Tropical Sprue: Diagnostic Challenge in an Ethiopian Adult Patient

Tropical Sprue: Diagnostic Challenge in an Ethiopian Adult Patient | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Tropical Sprue: Diagnostic Challenge in an Ethiopian Adult Patient Yonas Gedamu¹˒², Dzmtry Aliasiuk³ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7908136/v1 This work is licensed under a CC BY 4.0 License Status: Under Revision Version 1 posted 14 You are reading this latest preprint version Abstract Residents and travelers to the tropics are susceptible to tropical sprue (TS), a post-infectious disease of the small intestine marked by a malabsorption condition. Since TS can be mistaken for common diarrheal illnesses, particularly in nonendemic areas, diagnosis is still difficult. Here, we describe a 28-year-old guy who had severe weight loss and watery diarrhea for two years. For two years, he experienced sporadic cramping in his right lower abdomen and epigastrium. He occasionally experienced melena as well. Duodenal villi atrophy was discovered by upper GI endoscopy, and the biopsy result demonstrated villi atrophy characteristics. The patient's condition improved after beginning empirical treatment for tropical sprue. Chronic diarrhea malabsorption tropical sprue small bowel disease villous atrophy Figures Figure 1 Figure 2 Introduction One uncommon and acquired cause of malabsorption syndrome is tropical sprue. The disease known as tropical sprue has been around for a very long time; it was first mentioned more than two thousand years ago in the Charaka Samhita, an ancient Indian medical treatise ( 1 ). More than 200 years ago, a Yorkshireman named Dr. William Hillary recorded the first instances among the people living on the island of ( 2 ). The diagnosis has a geographic focus affecting the population living along a narrow band of landmass near the equator. The diagnosis is made almost exclusively in people from India, Southeast Asia, and the Caribbean islands, yet appears to spare populations in Jamaica, the Bahamas, and sub-Saharan Africa ( 3 ) It appears to be rare in Africa, but its real frequency is unknown as small bowel biopsies are not routinely done ( 4 , 5 ). In the current era of globalization and international travel, it is critical that all clinicians understand the potential for TS in patients who have visited endemic areas and present with diarrhea, malabsorption, multiple nutritional deficiencies, and small bowel mucosal abnormalities ( 6 ). Its cause is unknown, but its symptoms include various nutritional deficits, persistent diarrhea, and abnormalities of the small intestinal mucosa ( 1 ). Since TS can be mistaken for common diarrheal illnesses like Crohn's disease, celiac disease, bacterial overgrowth, and other infectious aetiologies, diagnosing it remains challenging ( 7 ). Case Presentation A 28 year old male patient presented with watery diarrhea for the past two years sometimes he had also melena. He had periodically episodic epigastric and right lower abdominal pain, nausea and vomiting. He had significant weight loss from 65 Kg to 44 Kg over the past two years. He had surgical therapy for peri-anal fistula 18 months back and cured from it. Long time ago he was treated for Pulmonary TB for 6 months, completed treatment and cured. No association of symptoms with gluten containing diet. He had no history of fever or joint pain. No family history of similar illness. No history of DM or HTN. He had no travel history to tropical sprue endemic country. No family history of IBD or CRC. After 5 days of admission he was discharged. On physical examination he was emaciated, his blood pressure was 90/60mmHg with the rest of vital signs within normal range. His weight was 44 Kgs, height 180cm and BMI was 13.6 (underweight). Pale conjunctiva, mild right lower quadrant tenderness, On laboratory investigations serum folate was < 0.8 (3.2–19.), K + = 2.93, Na + = 138, Cl = 100, Mg++= 2.69,mg/dl, Ca++= 7.58mg/dl (8.8–10.6), stool occult positive, ESR = 40 (0–20), WBC = 5.35K, Hgb = 11.7, MCV = 108, PLT = 210K, blood group B+, PTT = 34 (22-27s), PT = 14.8 (10-14s), and the other tests such as PICT was nonreactive, stool h.pylori antigen negative, HBsAg negative, TSH normal, Vit-B12 normal, CRP normal, HA1c normal, RFT normal, uric acid normal, LFT normal, U/A normal, stool exam no o/p seen, pancreatic amylase normal. Celiac serology checkup tTG-IgG and IgA were both negative. Abdomino-pelvic CT scan with contrast showed right lower quadrant short segment ileo-ileal intussusception (no bowel wall thickening seen, likely