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Tropical sprue

Tropical sprue is a rare, acquired malabsorption syndrome endemic to tropical regions, characterized by chronic or acute diarrhea, weight loss, and impaired absorption of nutrients such as fats, vitamins (particularly B12 and folic acid), and carbohydrates, resulting from damage to the small intestine mucosa.^[1] It primarily affects residents and long-term visitors (stays exceeding one month) in areas between 30° N and 30° S latitude, including parts of Southeast Asia (notably India), the Caribbean (such as Puerto Rico and Haiti), and Central America, with incidence declining due to improved sanitation and antibiotic use.^[2] The condition was first described in the 18th century and remains of enigmatic origin, though multifactorial etiology involving enteric infections—potentially from bacteria like Escherichia coli or Klebsiella—and subsequent small intestinal bacterial overgrowth leading to mucosal injury and enterotoxin production is widely implicated.^[3] Patients typically present with persistent watery or steatorrheic (fatty) diarrhea, abdominal bloating and cramping, anorexia, and signs of malnutrition including megaloblastic anemia, glossitis, edema, and fatigue; symptoms often develop insidiously over weeks to months in residents but more acutely in travelers.^[1] Diagnosis requires exclusion of other malabsorptive disorders (e.g., celiac disease, giardiasis) through clinical history of tropical exposure, laboratory tests showing low serum vitamin levels, elevated fecal fat (>6 g/24 hours), abnormal D-xylose absorption, and endoscopic or biopsy evidence of partial villous atrophy with intraepithelial lymphocytosis and minimal inflammation.^[2] Treatment centers on a prolonged course of broad-spectrum antibiotics such as tetracycline or doxycycline (250 mg four times daily for 3–6 months, extendable to 12 months in endemic residents), combined with folic acid (5 mg daily), vitamin B12 injections, iron supplementation, and nutritional support to reverse deficiencies and promote mucosal recovery, yielding excellent prognosis in travelers but with relapse rates up to 50% in those remaining in affected areas.^[3]

Clinical Features

Signs and Symptoms

Tropical sprue often presents differently depending on the duration of exposure. In short-term visitors (travelers), it typically begins acutely with watery diarrhea and malaise, often resembling an episode of traveler's diarrhea, which then progresses to chronic diarrhea lasting more than two weeks.^[1]^[4] In long-term residents of endemic areas, symptoms usually develop insidiously over weeks to months. The diarrhea is usually nonbloody, persistent, and may involve multiple loose or soft stools per day, sometimes accompanied by mucus and exacerbated by food intake.^[3]^[5] As the condition advances, steatorrhea develops due to fat malabsorption, resulting in bulky, pale, and foul-smelling stools that may float.^[1]^[3] Patients commonly experience significant weight loss, anorexia, and abdominal bloating or cramps, contributing to overall malaise and fatigue.^[5]^[2] Oral manifestations are frequent, including glossitis, angular cheilitis, and a sore tongue, often linked to nutritional deficiencies. Physical findings may include pedal edema and abdominal distention.^[1]^[4] Neurological symptoms such as paresthesia or ataxia may occur secondary to vitamin deficiencies, though these are more pronounced in prolonged cases.^[3]^[5] In pediatric patients, tropical sprue can manifest with growth failure alongside chronic diarrhea and weight loss, accounting for a notable proportion of malabsorption cases in regions like South Asia.^[4]^[5]

Complications

Untreated or prolonged tropical sprue leads to malabsorption of essential nutrients, resulting in various secondary complications that can significantly impact health.^[6] These arise primarily from deficiencies in vitamins, minerals, and proteins, exacerbating the disease's effects beyond initial gastrointestinal symptoms.^[7] Megaloblastic anemia is a common complication due to folate and vitamin B12 malabsorption, characterized by large, immature red blood cells and presenting with symptoms such as fatigue, pallor, and exertional dyspnea; laboratory findings include hypersegmented neutrophils.^[6] Iron deficiency anemia also frequently occurs, leading to microcytic hypochromic red blood cells and similar pallor, further contributing to overall fatigue and weakness.^[6]^[7] Osteoporosis and osteomalacia develop from chronic malabsorption of vitamin D and calcium, causing reduced bone density, increased fracture risk, and skeletal deformities, respectively.^[6] Vitamin B12 deficiency additionally predisposes individuals to peripheral neuropathy, manifesting as paresthesia and sensory loss, as well as subacute combined degeneration of the spinal cord, which involves demyelination and gait disturbances.^[6]^[8] Protein malnutrition in tropical sprue impairs immune function, increasing susceptibility to recurrent infections, including bacterial overgrowth in the small intestine.^[6]^[7] Rare but severe outcomes include heart failure secondary to profound anemia and electrolyte imbalances, or blindness from vitamin A deficiency affecting retinal function.^[6]^[1]

