Tropical sprue: revisiting an underrecognized disease

Brown, Ian S., Bettington, Andrew, Bettington, Mark and Rosty, Christophe (2014) Tropical sprue: revisiting an underrecognized disease. American Journal of Surgical Pathology, 38 5: 666-672. doi:10.1097/PAS.0000000000000153

Author Brown, Ian S.
Bettington, Andrew
Bettington, Mark
Rosty, Christophe
Title Tropical sprue: revisiting an underrecognized disease
Journal name American Journal of Surgical Pathology   Check publisher's open access policy
ISSN 1532-0979
Publication date 2014-05-01
Year available 2014
Sub-type Article (original research)
DOI 10.1097/PAS.0000000000000153
Volume 38
Issue 5
Start page 666
End page 672
Total pages 7
Place of publication Philadelphia, PA, United States
Publisher Lippincott Williams and Wilkins
Language eng
Formatted abstract
Tropical sprue is an acquired chronic diarrheal disorder of unclear etiology affecting residents of and visitors to tropical regions. Patients usually present with profuse diarrhea, weight loss, and malabsorption, notably of vitamin B12 and folate. The histologic changes typically resemble that of gluten-sensitive enteropathy. Reports of tropical sprue have become infrequent in the literature, and the diagnosis is often not considered either clinically or pathologically. This disease may, however, cause significant morbidity, although it is eminently treatable with broad-spectrum antibiotics. In this study, we report the clinical presentation of 12 tropical sprue patients along with the histologic changes of the intestinal mucosa and compare it with those of a series of 150 cases of gluten-sensitive enteropathy, the condition with which it is most frequently misdiagnosed. The cohort comprised 6 men and 6 women with a median age of 59 years (range, 38 to 78 y) with a history of residence or visitation in South Asia or Papua New Guinea. Partial villous blunting in the duodenal mucosa was present in 75% of cases, and a marked intraepithelial lymphocytosis was observed in all cases (mean per 100 epithelial cells 77.3; range, 42 to 124). A villous tip accentuation of intraepithelial lymphocytosis was not appreciable in most cases. No case of complete villous blunting (Marsh stage 3c) was identified in tropical sprue, contrasting with 25% in gluten-sensitive enteropathy cases. A duodenal mucosa eosinophil infiltrate was present in all cases with significantly higher counts compared with untreated gluten-sensitive enteropathy patients (26.6/HPF vs. 14.6/HPF; P=0.009). The ileal mucosa displayed more severe villous blunting with higher Marsh stages than in the corresponding duodenum from 5 patients. There was a mild intraepithelial lymphocytosis and eosinophil infiltrate in the colonic mucosa of half of the cases. Follow-up biopsies in 6 patients demonstrated a histologic response after oral folates and doxycycline treatment. In summary, tropical sprue is a pan-enteric inflammatory process often mistaken for gluten-sensitive enteropathy. Histologic findings suggesting tropical sprue in the appropriate clinical context include incomplete duodenal villous blunting without development of flat mucosa, frequent involvement of the terminal ileum with more marked inflammation and villous blunting than in the duodenum, and a conspicuous eosinophil infiltrate in the lamina propria. With the expansion of tourism and increasing employment opportunities in tropical regions, pathologists in the West are increasingly likely to encounter cases of tropical sprue and should be aware of this diagnosis.
Keyword Tropical sprue
Villous atrophy
Gluten-sensitive enteropathy
Celiac disease
Q-Index Code C1
Q-Index Status Confirmed Code
Institutional Status UQ

Document type: Journal Article
Sub-type: Article (original research)
Collections: Official 2015 Collection
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