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Tropical sprue — ESEGH MCQ

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ModerateLuminal GITropical sprueESEGH

A 46-year-old man presents with chronic diarrhoea, weight loss and glossitis after living in South Asia for 2 years. He has a macrocytic anaemia with low serum folate and vitamin B12 concentrations. While continuing a gluten-containing diet, his total IgA is normal and IgA tissue transglutaminase antibodies are negative. Duodenal biopsies show partial villous atrophy with chronic inflammation; periodic acid–Schiff staining shows no foamy macrophages. What is the most likely diagnosis?

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Correct answer: B — Tropical sprue

The diagnosis is tropical sprue. The discriminating combination is prolonged residence in an endemic tropical region, chronic diarrhoea and weight loss, combined folate and vitamin B12 deficiency, and seronegative small-intestinal villous atrophy. Tropical sprue may involve both proximal and distal small bowel, accounting for deficiencies of both vitamins. Whipple disease can produce malabsorption and villous distortion but typically shows periodic acid–Schiff-positive foamy macrophages and may be accompanied by migratory arthralgia or systemic features. Crohn's ileitis may impair vitamin B12 absorption but does not usually cause this combined deficiency and diffuse sprue-like presentation. Autoimmune gastritis explains vitamin B12 deficiency but not folate malabsorption or duodenal villous atrophy. Ulcerative colitis is a colonic disorder and does not explain small-bowel villous atrophy.

Reference: Ortiz-Prado E, et al. Tropical sprue: a narrative review of a neglected malabsorption syndrome. Gut Pathogens. 2026;18:15. https://pubmed.ncbi.nlm.nih.gov/41656249/