transient, correlation with ultrasound recommended) (Fig. 1 ). Six months before coming to our center he was at other center and chest CT scan result showed bilateral upper lobes and superior segments of lower lobe fibrosis, traction bronchiectasis and volume loss; multiple calcific and non-calcified pulmonary nodules-likely post-TB scar with granuloma. At other center UGIE was normal, colonoscopy showed only internal hemorrhoids. Abdominal u/s done at our center showed mild dilation of bowel loops 2cm to 3.5cm with active pendulum like peristalsis. Esophagogastroduodenoscopy revealed mucosal furrowing in the first and second part of duodenum. There was also atrophy of villi with scalloping with the impression of to rule out celiac disease and then biopsy result showed features of villi atrophy (Fig. 2 A, B). Colonoscopy was done under sedation including examination of the distal 60cm of the ileum and normal findings. For the suspicious diagnosis of chronic ileo-ileal intussusception patient underwent diagnostic laparoscopy which did not reveal any surgical pathology and biopsy of the one mesenteric lymph nodes was taken and it was normal finding TS was given careful consideration in light of the history, clinico-biological, endoscopic, and histological findings. A four-month antibiotic course was prescribed (tetracycline 250 mg four times daily) combined to a nutritional supplementation iron and folate. The patient reported feeling much better within a month, with weight increase and diarrhea resolved. At follow-up, the biochemical markers had returned to normal. The diagnosis of TS was confirmed by the response to treatment. On the one year latest follow-up visit, the person was in healthy condition. He gained 20Kgs weight and the diarrhea was completely gone. Discussion Poor hygiene, bacterial, viral, or parasite gastrointestinal infections, and immunological deficiencies are risk factors in the pathophysiology of tropical sprue ( 7 ). The commonest incriminated bacterias are Klebsiella pneumoniae, Escherichia coli and Enterobacter cloacae ( 8 , 9 ). Mucosal structural and function problems can result from the formation of enterotoxins by certain strains of enterotoxigenic K. pneumonia or E. coli. Furthermore, unabsorbed bile acids may also have a local effect. It is hypothesized that bacterial overgrowth causes small bowel stasis, which damages enterocytes by disrupting gut motility. Malabsorption and folate loss follow, and the ongoing folate loss impedes enterocyte repair ( 10 , 11 ). This explains the clinical signs and symptoms of TS, such as weight loss, anorexia, bloating and pain in the abdomen, and chronic diarrhea (frequently steatorrhea). Fever is rare. The diagnosis of TS is difficult. It is based on the combination of clinico-biological, histological and evolutionary criteria: ( 7 , 8 , and 12 ) • Compatible clinical presentation: diarrhea, weight loss, asthenia, • Evidence of a malabsorption syndrome of two unrelated substances, • Abnormal small intestinal mucosal histology, • Exclusion of other intestinal diseases with similar presentation, • Improvement after treatment with tetracycline and folic acid. In TS, findings of intestinal endoscopy are not specific. Indeed, celiac disease needs to be taken into account, particularly in light of the endoscopic abnormalities and histological resemblance to TS ( 9 , 13 ). Biopsy from the distal portion of the duodenum reveals villous atrophy and an increased infiltration of the lamina propria by chronic inflammatory cells (plasma cells and lymphocytes) ( 9 ). Our patient had endoscopy features of villi atrophy which is also supported by histology findings. The mainstay of treatment is antibiotic therapy with tetracycline or doxycycline for three to six months, combined with vitamin supplements, because of the assumed role of bacterial overgrowth in pathogenesis ( 1 , 14 ). Since expatriates typically recover fully and permanently, the prognosis for TS is typically favorable ( 14 ). Our patient's clinical response was complete. Relapses can happen in about 50% of patients who stay in endemic areas, necessitating a lengthy follow-up because of the possibility of re-exposure to the infectious agent ( 1 ). Conclusion Tropical sprue diagnosis remains challenging since it can be confused with common diarrheal diseases, especially in nonendemic areas. Antibiotics and vitamin supplementation are the main stay of therapy. Clinical correlation has to be done to prevent delayed diagnosis and subsequent morbidity. Abbreviations TS: Tropical sprue, UGIE: upper