrotra M, Kumar S, et al. Spectrum of malabsorption syndrome among adults & factors differentiating celiac disease & tropical malabsorption. Indian J Med Res. 2012 Sep. 136(3):451-9. [Medline]. [Full Text].

  7. Green PH, Shane E, Rotterdam H, Forde KA, Grossbard L. Significance of unsuspected celiac disease detected at endoscopy. Gastrointest Endosc. 2000 Jan. 51(1):60-5. [Medline].

  8. Ritchie BK, Brewster DR, Davidson GP, Tran CD, et al. 13C-sucrose breath test: novel use of a noninvasive biomarker of environmental gut health. Pediatrics. 2009 Aug. 124(2):620-6. [Medline].

  9. Lo A, Guelrud M, Essenfeld H, Bonis P. Classification of villous atrophy with enhanced magnification endoscopy in patients with celiac disease and tropical sprue. Gastrointest Endosc. 2007 Aug. 66(2):377-82. [Medline]. [Full Text].

  10. Cook GC. Aetiology and pathogenesis of postinfective tropical malabsorption (tropical sprue). Lancet. 1984 Mar 31. 1(8379):721-3. [Medline].

  11. Dutta AK, Chacko A, Avinash B. Suboptimal performance of IgG anti-tissue transglutaminase in the diagnosis of celiac disease in a tropical country. Dig Dis Sci. 2009 Mar 31. epub ahead of print. [Medline].

  12. Evans KE, Leeds JS, Sanders DS. Be vigilant for patients with coeliac disease. Practitioner. 2009 Oct. 253(1722):19-22, 2. [Medline].

  13. Farthing MJ. Tropical malabsorption and tropical diarrhea. Feldman M, ed. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 6th ed. Philadelphia, Pa: WB Saunders Co; 1998. 1574-84.

  14. Floch MH, Ozick L. Tropical sprue. In: Hurst JW, ed. Medicine for the Practicing Physician. 3rd ed. Boston, Mass: Butterworth. 1992:1547-1549.

  15. French AB. Tropical sprue--specific disease or extreme of a spectrum?. Ann Intern Med. 1968 Jun. 68(6):1362-5. [Medline].

  16. Gilman AG, ed. The Pharmacological Basis of Therapeutics. 8th ed. New York, NY:. Pergamon Press Inc. 1990.

  17. Greeberger NJ, Isselbacher KJ. Disorders of absorption. Fauci AS, ed. Harrison's Principle of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998. 1626.

  18. Klipstein FA. Tropical sprue in travelers and expatriates living abroad. Gastroenterology. 1981 Mar. 80(3):590-600. [Medline].

  19. Klipstein FA. Tropical sprue--an iceberg disease?. Ann Intern Med. 1967 Mar. 66(3):622-3. [Medline].

  20. Klipstein FA, Baker SJ. Regarding the definition of tropical sprue. Gastroenterology. 1970 May. 58(5):717-21. [Medline].

  21. Kuhlmann FM, Weil GJ. Infectious risks for travelers to the tropics. Mo Med. 2009 Jul-Aug. 106(4):263-8. [Medline].

  22. Nath SK. Tropical sprue. Curr Gastroenterol Rep. 2005 Oct. 7(5):343-9. [Medline].

  23. Thielman NM, Guerrant RL. Persistent diarrhea in the returned traveler. Infect Dis Clin North Am. 1998 Jun. 12(2):489-501. [Medline].

  24. Toskes P. Malabsorption. Bennet JC, Plum F, eds. Cecil's Textbook of Medicine. 20th ed. Philadelphia, Pa: WB Saunders Co; 1996. 705-6.

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Subtotal villous atrophy (H&E, orig. mag. ×10).
Tropical sprue (H&E, orig. mag. ×10).
Endoscopic views of unsuspected celiac disease. A: Absent duodenal folds. B: Mucosal fissures and scalloped folds. C: Scalloped fold.
 
 
 
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