Pathogenesis

Etiology

The etiology of tropical sprue remains incompletely understood, but the primary hypothesis centers on an infectious origin involving bacterial overgrowth in the small intestine, often triggered by enterotoxigenic bacteria such as Escherichia coli.^[1] This overgrowth is thought to initiate mucosal injury, leading to malabsorption, with documented associations to coliform organisms including E. coli, Klebsiella pneumoniae, and Enterobacter cloacae.^[1] Microbial toxins produced by these bacteria are proposed to damage the intestinal epithelium directly, disrupting nutrient absorption mechanisms.^[9] The condition is strongly linked to environmental exposures in endemic tropical and subtropical regions, particularly through ingestion of contaminated water or food harboring these pathogens, though it is not considered directly contagious from person to person.^[10] While protozoal infections such as Giardia lamblia have been investigated, they are not regarded as the primary cause, as stool examinations typically exclude them in confirmed cases.^[1] Autoimmune or genetic factors have been largely excluded as initiators, distinguishing tropical sprue from conditions like celiac disease, which involve immune-mediated or hereditary components.^[1] Recent research emphasizes gut microbiome dysbiosis as a key trigger, with small intestinal bacterial overgrowth (SIBO) and alterations in microbial composition contributing to the syndrome's persistence, potentially exacerbated by impaired gut motility.^[11]^[12]

Pathophysiology

Tropical sprue is characterized by progressive damage to the small intestinal mucosa, primarily affecting the duodenum and jejunum, leading to malabsorption through structural and functional alterations.^[1] The hallmark histopathological changes include abnormal shortening and blunting of the intestinal villi, which significantly reduces the absorptive surface area available for nutrient uptake.^[13] Accompanying these alterations are crypt hyperplasia, marked by increased crypt depth and nuclear immaturity in enterocytes, as well as an expansion of inflammatory cells in the lamina propria and intraepithelial lymphocytic infiltration.^[14] These features result from an initial enterocyte injury, often triggered by microbial factors, leading to mucosal flattening and impaired epithelial renewal.^[15] The mucosal damage directly impairs the absorption of multiple nutrients. Fat malabsorption is prominent, manifesting as steatorrhea due to reduced enterocyte function and interference with bile salt reabsorption, while carbohydrate absorption is compromised, often resulting in secondary lactose intolerance from brush border enzyme deficiencies.^[16] Protein absorption is similarly affected, contributing to overall nutritional deficits, alongside specific deficiencies in vitamins such as folate, vitamin B12, and fat-soluble vitamins A, D, E, and K, which arise from diminished transport mechanisms in the damaged epithelium.^[13] Bacterial overgrowth in the small intestine, frequently involving coliforms like Escherichia coli and Klebsiella species, exacerbates these issues by deconjugating bile salts, further hindering fat emulsification and absorption, and producing metabolites that inhibit nutrient uptake.^[17] Systemic consequences stem from the chronic malabsorption and protein loss across the altered mucosa. Hypoalbuminemia develops due to reduced synthesis and increased enteric loss of albumin, leading to peripheral edema and other manifestations of protein-energy malnutrition.^[1] Unlike celiac disease, which involves gluten sensitivity and irreversible damage without dietary intervention, tropical sprue lacks gluten dependence and demonstrates partial reversibility of villous architecture and absorptive function with antibiotic and nutritional therapy.^[18] This distinction highlights the infectious and dysbiotic components driving the pathophysiology in tropical sprue.^[19]