gastrointestinal endoscopy Declarations Funding: Not applicable Competing interests: The authors declare that they have no competing interests. Ethics approval: Written informed consent was taken as it is a case report Consent to participate: Informed consent was taken. The case report was conducted under the Declaration of Helsinki. Written Consent for publication: written consent for publication was obtained from the patient. Availability of data and material: Not applicable Code availability: Not applicable Authors’ contributions: YG and DA designed the report, collected and assembled the patient data. YG, and DA wrote the paper. Both authors read and approved the final manuscript. Author Contribution YG and DA designed the report, collected and assembled the patient data. YG, and DA wrote the paper. Both authors read and approved the final manuscript. Acknowledgement None References Ramakrishna BS, Venkataraman S, Mukhopadhya A. Tropical malabsorption. Postgrad Med J. 2006;82:779–87. Bartholomew C. William Hillary and sprue in the Caribbean: 230 years later. Gut. 1989; 30 Spec No: 17–21. Lim ML. A perspective on tropical sprue. Curr Gastroenterol Rep. 2001;3:322–7. Louis-Auguste J, Kelly P. Tropical enteropathies. Curr Gastroenterol Rep. 2017;19(7):29. Klipstein FA. Tropical sprue in travelers and expatriates living abroad. Gastroenterol. 1981;80:590–600. Klipstein FA, Baker SJ. Regarding the definition of tropical sprue. Gastroenterology. 1970;58:717–21. Ghoshal UC, Srivastava D, Verma A, et al. Tropical Sprue in 2014: the New Face of an Old Disease. Curr Gastroenterol Rep. 2014;16(6):391. Macaigne G, Boivin JF, Auriault ML et al. Sprue tropicale: à propos de 2 cas observés dans la région parisienne. Gastroenterol. Clin. Biol. 2004; 28: 913–916. GCB-10-2004-28-10-0399-8320-101019-ART14. Ranjan P, Ghoshal UC, Aggarwal R, et al. Etiological spectrum of sporadic malabsorption syndrome in northern Indian adults at a tertiary hospital. Indian J Gastroenterol. 2004;23:94–8. Klipstein FA, Engert RF, Short HB. Enterotoxigenicity of colonizing coliform bacteria in tropical sprue and blind-loop syndrome. Lancet. 1978;2:342–4. Cook GC. Aetiology and pathogenesis of post infective tropical malabsorption (tropical sprue). Lancet. 1984;1:721–3. Klipstein FA, Corcino JJ. Factors responsible for weight loss in tropical sprue. Am J Clin Nutr. 1977;30:1703–8. Green PHR, Paski S, Ko CW, et al. AGA Clinical practice update on management of refractory celiac disease. Expert Rev Gastroenterol. 2022;163(5):1461–9. Nath SK. Tropical sprue. Curr Gastroenterol Rep. 2005;7:343–9. 10.1007/s11894-005-0002-4 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Revision Version 1 posted Editorial decision: Revision requested 12 Jan, 2026 Reviews received at journal 29 Nov, 2025 Reviews received at journal 27 Nov, 2025 Reviews received at journal 19 Nov, 2025 Reviews received at journal 19 Nov, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviewers agreed at journal 17 Nov, 2025 Reviewers agreed at journal 15 Nov, 2025 Reviewers agreed at journal 15 Nov, 2025 Reviewers agreed at journal 12 Nov, 2025 Reviewers invited by journal 12 Nov, 2025 Editor assigned by journal 28 Oct, 2025 Submission checks completed at journal 27 Oct, 2025 First submitted to journal 20 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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10:08:04","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":36573,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7908136/v1/3efb6b07862a7f8a1a1842dc.html"},{"id":96709473,"identity":"5a522c59-ec64-4e64-923c-5e98e53cc320","added_by":"auto","created_at":"2025-11-25 10:09:04","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":565062,"visible":true,"origin":"","legend":"\u003cp\u003eAbdominal CT scan showing multiple dilated and fluid filled jejunum and ileum loops, no mucosal thickening or hyper enhancement seen. There is short segment ileo-ileal intussusception in the right lower quadrant, no bowel wall thickening or mass seen. The other bowel loops have normal size and wall thickness.