Acute myocardial infarction in a young adult with hyperhomocysteinaemia secondary to tropical sprue.

Coronary heart disease and its complications remain the most common cause of morbidity and mortality throughout the world. In addition, its incidence among adults <45 years of age has also been steadily increasing in the past few decades. Besides the typical aetiology such as coronary artery abnormalities or autoimmune disorders, increasing rates can be attributed to escalating trends of obesity, type 2 diabetes mellitus, and illicit abuse of drugs such as cocaine and amphetamines in the younger population.1 Every cardiovascular event in a young adult must be thoroughly investigated as the aetiology is typically unconventional. Our case reports a young man who developed an acute inferior wall myocardial infarction (IWMI) in the setting of hyperhomocysteinaemia secondary to vitamin B12-folate deficiency itself due to tropical sprue.

Malabsorption Spectrums in India.

Among the causes of malabsorption, tropical sprue is one of the leading cause.Several reports indicating that celiac disease, now being recognised more frequently. MATERIAL: 94 patients, aged more than 12 years, presenting with Chronic diarrhoea and malabsorption syndrome were analyzed by clinical presentation, endoscopic and histopathological examination.The spectrum of disease in these patients and features differentiating celiac disease and tropical sprue are reported here. OBSERVATION: Most common cause was Celiac Disease (65%), followed by Tropical Sprue (21%), common variable immunodeficiency (2%), lymphangiectasia (1%), idiopathic (3%). Patients with celiac disease were younger,having anemia, scalloping of folds,moderate or severe villous atrophy, crypt hyperplasia, diffuse epithelial damage. Patients with tropical sprue were older and more often normal duodenal epithelium. CONCLUSION: Malabsorption, a disease which is often missed and not recognised by clinicians. A meticulous search for diagnosis is required.

Clinical, endoscopic, and histological differentiation between celiac disease and tropical sprue: A systematic review.

BACKGROUND AND AIM: While the prevalence of celiac disease (CD) is increasing globally, the prevalence of tropical sprue (TS) is declining. Still, there are certain regions in the world where both patients with CD and TS exist and differentiation between them is a challenging task. We conducted a systematic review of the literature to find out differentiating clinical, endoscopic, and histological characteristics between CD and TS. METHODS: Medline, PubMed, and EMBASE databases were searched for keywords: celiac disease, coeliac, celiac, tropical sprue, sprue, clinical presentation, endoscopy, and histology. Studies published between August 1960 and January 2018 were reviewed. Out of 1063 articles available, 12 articles were included in the final analysis. RESULTS: Between the patients with CD and TS, there was no difference in the prevalence and duration of chronic diarrhea, abdominal distension, weight loss, extent of abnormal fecal fat content, and density of intestinal inflammation. The following features were more common in CD: short stature, vomiting/dyspepsia, endoscopic scalloping/attenuation of duodenal folds, histological high modified Marsh changes, crescendo type of IELosis, surface epithelial denudation, surface mucosal flattening, thickening of subepithelial basement membrane and celiac seropositivity; while those in TS include anemia, abnormal urinary D-xylose test, endoscopic either normal duodenal folds or mild attenuation, histologically decrescendo type of IELosis, low modified Marsh changes, patchy mucosal changes, and mucosal eosinophilia. CONCLUSIONS: Both patients with CD and TS have overlapping clinical, endoscopic, and histological characteristics, and there is no single diagnostic feature for differentiating CD from TS except for celiac specific serological tests.

Post-infectious IBS, tropical sprue and small intestinal bacterial overgrowth: the missing link.

