P4161 - Don`t Let Tropical Sprue Fool You

Abdul Arham, MBBS, MD¹, Musfira Khalid, MBBS², Faheem Javad, MBBS³, Saad Ur Rehman, BSc, MBBS⁴, Abira Khalid, MBBS⁵, Abdul Waheed, MBBS⁶, Abu Hurairah, MD⁷, Gabriella Primera, DO, MPH^8
1UMass Chan-Baystate Medical Center, Springfield, MA; ²Fatima Jinnah Medical University, Mississauga, ON, Canada; ³Al-Nafees Medical College, Mississauga, ON, Canada; ⁴Hameed Latif Hospital, Lahore, Punjab, Pakistan; ⁵Fatima Jinnah Medical University, Lahore, Punjab, Pakistan; ⁶Ameer-ud-Din Medical College, PGMI, Lahore, Punjab, Pakistan; ⁷AdventHealth, Orlando, FL; ⁸University of Massachusetts Chan Medical School-Baystate Medical Center, Springfield, MA

Introduction: Malabsorption syndrome may lead to serious complications, including a weak immune system and failure to thrive. A rare cause of such disorders, tropical sprue (TS), poses diagnostic challenge in areas prone to celiac disease due to similar symptoms and histologic findings. We present this case of a Canadian visitor whose health deteriorated in Islamabad to highlight the importance of keeping tropical sprue in mind when considering celiac disease (CD).

Case Description/Methods: A 24-year-old man presented with three months of persistent loose stools, vomiting and 40 kg weight loss. He presented hypotensive with pale, dry scaly skin, and a benign abdominal exam. Labs revealed megaloblastic anemia, abdominal ultrasound showed biliary sludge, and CT scan was unremarkable. An upper-GI endoscopy demonstrated villous blunting and intraepithelial lymphocytes consistent with Marsh category type 3A and a diagnosis of celiac disease. 3 weeks later, he presented with severe lethargy and immobility. At this time the patient was diagnosed with tropical sprue after a repeat endoscopy yielded a similar microscopic picture and negative serological and genetic testing for gluten enteropathy. After treatment with tetracycline and folate replacement, his symptoms improved.

Discussion: While the etiology of tropical sprue is not well understood, an intestinal infection is suspected to be inciting factor leading to mucosal injury, delayed intestinal transit, and bacterial overgrowth. The incidence in North America is 1% and 8% in tropical regions [2]. Despite its prevalence in Pakistan, this case presented a diagnostic challenge due to its overlapping features with CD. The presence of ileum involvement with megaloblastic anemia, only partially blunted villi, intraepithelial eosinophils, and radiologically thickened folds in the jejunum, are all suggestive of TS. However, diagnosis of tropical sprue can only be made by ruling out CD with negative gluten enteropathy serological testing. Tetracyclines and vitamin replacement can result in symptom improvement and resolution [2]. While tropical sprue can be difficult to diagnose, thorough laboratory and endoscopic evaluations can yield the correct diagnosis and decrease morbidity.





Disclosures:


Abdul Arham, MBBS, MD¹, Musfira Khalid, MBBS², Faheem Javad, MBBS³, Saad Ur Rehman, BSc, MBBS⁴, Abira Khalid, MBBS⁵, Abdul Waheed, MBBS⁶, Abu Hurairah, MD⁷, Gabriella Primera, DO, MPH⁸. P4161 - Don`t Let Tropical Sprue Fool You, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.