Diagnosis

Clinical Evaluation

The clinical evaluation of tropical sprue begins with a detailed history to identify risk factors and symptom chronology. Patients typically report prolonged residence or travel to endemic regions, such as the Caribbean, southern India, South Asia, or Southeast Asia, lasting at least one to three months, as shorter visits rarely lead to the condition.^[1]^[20]^[16] A hallmark is chronic diarrhea persisting for more than one month, often watery, foul-smelling, and accompanied by steatorrhea, which remains unresponsive to standard antidiarrheal treatments.^[21]^[20] The timeline helps exclude acute travelers' diarrheas or infections, as tropical sprue symptoms may onset during exposure or emerge years later, distinguishing it from self-limited gastrointestinal illnesses.^[1]^[21] Physical examination reveals signs of malabsorption and nutritional deficits. Common findings include cachexia and significant weight loss due to prolonged nutrient malabsorption, pallor from anemia, and cheilosis or glossitis indicating deficiencies in vitamins such as folate or B12.^[1]^[20]^[16] Additional features may encompass abdominal distention, hyperactive bowel sounds with borborygmi, and peripheral edema, reflecting fluid and electrolyte imbalances.^[1]^[21] Dehydration signs, such as reduced skin turgor, may also be evident in advanced cases.^[10] Suspicion for tropical sprue arises when chronic diarrhea and malabsorptive symptoms, such as bloating and fatigue, align with tropical exposure history, prompting consideration within the broader category of malabsorption syndromes. No specific scoring systems exist exclusively for tropical sprue, but clinical criteria for malabsorption—emphasizing persistent symptoms unresponsive to initial interventions—guide initial assessment.^[1]^[20] Evaluation must rule out mimicking factors, including dietary intolerances or medications that could simulate gastrointestinal symptoms, to refine diagnostic suspicion before confirmatory testing.^[20] Core symptoms like steatorrhea and weight loss further support this clinical context.^[16]

Laboratory and Histological Findings

Laboratory investigations in tropical sprue typically reveal evidence of malabsorption and nutritional deficiencies. Stool studies demonstrate steatorrhea, with quantitative fecal fat excretion exceeding 6 g per 24 hours on a 100 g fat diet, confirming fat malabsorption.^[1] The D-xylose absorption test shows malabsorption, indicated by urinary excretion of less than 4 g in a 5-hour collection after an oral dose or serum levels below 20 mg/dL at 1 hour.^[1] Fecal elastase levels are normal or elevated, helping to exclude pancreatic exocrine insufficiency as a contributing factor.^[2] Blood tests commonly uncover megaloblastic anemia with macrocytic red blood cells (elevated mean corpuscular volume), low serum folate and vitamin B12 levels, and occasional deficiencies in iron and vitamin D.^[1] Hypoalbuminemia and low serum cholesterol are frequently observed, reflecting protein and lipid malabsorption, while electrolyte imbalances such as hypokalemia, hypochloremia, and hyponatremia may occur due to diarrheal losses. Stool examinations for pathogens, including parasites like Giardia and bacteria, are negative, supporting the diagnosis after ruling out infectious causes.^[1] Histological examination of small bowel biopsies, obtained via upper endoscopy from the duodenum or jejunum, is essential for confirmation. Findings include subtotal or partial villous atrophy, crypt hyperplasia with increased crypt depth, and mild chronic inflammation characterized by intraepithelial lymphocytic infiltration and plasma cell predominance in the lamina propria, often with some eosinophils but without granulomas or significant acute inflammation.^[22] These changes are more pronounced in the jejunum and ileum than in the duodenum, and lipid-laden macrophages may be present in the lamina propria.^[1] Imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) of the abdomen are used primarily to exclude alternative causes like tumors or strictures, often revealing nonspecific dilated small bowel loops with thickened mucosal folds, though findings may be normal in uncomplicated cases.^[23] Serological testing for celiac disease, including anti-tissue transglutaminase (anti-tTG) and anti-endomysial (anti-EMA) antibodies, is negative, aiding differentiation from celiac disease despite overlapping histological features.^[16] An indirect confirmatory approach involves a therapeutic trial of broad-spectrum antibiotics (such as tetracycline) combined with folate supplementation, to which patients typically respond with improved absorption and resolution of histological abnormalities within months.^[1]