Evidence is emerging that IBS, a hitherto enigmatic disorder thought to be predominantly related to psychological factors, has a microorganic basis in a subset of patients with the disease. Post-infectious IBS (PI-IBS), commonly of the diarrhoea-predominant subtype (defined as new development of IBS following acute infectious diarrhoea), is one such condition known to occur in up to 10-30% individuals after acute gastroenteritis. However, following acute infectious gastroenteritis, patients can also develop post-infectious malabsorption syndrome (PI-MAS), popularly known as tropical sprue. As no study on PI-IBS has rigorously excluded tropical sprue by appropriate investigations, including small intestinal biopsy, the frequency of tropical sprue among patients with PI-IBS is not known. Small intestinal bacterial overgrowth (SIBO) has been suggested to be associated with IBS in general, and in particular diarrhoea-predominant IBS, including PI-IBS. SIBO is also known to be associated with tropical sprue. As both IBS, particularly the subset probably associated with SIBO, and tropical sprue improve with antibiotic treatment, we provide evidence and an explanatory model to support a link among these disorders.

Distinguishing tropical sprue from celiac disease in returning travellers with chronic diarrhoea: a diagnostic challenge?

BACKGROUND: Within the present era of worldwide travel, it is important for all clinicians to consider the possibility of tropical sprue (TS) in returning patients with persistent diarrhoea after travel. The symptoms and histologic findings of TS can resemble but also be confused with celiac disease (CD). MATERIAL AND METHOD: Patients at our institute diagnosed with CD or TS in the period January 2000-December 2010 were eligible for inclusion. Of all patients, demographic, clinical, laboratory and endoscopy data on admission and in follow-up were collected retrospectively. RESULTS: 28 CD and 7 TS patients were included. There were no differences in baseline clinical characteristics, duration of stay in a tropical region or in laboratory findings on admission. However, in the majority of CD patients antibodies against endomysium (EMA) or tissue transglutaminase (tTG) were present at presentation but absent in all TS patients at presentation. CONCLUSIONS: In returning travellers with persistent diarrhoea, a diagnosis of CD is unlikely in case of absence of anti-EMA or anti-tTG antibodies but conversely increases the likelihood of TS. This distinct immunoserological profile may be of help in selecting the optimal treatment in returning travelers with chronic diarrhoea after staying in a tropical region.

Spectrum of malabsorption syndrome among adults & factors differentiating celiac disease & tropical malabsorption.

BACKGROUND & OBJECTIVES: Aetiology of malabsorption syndrome (MAS) differs in tropical and temperate countries over time; clinical and laboratory parameters may differentiate between various causes. This study was undertaken to investigate the spectrum of MAS among Indian adults and to find out the features that may help to differentiate between TM and celiac disease. METHODS: Causes of MAS, and factors differentiating tropical malabsorption (TM) from celiac disease (CD) were determined in 275 patients. RESULTS: Using standard criteria, causes in 275 patients [age 37.5+13.2 yr, 170, (61.5%) male] were, TM 101 (37%), CD 53 (19%), small intestinal bacterial overgrowth 28 (10%), AIDS 15 (5.4%), giardiasis 13 (5%), hypogammaglobulinemia 12 (4%), intestinal tuberculosis 7 (2.5%), strongyloidiasis 6 (2%), immunoproliferative small intestinal disease 5 (2%), Crohn's disease 6 (2%), amyloidosis 4 (1.5%), intestinal lymphangiectasia 3 (1%) and unknown 22 (8%). On univariate analysis, patients with CD were younger than TM (30.6+12 vs. 39.3+12.6 yr, P<0.001), had lower body weight (41.3+11.8 vs. 49.9+11.2 kg, P<0.001), longer diarrhoea duration (median 36 inter-quartile range 17.8-120 vs. 24-months, 8-48, P<0.01), lower stool frequency (6/day, 5-8 vs. 8, 5-10, P<0.05), lower haemoglobin (9.4+3.2 vs. 10.4+2.7 g/dl, P<0.05), higher platelet count (2,58,000, range 1,35,500-3,23,500 vs. 1,60,000, 1,26,000-2,58,000/mm 3 , P<0.05), and more often had hepatomegaly (9/53, 17% vs. 4/101, 4%, P<0.01), and subtotal or partial villous atrophy (36/50, 72% vs. 28/87, 32%, P<0.001). Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were significant on multivariate analysis. INTERPRETATION & CONCLUSIONS: TM and CD are common causes of MAS among Indian adults. Younger age (<35 yr), longer diarrhoea duration, higher platelet count and villous atrophy were found to be associated with CD.