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-7908136/v1/21c34573a5e4c617805018bb.jpeg"},{"id":96652480,"identity":"f88f7928-4e51-4890-ba8d-9573c5f7466c","added_by":"auto","created_at":"2025-11-24 16:34:43","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1483371,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Endoscopy revealed mucosal furrowing in the first and second part of duodenum. There was also partial villous atrophy with scalloping (B) Duodenal mucosal biopsy showed mild villi atrophy having \u0026lt; 20 IEL/100 enterocytes. There are mild mixed inflammatory cells in the lamina propria. No crypt abnormality is seen. No sign of dysplasia is seen. No feature of celiac disease is seen with a histologic conclusion of chronic, active duodenitis, mild\u003cu\u003e \u003c/u\u003e(C)\u003c/p\u003e\n\u003cp\u003eFor the suspicious diagnosis of chronic ileo-ileal intussusception patient underwent diagnostic laparoscopy which did not reveal any surgical pathology and biopsy of the one mesenteric lymph nodes was taken and it was normal finding\u003c/p\u003e\n\u003cp\u003eTS was given careful consideration in light of the history, clinico-biological, endoscopic, and histological findings.\u003c/p\u003e\n\u003cp\u003eA four-month antibiotic course was prescribed (tetracycline 250 mg four times daily) combined to a nutritional supplementation iron and folate. The patient reported feeling much better within a month, with weight increase and diarrhea resolved. At follow-up, the biochemical markers had returned to normal. The diagnosis of TS was confirmed by the response to treatment. On the one year latest follow-up visit, the person was in healthy condition. He gained 20Kgs weight and the diarrhea was completely gone.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7908136/v1/7033fe366c61263241e836e4.jpg"},{"id":96712714,"identity":"57004ce0-d6ff-4bd1-9963-6d1a019e3db8","added_by":"auto","created_at":"2025-11-25 10:16:13","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2314247,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7908136/v1/966d50dc-6e84-4d09-aa5a-d412f759ac58.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Tropical Sprue: Diagnostic Challenge in an Ethiopian Adult Patient","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOne uncommon and acquired cause of malabsorption syndrome is tropical sprue. The disease known as tropical sprue has been around for a very long time; it was first mentioned more than two thousand years ago in the Charaka Samhita, an ancient Indian medical treatise (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). More than 200 years ago, a Yorkshireman named Dr. William Hillary recorded the first instances among the people living on the island of (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe diagnosis has a geographic focus affecting the population living along a narrow band of landmass near the equator. The diagnosis is made almost exclusively in people from India, Southeast Asia, and the Caribbean islands, yet appears to spare populations in Jamaica, the Bahamas, and sub-Saharan Africa (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eIt appears to be rare in Africa, but its real frequency is unknown as small bowel biopsies are not routinely done (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn the current era of globalization and international travel, it is critical that all clinicians understand the potential for TS in patients who have visited endemic areas and present with diarrhea, malabsorption, multiple nutritional deficiencies, and small bowel mucosal abnormalities (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIts cause is unknown, but its symptoms include various nutritional deficits, persistent diarrhea, and abnormalities of the small intestinal mucosa (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSince TS can be mistaken for common diarrheal illnesses like Crohn's disease, celiac disease, bacterial overgrowth, and other infectious aetiologies, diagnosing it remains challenging (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 28 year old male patient presented with watery diarrhea for the past two years sometimes he had also melena. He had periodically episodic epigastric and right lower abdominal pain, nausea and vomiting. He had significant weight loss from 65 Kg to 44 Kg over the past two years. He had surgical therapy for peri-anal fistula 18 months back and cured from it. Long time ago he was treated for Pulmonary TB for 6 months, completed treatment and cured. No association of symptoms with gluten containing diet. He had no history of fever or joint pain. No family history of similar illness. No history of DM or HTN. He had no travel history to tropical sprue endemic country. No family history of IBD or CRC. After 5 days of admission he was discharged. On physical examination he was emaciated, his blood pressure was 90/60mmHg with the rest of vital signs within normal range. His weight was 44 Kgs, height 180cm and BMI was 13.6 (underweight). Pale conjunctiva, mild right lower