eMedicine Specialties > Gastroenterology > Intestine

Sprue, Tropical

Author: Rohan C Clarke, MD, Consulting Staff, Department of Gastroenterology, JPS Health Systems Hospital
Coauthor(s): Rachael M Ferraro, DO, Consulting Staff, Department of Internal Medicine, Regency Hospital and Kindred Hospital; Lisa Ozick, MD, Former Chief, Division of Gastroenterology, Harlem Hospital Center; Sabo B Tanimu, MD, Fellow, Department of Medicine, Division of Gastroenterology, Harlem Hospital Center; Oluyinka S Adediji, MD, Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama
Contributor Information and Disclosures

Updated: Jan 3, 2010

Introduction

Background

Tropical sprue (TS) is a syndrome characterized by acute or chronic diarrhea, weight loss, and malabsorption of nutrients. It occurs in residents of or visitors to the tropics and subtropics. The first description of tropical sprue is attributed to William Hillary's 1759 account of his observations of chronic diarrhea while in Barbados. Subsequently, tropical sprue was described in tropical climates throughout the world. The definition has been expanded to include malabsorption of at least 2 different substances when other causes are excluded.


Tropical sprue (H&E, orig. mag. ×10).

Tropical sprue (H&E, orig. mag. ×10).

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Tropical sprue (H&E, orig. mag. ×10).

Tropical sprue (H&E, orig. mag. ×10).


Endoscopic views of unsuspected celiac disease. <...

Endoscopic views of unsuspected celiac disease. A: Absent duodenal folds. B: Mucosal fissures and scalloped folds. C: Scalloped fold.

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Endoscopic views of unsuspected celiac disease. <...

Endoscopic views of unsuspected celiac disease. A: Absent duodenal folds. B: Mucosal fissures and scalloped folds. C: Scalloped fold.


The exact causative factor of tropical sprue is unknown, but an intestinal microbial infection is believed to be the initiating insult. The infection results in enterocyte injury, intestinal stasis, and possible bacteria overgrowth. Villous destruction and demonstrable nutrient malabsorption occur in varying degrees. Folate, vitamin B-12, and iron deficiencies are the most common nutrient deficiencies.

Pathophysiology

The exact role of microbial agents in the initiation and propagation of the disease is poorly understood. One theory is that an acute intestinal infection leads to jejunal and ileal mucosa injury; then intestinal bacterial overgrowth and increased plasma enteroglucagon results in retardation of small-intestinal transit. Central to this process is folate deficiency, which probably contributes to further mucosal injury.

Hormone enteroglucagon and motilin levels are elevated in patients with tropical sprue. Enterocyte injury can cause these elevations. Enteroglucagon causes intestinal stasis, but the role of motilin is not clear.

The upper small intestine is predominantly affected; however, because it is a progressive and contiguous disease, the distal small intestine up to the terminal ileum may be involved. Pathological changes are rarely demonstrated in the stomach and colon. Coliform bacteria, such as Klebsiella, E coli and Enterobacter species are isolated and are the usual organisms associated with tropical sprue.1,2,3,4

Frequency

United States

Tropical sprue occurs in geographically limited areas. The syndrome is not reported in US patients unless they have lived in or traveled to any of the areas described below.

International

Tropical sprue occurs in both epidemic and endemic forms, primarily in Southeast Asia and the Caribbean. The actual prevalence of the endemic form is difficult to estimate, but rates as high as 8% are reported in Puerto Rico. One unusual feature is that tropical sprue appears to be limited to certain geographic areas, even within the tropics. For example, although tropical sprue is commonly reported in Puerto Rico and the Dominican Republic, it is not reported in Jamaica. Only a few cases are reported in emigrants from southern Africa.

Mortality/Morbidity

Acute illness complicated by fluid and electrolyte deficits is rarely fatal. The frequency of this complication is not known but appears to be decreasing. Chronic illness with severe malabsorption and anemia can also lead to death, but this usually occurs in patients with comorbid conditions.

Race

Tropical sprue is confined to geographic regions, but it is observed in individuals of all races who live in or visit those regions.

Sex

The male-to-female ratio is equal.

Age

Tropical sprue is primarily an adult disease, but it has been described in children.