Diarrhoea due to small bowel diseases.

Small intestinal diseases are a common, though often overlooked cause of diarrhoeal illness. Fully 1% of the Caucasian population are affected by coeliac disease and a substantial portion of children living in poverty in the developing world are affected by environmental enteropathy. These are but two examples of the many diseases that cause mucosal injury to the primary digestive and absorptive organ in our body. While diarrhoea may be a common, though not universally seen symptom of small bowel mucosal disease, the consequent malabsorption can lead to substantial malnutrition and nutrient deficiencies. The small intestine, unlike the colon, has been relatively inaccessible, and systematic evaluation is often necessary to identify and treat small intestinal mucosal diseases that lead to diarrhoea. Immunodeficiency states, including HIV enteropathy, adult autoimmune enteropathy, drug-associated enteropathy, and tropical sprue continue to occur and require specific therapy. All patients with severe diarrhoea or diarrhoea associated with features suggestive of malabsorption may have a disease of the small intestinal mucosa that requires careful evaluation and targeted management.

Spectrum of malabsorption in India--tropical sprue is still the leader.

INTRODUCTION: Two decades ago tropical sprue, Immunoproliferative Small Intestinal Disease (IPSID) and infections were common causes of malabsorption in India. It is possible that implementation of preventive health measures and improved sanitation may have changed the spectrum of disorders causing malabsorption. The aim of this study therefore was to assess the spectrum of malabsorption seen at our center during the past nine years. METHODOLOGY: Patients seen at our center with malabsorption from January 2000 to December 2008 were included in this study. The etiological, clinical and investigation details were recorded on uniform structured data forms. The data obtained was retrospectively analyzed. RESULTS: Malabsorption was detected in 124 patients during the study period. The mean age of patients was 31.9+16 years and 60.5% were males. Tropical sprue was the commonest etiology (29%) followed by celiac and Crohn's disease (15.3% each). Other important etiologies included parasitic infestations (9.7%) and immune deficiency disorders (5.6%). Intestinal tuberculosis was seen in only 2.4% patients. CONCLUSIONS: We are witnessing a change in etiological spectrum of malabsorption . Celiac disease and inflammatory bowel disorders are emerging as important causes and ImmunoProliferative Small Intestinal Disease (IPSID) and intestinal tuberculosis are on the decline. Tropical Sprue however continues to be the commonest cause as in the past.

Diagnostic value of endoscopy for the diagnosis of giardiasis and other intestinal diseases in patients with persistent diarrhea from tropical or subtropical areas.

OBJECTIVE: Upper endoscopy has been suggested as a valuable tool in the diagnosis of giardiasis. The aim of this study was to compare two methods based on endoscopy, i.e. microscopy of duodenal fluid and histology, with a fluorescent-antibody assay for the detection of Giardia lamblia cysts in stool specimens. The role of endoscopy in the identification of other causes of chronic diarrhea acquired during travel abroad was also evaluated. MATERIAL AND METHODS: Thirty-one patients (9 F, 22 M, median age 39 years, range 19-63 years) with persistent diarrhea after returning from tropical or subtropical areas agreed to undergo upper gastrointestinal endoscopy before and after treatment. Lower gastrointestinal endoscopy was subsequently performed. Three stool samples from each patient were examined using the direct fluorescent-antibody assay (DFA) for the detection of G. lamblia, and by routine methods for other protozoal and bacterial enteric pathogens. Each patient underwent upper endoscopy and biopsies and duodenal fluid samples were taken. In 12 patients a further lower endoscopy was performed. RESULTS: In 16 patients G. lamblia was detected in stool samples by DFA (relative sensitivity: 100%). Histology of duodenal biopsies and microscopy of duodenal fluids allowed diagnosis of giardiasis to be made in only 8, and 3 patients, respectively (relative sensitivities: 21% and 44%). Besides giardiasis, upper endoscopic examination revealed an alternative diagnosis (tropical sprue), whereas six additional diagnoses were made by colonoscopy. In six patients the cause of chronic diarrhea remained unclear. CONCLUSIONS: Compared to stool examinations using DFA, upper endoscopy is less sensitive for the diagnosis of giardiasis. In patients with negative stool examinations, lower endoscopy yields relevant diagnoses more often than upper endoscopy.