quadrant tenderness, On laboratory investigations serum folate was \u0026lt;\u0026thinsp;0.8 (3.2\u0026ndash;19.), K\u0026thinsp;+\u0026thinsp;=\u0026thinsp;2.93, Na\u0026thinsp;+\u0026thinsp;=\u0026thinsp;138, Cl\u0026thinsp;=\u0026thinsp;100, Mg++= 2.69,mg/dl, Ca++= 7.58mg/dl (8.8\u0026ndash;10.6), stool occult positive, ESR\u0026thinsp;=\u0026thinsp;40 (0\u0026ndash;20), WBC\u0026thinsp;=\u0026thinsp;5.35K, Hgb\u0026thinsp;=\u0026thinsp;11.7, MCV\u0026thinsp;=\u0026thinsp;108, PLT\u0026thinsp;=\u0026thinsp;210K, blood group B+, PTT\u0026thinsp;=\u0026thinsp;34 (22-27s), PT\u0026thinsp;=\u0026thinsp;14.8 (10-14s), and the other tests such as PICT was nonreactive, stool h.pylori antigen negative, HBsAg negative, TSH normal, Vit-B12 normal, CRP normal, HA1c normal, RFT normal, uric acid normal, LFT normal, U/A normal, stool exam no o/p seen, pancreatic amylase normal. Celiac serology checkup tTG-IgG and IgA were both negative. Abdomino-pelvic CT scan with contrast showed right lower quadrant short segment ileo-ileal intussusception (no bowel wall thickening seen, likely transient, correlation with ultrasound recommended) (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Six months before coming to our center he was at other center and chest CT scan result showed bilateral upper lobes and superior segments of lower lobe fibrosis, traction bronchiectasis and volume loss; multiple calcific and non-calcified pulmonary nodules-likely post-TB scar with granuloma. At other center UGIE was normal, colonoscopy showed only internal hemorrhoids.\u003c/p\u003e\u003cp\u003eAbdominal u/s done at our center showed mild dilation of bowel loops 2cm to 3.5cm with active pendulum like peristalsis. Esophagogastroduodenoscopy revealed mucosal furrowing in the first and second part of duodenum. There was also atrophy of villi with scalloping with the impression of to rule out celiac disease and then biopsy result showed features of villi atrophy (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA, B). Colonoscopy was done under sedation including examination of the distal 60cm of the ileum and normal findings.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFor the suspicious diagnosis of chronic ileo-ileal intussusception patient underwent diagnostic laparoscopy which did not reveal any surgical pathology and biopsy of the one mesenteric lymph nodes was taken and it was normal finding\u003c/p\u003e\u003cp\u003eTS was given careful consideration in light of the history, clinico-biological, endoscopic, and histological findings.\u003c/p\u003e\u003cp\u003eA four-month antibiotic course was prescribed (tetracycline 250 mg four times daily) combined to a nutritional supplementation iron and folate. The patient reported feeling much better within a month, with weight increase and diarrhea resolved. At follow-up, the biochemical markers had returned to normal. The diagnosis of TS was confirmed by the response to treatment. On the one year latest follow-up visit, the person was in healthy condition. He gained 20Kgs weight and the diarrhea was completely gone.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePoor hygiene, bacterial, viral, or parasite gastrointestinal infections, and immunological deficiencies are risk factors in the pathophysiology of tropical sprue (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The commonest incriminated bacterias are Klebsiella pneumoniae, Escherichia coli and Enterobacter cloacae (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Mucosal structural and function problems can result from the formation of enterotoxins by certain strains of enterotoxigenic K. pneumonia or E. coli. Furthermore, unabsorbed bile acids may also have a local effect.\u003c/p\u003e\u003cp\u003eIt is hypothesized that bacterial overgrowth causes small bowel stasis, which damages enterocytes by disrupting gut motility. Malabsorption and folate loss follow, and the ongoing folate loss impedes enterocyte repair (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis explains the clinical signs and symptoms of TS, such as weight loss, anorexia, bloating and pain in the abdomen, and chronic diarrhea (frequently steatorrhea). Fever is rare.