Management

Treatment

The primary treatment for tropical sprue consists of prolonged antibiotic therapy to target presumed infectious etiology, combined with folate supplementation to promote intestinal mucosal repair and correct megaloblastic anemia.^[1] Tetracycline is the first-line antibiotic, administered at a dose of 250 mg orally four times daily for 3 to 6 months, with potential extension to 12 months in cases of relapse or endemic exposure.^[24] Alternatives include doxycycline at 100 mg orally daily or trimethoprim-sulfamethoxazole at double-strength twice daily for the same duration, particularly for patients intolerant to tetracycline or in regions with resistance patterns.^[25]^[1] Nutritional deficiencies are addressed concurrently with folic acid at 5 mg orally daily for at least 3 to 6 months to reverse anemia and support epithelial regeneration.^[24] Vitamin B12 is supplemented parenterally at 1 mg intramuscularly monthly (or 1000 mcg weekly initially) to ensure absorption despite malabsorption.^[24] Additional multivitamin and mineral replacement, including iron (e.g., ferrous sulfate for anemia), calcium, and fat-soluble vitamins (A, D, E, K), is provided based on documented deficiencies to prevent complications such as osteoporosis or coagulopathy.^[1] Supportive care focuses on symptom relief and nutritional optimization, including antidiarrheal agents like loperamide (2-4 mg orally as needed, up to 16 mg daily) to control diarrhea, and rehydration with oral or intravenous electrolyte solutions for dehydration.^[26] In severe cases with profound malabsorption, elemental diets or parenteral nutrition may be employed temporarily to facilitate nutrient delivery and weight stabilization.^[1] Response to therapy is monitored through clinical parameters such as weight gain (typically 1-2 kg per month), resolution of diarrhea within 1-2 weeks, and normalization of stool frequency over months.^[20] Laboratory assessments include repeat complete blood counts to track hemoglobin levels, serum folate and B12 concentrations, and absorption tests (e.g., D-xylose or fecal fat); small bowel biopsy may be repeated after 6 months to confirm mucosal recovery with villous regrowth.^[20]^[1] In pregnant patients, tetracycline is contraindicated due to risks of fetal dental and bone abnormalities, necessitating alternatives like trimethoprim-sulfamethoxazole (with caution in the third trimester due to kernicterus risk) or other non-teratogenic antibiotics, alongside standard folate and B12 dosing to support maternal and fetal nutrition.^[26] For children, especially those under 8 years, tetracycline is avoided to prevent tooth discoloration; dosing adjustments include vitamin B12 at 100 mcg intramuscularly and folic acid at 5 mg daily, with antibiotics selected based on age-appropriate safety profiles such as amoxicillin or macrolides if needed.^[27]

Prevention

Preventing tropical sprue primarily involves minimizing exposure to potential infectious triggers in endemic regions, such as parts of Southeast Asia, the Caribbean, and southern India, through vigilant hygiene practices. Travelers and residents should prioritize safe food and water consumption by boiling or treating water to eliminate contaminants, avoiding uncooked vegetables, and opting for peeled fruits to reduce the risk of ingesting enteric pathogens that may initiate the condition.^[1]^[28] Prophylactic antibiotics are not routinely recommended for most travelers due to concerns over antimicrobial resistance and potential side effects, but short-term use may be considered for high-risk individuals on brief, critical trips to endemic areas. For example, doxycycline at 100 mg daily has been effective in preventing traveler's diarrhea, which can precede tropical sprue, offering up to 80-90% protection against bacterial causes, though its role in specifically averting sprue remains indirect.^[29] Vaccinations against related gastrointestinal infections, such as typhoid and cholera, are advisable for individuals traveling to or residing in high-risk tropical areas, as these may help mitigate acute diarrheal episodes that could progress to sprue. In endemic communities, nutritional support programs aimed at maintaining adequate folate, vitamin B12, and iron levels prior to potential exposure can strengthen gut resilience and reduce susceptibility to malabsorption syndromes like tropical sprue.^[10] Prompt treatment of acute diarrheal illnesses encountered in tropical settings is crucial to halt progression to chronic malabsorption; early intervention with rehydration and targeted antimicrobials can prevent the development of tropical sprue in affected individuals.^[10] On a broader scale, public health initiatives focusing on improved sanitation and water quality in endemic regions have been associated with declining incidence rates of tropical sprue, as observed in parts of India where enhanced hygiene infrastructure reduced environmental pathogen loads.^[30]90025-1/pdf)

