Approach
TS should be suspected in any patient with chronic diarrhea, weight loss, and signs/symptoms of malabsorption who has spent more than 2 weeks living in an endemic tropical area.
History
In nonnative patients, the symptoms of malabsorption tend to shortly follow an acute diarrheal illness. Natives tend to have a more indolent onset of malabsorption and chronic diarrhea. Generalized symptoms of malabsorption (weight loss, steatorrhea, fatigue) and features suggestive of specific nutrient deficiencies should raise suspicion of TS.
Physical exam
If the patient displays any of the wide range of findings associated with specific nutritional deficiencies, suspicion of TS should be raised, especially if the combination of findings suggests malabsorption of 2 or more nutrients. Such findings might include glossitis, cheilitis, altered sensation, diminished deep tendon reflexes, pallor and rash in cases of B12 deficiency; leg swelling, hair loss, and pedal edema in case of hypoproteinemia; and dry eyes in case of vitamin A deficiency.
Key tests
A CBC shows macrocytic anemia; the diagnosis of TS should be questioned if increased MCV is not present.
Blood tests, including folate and vitamin B12 levels, quantitative fecal fat assay, and D-xylose test should be performed to confirm the clinical impression of malabsorption.[1]
Further radiographic, stool, and blood tests should be requested to rule out other possible causes of symptoms such as helminth infection, lymphoma, and celiac disease.
If TS is still suspected, request an upper gastrointestinal endoscopy to obtain small-bowel biopsies. Duodenal and/or jejunal biopsies typically reveal short villi, elongated crypts, and inflammatory cells in the lamina propria; none of these findings are specific for TS. While these histologic changes can be indistinguishable from those seen in patients with celiac disease, TS is associated with a much more pronounced eosinophilic infiltrate in the duodenum than is seen in celiac disease.[24][Figure caption and citation for the preceding image starts]: Endoscopy, normal and TS villi changes, duodenumFrom the collection of Dr M. Guelrud; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Tropical sprue; ridged and foveolar patterns; duodenumFrom the collection of Dr M. Guelrud; used with permission [Citation ends].
[Figure caption and citation for the preceding image starts]: Tropical sprue; scalloping, mosaic appearance, and mucosal grooves; duodenumFrom the collection of Dr M. Guelrud; used with permission [Citation ends].
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