\u003c/p\u003e\u003cp\u003eThe diagnosis of TS is difficult. It is based on the combination of clinico-biological, histological and evolutionary criteria: (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, and \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u0026bull; Compatible clinical presentation: diarrhea, weight loss, asthenia,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; Evidence of a malabsorption syndrome of two unrelated substances,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; Abnormal small intestinal mucosal histology,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; Exclusion of other intestinal diseases with similar presentation,\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u0026bull; Improvement after treatment with tetracycline and folic acid.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eIn TS, findings of intestinal endoscopy are not specific. Indeed, celiac disease needs to be taken into account, particularly in light of the endoscopic abnormalities and histological resemblance to TS (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Biopsy from the distal portion of the duodenum reveals villous atrophy and an increased infiltration of the lamina propria by chronic inflammatory cells (plasma cells and lymphocytes) (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Our patient had endoscopy features of villi atrophy which is also supported by histology findings.\u003c/p\u003e\u003cp\u003eThe mainstay of treatment is antibiotic therapy with tetracycline or doxycycline for three to six months, combined with vitamin supplements, because of the assumed role of bacterial overgrowth in pathogenesis (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSince expatriates typically recover fully and permanently, the prognosis for TS is typically favorable (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Our patient's clinical response was complete. Relapses can happen in about 50% of patients who stay in endemic areas, necessitating a lengthy follow-up because of the possibility of re-exposure to the infectious agent (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTropical sprue diagnosis remains challenging since it can be confused with common diarrheal diseases, especially in nonendemic areas. Antibiotics and vitamin supplementation are the main stay of therapy. Clinical correlation has to be done to prevent delayed diagnosis and subsequent morbidity.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTS: Tropical sprue, UGIE: upper gastrointestinal endoscopy\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003cp\u003eCompeting interests: The authors declare that they have no competing interests.\u003c/p\u003e\u003cp\u003eEthics approval: Written informed consent was taken as it is a case report\u003c/p\u003e\u003cp\u003eConsent to participate: Informed consent was taken. The case report was conducted under the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003eWritten Consent for publication: written consent for publication was obtained from the patient.\u003c/p\u003e\u003cp\u003eAvailability of data and material: Not applicable\u003c/p\u003e\u003cp\u003eCode availability: Not applicable\u003c/p\u003e\u003cp\u003eAuthors\u0026rsquo; contributions: YG and DA designed the report, collected and assembled the patient data. YG, and DA wrote the paper. Both authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eYG and DA designed the report, collected and assembled the patient data. YG, and DA wrote the paper. Both authors read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRamakrishna BS, Venkataraman S, Mukhopadhya A. Tropical malabsorption. Postgrad Med J. 2006;82:779\u0026ndash;87.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBartholomew C. William Hillary and sprue in the Caribbean: 230 years later. Gut. 1989; 30 Spec No: 17\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLim ML. A perspective on tropical sprue. Curr Gastroenterol Rep. 2001;3:322\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLouis-Auguste J, Kelly P. Tropical enteropathies. Curr Gastroenterol Rep. 2017;19(7):29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlipstein FA. Tropical sprue in travelers and expatriates living abroad. Gastroenterol. 1981;80:590\u0026ndash;600.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlipstein FA, Baker SJ. Regarding the definition of tropical sprue. Gastroenterology. 1970;58:717\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGhoshal UC, Srivastava D, Verma A, et al. Tropical Sprue in 2014: the New Face of an Old Disease. Curr Gastroenterol Rep. 2014;16(6):391.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMacaigne G, Boivin JF, Auriault ML et al. Sprue tropicale: \u0026agrave; propos de 2 cas observ\u0026eacute;s dans la r\u0026eacute;gion parisienne. Gastroenterol. Clin. Biol. 2004; 28: 913\u0026ndash;916. GCB-10-2004-28-10-0399-8320-101019-ART14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRanjan P, Ghoshal UC, Aggarwal R, et al. Etiological spectrum of sporadic malabsorption syndrome in northern Indian adults at a tertiary hospital. Indian J Gastroenterol. 