Clinical

History

  • Tropical sprue manifests clinically with a spectrum of signs and symptoms. It may develop in natives or travelers to the tropics, and it may not appear until as long as 10 years after the patient has left there. No definitive marker of tropical sprue exists; hence, these claims remain unsubstantiated. Patients may experience the following:
    • Diarrhea
    • Weight loss
    • Leg swelling
    • Fatigue
    • Fever

Physical

  • Examination may reveal the following:
    • Weight loss
    • Dehydration
    • Pallor
    • Oral mucosa changes (glossitis, stomatitis)
    • Edema
  • Consider specific causes of diarrhea and malabsorption.
  • Consider the diagnosis of tropical sprue if the initial history, physical, and laboratory workups are suggestive of mucosal malabsorption.
  • Although tropical sprue can manifest as an acute diarrheal illness, the clinical diagnosis is usually not considered until patients present with chronic symptoms.
  • Diarrhea and fat malabsorption may occasionally be difficult to differentiate. Perform a 24- to 72-hour stool test for fat. Total stool fat less than 6-7 g/d excludes steatorrhea; therefore, consider chronic diarrhea.

Causes

  • Environmental
  • Residence or travel in an endemic tropical area

More on Sprue, Tropical

Overview: Sprue, Tropical
Differential Diagnoses & Workup: Sprue, Tropical
Treatment & Medication: Sprue, Tropical
Follow-up: Sprue, Tropical
Multimedia: Sprue, Tropical
References
Further Reading
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References

  1. Gray, GM. Tropical Sprue. In: 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. Green PH, Shane E, Rotterdam H, Forde KA, Grossbard L. Significance of unsuspected celiac disease detected at endoscopy. Gastrointest Endosc. Jan 2000;51(1):60-5. [Medline]. [Full Text].

  6. 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. Aug 2009;124(2):620-6. [Medline].

  7. 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. Aug 2007;66(2):377-82. [Medline]. [Full Text].

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

  9. 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. Mar 31 2009;epub ahead of print. [Medline].

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

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

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

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

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

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

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

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

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

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

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

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

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

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Further Reading

Related eMedicine Topics

Clinical Guidelines

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Keywords

tropical sprue, malabsorption syndromes, aphthoids chronica, diarrhea, cachectic diarrhea, psilosis, postinfective tropical malabsorption, TS, intestinal stasis, mucosal injury, ileal mucosa injury, mucosal malabsorption, intestinal malabsorption, malabsorption of nutrients, villous atrophy, enterocyte injury, intestinal stasis, jejunal mucosa injury, tropical diarrhea

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Contributor Information and Disclosures

Author

Rohan C Clarke, MD, Consulting Staff, 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, and American Society of Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Coauthor(s)

Rachael M Ferraro, DO, Consulting Staff, Department of Internal Medicine, Regency Hospital and Kindred Hospital
Rachael M Ferraro, DO is a member of the following medical societies: American College of Osteopathic Internists, American College of Physicians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Lisa Ozick, MD, Former Chief, Division of Gastroenterology, Harlem Hospital Center
Lisa Ozick, 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 Medical Association, American Society for Gastrointestinal Endoscopy, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Sabo B Tanimu, MD, Fellow, Department of Medicine, Division of Gastroenterology, Harlem Hospital Center
Disclosure: Nothing to disclose.

Oluyinka S Adediji, MD, Consulting Staff, Department of Adult and General Medicine, Health Services Incorporated, Montgomery, Alabama
Oluyinka S Adediji, MD is a member of the following medical societies: American College of Physicians and American Medical Association
Disclosure: Nothing to disclose.

Medical Editor

Manoop S Bhutani, MD, FACG, FACP, Professor, Department of Medicine, Division of Gastroenterology, Director, Center for Endoscopic Ultrasound, Co-Director, Center for Endoscopic Research, Training and Innovation, University of Texas Medical Branch at Galveston
Manoop S Bhutani, MD, FACG, FACP 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, and American Society for Gastrointestinal Endoscopy
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Noel Williams, MD, 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 is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine; Consulting Staff, Department of Medicine, Section of Gastroenterology and Hepatology, Hospital of the Medical College of Pennsylvania
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 and Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility
Disclosure: Nothing to disclose.

 
 
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