Epidemiology and History

Epidemiology

Tropical sprue is endemic to tropical and subtropical regions between approximately 30° N and 30° S latitude, with the highest prevalence reported in parts of the Caribbean, including Puerto Rico, Haiti, the Dominican Republic, and Cuba, as well as in southern India, Sri Lanka, Pakistan, and Southeast Asia, such as Myanmar, Thailand, and the Philippines.^[1]^[3] The condition is notably rare in sub-Saharan Africa (with limited expatriate cases in areas like Nigeria and South Africa), China, the Middle East, and North America.^[1]^[3] The disease affects both indigenous populations and expatriates or travelers residing in endemic areas for extended periods, typically more than one month, with incidence rates among long-term residents estimated at 5-10%, including up to 8% in Puerto Rico.^[1]^[15] It is uncommon among short-term tourists, with rates below 1%.^[1] Demographically, tropical sprue shows no significant gender disparity, with equal prevalence in males and females, and primarily impacts adults aged 20-50 years, though cases in children have been documented but are less frequently studied, possibly due to protective factors like breastfeeding.^[1]^[15]^[3] Seasonal variations in incidence have been observed, with peaks often linked to periods of increased environmental contamination, such as during or preceding rainy seasons in some regions; for example, outbreaks in the Philippines occur from March to July, while in Puerto Rico, they align with the early months of the year.^[3] Overall incidence has declined in areas like India and Pakistan due to improvements in sanitation, hygiene, and widespread antibiotic use, yet the condition persists in rural tropical settings as of 2025, particularly among lower socioeconomic groups affected by poverty and inadequate hygiene practices.^[1]^[31]^[32]

History

Tropical sprue has been recognized in medical literature for centuries, with early descriptions predating modern terminology. Ancient Indian texts, such as the Charaka Samhita from the second century BC, alluded to a similar malabsorption syndrome known as "grahani vyadhi," characterized by chronic diarrhea and digestive disturbances.^[33] In the 18th century, British physician William Hillary provided the first detailed Western account in 1759, documenting chronic diarrhea, weight loss, and associated aphthous ulcers among residents of Barbados in the West Indies.^[15] By the early 19th century, British physicians in Jamaica described a comparable condition as "hill diarrhea," noting its occurrence among expatriates at higher elevations and linking it to prolonged tropical exposure.90025-1/pdf) The term "tropical sprue" was formalized in 1880 by Sir Patrick Manson, who applied it to persistent diarrheal disorders observed in Southeast Asian populations, emphasizing its distinction from acute infections.^[1] In the 1930s, Philip Manson-Bahr elevated the understanding of tropical sprue by establishing it as a discrete clinical entity, particularly through his analyses of over 200 cases in Ceylon (modern-day Sri Lanka), where he connected the syndrome to severe malabsorption resulting in megaloblastic anemia and nutritional deficiencies.^[34] His work, including studies on treatment responses to marmite (a vitamin B-rich yeast extract), highlighted the role of folate and B vitamins in symptom amelioration.^[35] During World War II, tropical sprue emerged as a major health issue, accounting for one-sixth of casualties among Allied forces in India and Southeast Asia, with epidemics affecting soldiers and prisoners of war.^[33] Post-WWII investigations, including those on returning military personnel, reinforced an infectious etiology through outbreak patterns and the observed benefits of sulfonamide antibiotics, suggesting environmental or bacterial triggers in endemic areas.^[36] The 1960s and 1970s marked a pivotal era for diagnostic advancements, driven by histopathological research in southern India. Pioneers like S.J. Baker and V.I. Mathan employed peroral jejunal biopsies to reveal partial villous atrophy, crypt hyperplasia, and mononuclear infiltrates in affected patients, features that differentiated tropical sprue from celiac disease, which typically shows total villous flattening.^[1] These studies, amid epidemics that claimed 30,000 to 40,000 lives in regions like Tamil Nadu between 1960 and 1962, also documented the condition's epidemiological spread and its impact on indigenous populations.^[37] From the 1980s through the 2000s, therapeutic trials solidified empirical management strategies. Controlled studies demonstrated that a six-month course of tetracycline, often combined with folic acid supplementation, effectively reversed malabsorption, promoted mucosal recovery, and alleviated anemia in the majority of cases.^[38] In the 2010s to the mid-2020s, metagenomic and microbiome analyses have implicated small intestinal bacterial overgrowth and dysbiosis—featuring overabundance of Enterobacteriaceae like Klebsiella and Escherichia coli—as central to pathogenesis, though attempts to identify a single causative pathogen have remained inconclusive.^[31]

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