2004;23:94\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlipstein FA, Engert RF, Short HB. Enterotoxigenicity of colonizing coliform bacteria in tropical sprue and blind-loop syndrome. Lancet. 1978;2:342\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCook GC. Aetiology and pathogenesis of post infective tropical malabsorption (tropical sprue). Lancet. 1984;1:721\u0026ndash;3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKlipstein FA, Corcino JJ. Factors responsible for weight loss in tropical sprue. Am J Clin Nutr. 1977;30:1703\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGreen PHR, Paski S, Ko CW, et al. AGA Clinical practice update on management of refractory celiac disease. Expert Rev Gastroenterol. 2022;163(5):1461\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNath SK. Tropical sprue. Curr Gastroenterol Rep. 2005;7:343\u0026ndash;9. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11894-005-0002-4\u003c/span\u003e\u003cspan address=\"10.1007/s11894-005-0002-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Chronic diarrhea, malabsorption, tropical sprue, small bowel disease, villous atrophy","lastPublishedDoi":"10.21203/rs.3.rs-7908136/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7908136/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eResidents and travelers to the tropics are susceptible to tropical sprue (TS), a post-infectious disease of the small intestine marked by a malabsorption condition. Since TS can be mistaken for common diarrheal illnesses, particularly in nonendemic areas, diagnosis is still difficult. Here, we describe a 28-year-old guy who had severe weight loss and watery diarrhea for two years. For two years, he experienced sporadic cramping in his right lower abdomen and epigastrium. He occasionally experienced melena as well. Duodenal villi atrophy was discovered by upper GI endoscopy, and the biopsy result demonstrated villi atrophy characteristics. The patient's condition improved after beginning empirical treatment for tropical sprue.\u003c/p\u003e","manuscriptTitle":"Tropical Sprue: Diagnostic Challenge in an Ethiopian Adult Patient","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-24 16:34:38","doi":"10.21203/rs.3.rs-7908136/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-12T10:47:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-29T23:19:43+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-27T21:35:17+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-19T21:54:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-19T17:36:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"170720862235466676378201541620759071163","date":"2025-11-17T14:28:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"95361927743691684921663875025124466461","date":"2025-11-17T09:36:21+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294968565682550398271259543234231721771","date":"2025-11-16T01:13:36+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266523154976614871606501774760275456986","date":"2025-11-15T06:51:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"275604512079832760046359785307832454366","date":"2025-11-12T18:10:17+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-12T08:54:57+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-28T08:21:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-28T02:42:39+00:00","index":"","fulltext":""},{"type":"submitted","content":"SN Comprehensive Clinical Medicine","date":"2025-10-20T18:08:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"sn-comprehensive-clinical-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"sncm","sideBox":"Learn more about [SN Comprehensive Clinical Medicine](https://www.springer.com/journal/42399)","snPcode":"42399","submissionUrl":"https://submission.nature.com/new-submission/42399/3","title":"SN Comprehensive Clinical Medicine","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"4fce0176-b2af-48c8-9b8d-2e837040faee","owner":[],"postedDate":"November 24th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"in-revision","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T10:54:08+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-24 16:34:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7908136","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7908136","identity":"rs-7908136","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}