[Fever of unknown origin in the 21st century: infectious diseases]. / Fieber unklarer Genese im 21. Jahrhundert. Teil 1: Infektionskrankheiten.

Fever of unknown origin (FUO) is a rare but important disease. The definition of FUO has not changed in the last 50 years. Classical FUO is defined by an illness of at least 3 weeks duration with fever greater than 38 masculine C, and no established diagnosis after 1 week of hospital investigation. The causes of FUO can be divided in four categories: infectious diseases, noninfectious inflammatory diseases, neoplasms, and others (miscellaneous). Recent studies have surprisingly shown that despite improved diagnostic procedures the percentage of patients with FUO, in which no diagnosis after intensive investigations in specialized centres can be found, has increased. However, finding the correct diagnosis in FUO is essential for these patients for psychological and vital reasons. Therefore and because of economic reasons patients with FUO should be investigated in specialized centres with a department for rheumatology and infectious diseases.

Etiological spectrum of sporadic malabsorption syndrome in northern Indian adults at a tertiary hospital.

BACKGROUND: The etiology of malabsorption syndrome (MAS) may differ in different geographical regions. Limited data are available on the etiological spectrum of MAS among Indian adults. METHODS: Ninety-nine consecutive adult patients with MAS (urine d-xylose <1 g/5 g/5 h with or without increased fecal fat (> or =7 g/24 h) were evaluated for cause of MAS using standard criteria. Past medical records were examined to know the nature of treatment received. RESULTS: The etiology of MAS was: tropical sprue 39, celiac disease 9, Crohn's disease 9, giardiasis 8, small intestinal bacterial overgrowth in absence of another cause of MAS 8, panhypogammaglobulinemia 2 (one with strongyloidiasis), intestinal lymphangiectasia 1, intestinal tuberculosis 4, idiopathic 15, acquired immunodeficiency syndrome 2, and amyloidosis 2. Twenty-eight patients had received anti-tubercular treatment earlier. CONCLUSIONS: Tropical sprue, celiac disease and Crohn's disease are common causes of MAS in Indian adults. Inappropriate anti-tubercular treatment is common in them and needs to be discouraged.

Exocrine pancreatic insufficiency in tropical sprue.

BACKGROUND: Pancreatic insufficiency may appear secondary to several intestinal disorders. It may contribute to malabsorption in tropical sprue (TS). METHODS: The exocrine pancreatic function was evaluated with the indirect pancreolauryl test (PT) in 56 patients with TS. The PT results were analyzed and correlated with serum albumin levels, degree of intestinal atrophy, and steatorrhea. RESULTS: Abnormally low values were found in 36 (64.2%) cases. A significant relationship was not observed between PT and hypoalbuminemia. Patients with more severe damage by intestinal biopsy tended to have lower PT values. No relationship was found between pancreatic insufficiency and steatorrhea (expressed as g/24 h), but patients with pancreatic insufficiency had increased stool fat concentrations (expressed as percentage of wet stool weight). All patients responded favorably to treatment with folic acid and tetracycline. Fifteen patients with abnormal initial PT values underwent a repeat PT after a 6-week therapy; all of them showed normalization of PT values. CONCLUSIONS: The abnormal exocrine pancreatic function found with an indirect test in patients with TS is probably secondary to a low pancreatic hormonal stimulation due to intestinal damage, as occurs in celiac sprue. These abnormalities are reversible after specific treatment for TS.