![]() Malabsorption of iron, folate, vitamin B 12 and associated deficiencies of vitamins A, D and Kare also common. The most common symptoms of tropical sprue are abdominal cramps, diarrhea, indigestion, irritability, muscle cramps, numbness, and weight loss. There is no associated specificity for race, gender or age. It is still seen in Southeast Asia and the Caribbean, excluding Jamaica. Tropical sprue may not develop until after the patient has left the tropical area, lagging even up to 10 years. This condition is common in patients who have lived or visited tropical places for extended periods of time. The inflammation causes malabsorption of nutrients due to the increased swelling of the small intestine. Tropical sprue is caused by inflammation and damage to the small intestine from a suspected yet unidentified bacterial infection. Vitamin B 12:104pg/mL Folic acid>20ng/mL She was treated with sulfamethoxazole and trimethoprim for next three months. Follow up testing revealed: WBC 4.4k/uL HGB: 10.7g/dL HCT: 31.9% MCV: 86fL Platelets: 194 k/uL Ferritin: 122ng/mL ALT: 26U/L AST: 20U/L Iron: 80ug/dL TIBC: 275ug/dL 29% saturation. ![]() Follow up duodenal biopsy showed signs of improvement including partial villous regeneration and decrease of intraepithelial lymphocytes ( Figure 4). The repeat EGD showed only mild duodenopathy without changes consistent with celiac sprue ( Figure 3). She had improved energy, cognitive function, and she looked a lot younger by people who knew her. The patient returned 3 months later for an upper endoscopy. After the treatments, vitamin B 12 and two multivitamins daily were prescribed. For atypical sprue and possible tropical sprue, sulfamethoxazole and trimethoprim was prescribed for the next three months. (A) Low power (10x) (B) high power (20x).īased on the results, the patient was treated for with clarithromycin, pantoprazole, metronidazole and amoxicillin. ![]() pylori was positive on the gastric biopsy results.įigure 2 First duodenal biopsy showing severe villous blunting, crypt hyperplasia with marked increased intraepithelial lymphocytes and epithelial degeneration. Additional tests revealed: low vitamin B 12 (31pg/mL) Folic acid: 9.1ng/mL t-Transglutaminase (tTG) IgA<2U/mL H. Random biopsies of the colonic mucosa were negative for microscopic colitis. Her colonoscopy was normal throughout including the terminal ileum. The results showed that her DQ2 was positive, and DQ8 negative. To exclude celiac disease, HLA-DQ testing was performed. Due to her atypical presentation, vitamin B 12, folic acid and thiamine levels were ordered. 4The low prevalence of celiac sprue in the Nepalese population, and patient’s years spent in Southeast Asia raised the possibility of tropical sprue as a diagnosis associated with malabsorption and reversible dementia. Flattening and scalloping of the duodenal folds were noted in the entire duodenum, along with some thickening, typical for celiac sprue ( Figures1 &v2). An upper endoscopy revealed mild inflammation of the gastric antrum. Comprehensive metabolic panel was normal except for BUN: 7mg/dL ALT: 34 IU/L, and TSH: 2.730uIU/ml. Pylori stool antigen: negative stool O & P: negative WBC: 4,100/uL with a mild lymphocytosis of 51%, hemoglobin: 9.5 g/dL, hematocrit: 27.1%, MCV: 107fL, RDW: 15.6%, platelets: 105,000/uL. Her initial physical exam was unremarkable other than a faint murmur in all regions of her chest. Despite the interpreter’s involvement and clear instructions given about the colonoscopy prep, the patient could not follow the instructions due to her significant memory problems. She denied dysphagia, nausea/vomiting, fever, sick contacts, melena or hematochezia. She was given ranitidine, which did not change her complaints. She complained of chronic constipation with intermittent diarrhea every few days, and epigastric burning aggravated with spicy foods. In last 10years, she had significant decline of her energy levels, appetite, and cognitive functions and was diagnosed presumptively with early onset Alzheimer’s disease. The patient spent 10years in a refugee camp in Bhutan before she immigrated to the U.S. She presented with a complaint of a 10-lb weight loss, heme positive stool, dyspepsia and a decrease in appetite. 1–3 A 61-year old, originally Nepalese, female patient was sent as a direct referral for an EGD and a colonoscopy for severe “iron deficiency anemia” and a positive FIT test. Misdiagnosis can result in delay of adequate treatment in a patient with this illness. Tropical Sprue is an uncommon cause of small bowel malabsorption, in the Western world, and often overlooked by the medical community.
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