Tropical sprue differential diagnosis: Difference between revisions
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{{familytree | | | | | | | D05 | | | | D02 | | | | | | | | | | | | | | | | | | D05 = Specific treatment per results and symptomatic treatment | D02= Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }} | {{familytree | | | | | | | D05 | | | | D02 | | | | | | | | | | | | | | | | | | D05 = Specific treatment per results and symptomatic treatment | D02= Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation }} | ||
{{familytree/end}} | {{familytree/end}} | ||
Tropical sprue must be differentiated from other diseases that may cause [[chronic diarrhea]], [[weight loss]], and [[abdominal pain]] especially in [[Immunocompromised|immunocompromised patients]]. | |||
{| style="border: 0px; font-size: 120%; margin: 3px; width:1000px;" align="center" | |||
|+ | |||
! style="background: #4479BA; color:#FFF; width: 150px;" | Disease | |||
! style="background: #4479BA; color:#FFF; width: 200px;" | Prominent clinical findings | |||
! style="background: #4479BA; color:#FFF; width: 200px;" | Laboratory or radiological findings | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Giardiasis|Chronic giardiasis]]<ref name="pmid11113253">{{cite journal |vauthors=Thompson RC |title=Giardiasis as a re-emerging infectious disease and its zoonotic potential |journal=Int. J. Parasitol. |volume=30 |issue=12-13 |pages=1259–67 |year=2000 |pmid=11113253 |doi= |url=}}</ref> | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* [[Giardiasis|Chronic giardiasis]] may develop after acute episode of giardiasis or without any acute events. | |||
* Loose foul smelling stools | |||
* [[Flatulence]] | |||
* [[Fatigue]] | |||
* [[Weight loss]] | |||
* [[Steatorrhea]] | |||
* Some patients develop acquired [[lactose intolerance]] (manifested by exacerbation of symptoms following ingestion of dairy products) | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* Microscopic identification of the organism in the stool | |||
* [[Hypoalbuminaemia]] | |||
* [[Vitamin B12]] and [[Folate deficiency|folate deficiencies]] (as the organism inhabits the [[duodenum]]) | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Cryptosporidiosis]]<ref name="pmid17172373">{{cite journal |vauthors=Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L |title=Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City |journal=Am. J. Trop. Med. Hyg. |volume=75 |issue=6 |pages=1095–8 |year=2006 |pmid=17172373 |doi= |url=}}</ref> | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* [[Incubation period]] is 7-10 days. | |||
* In [[immunocompetent]] patients: | |||
:* Disease might be asymptomatic or cause [[gastroenteritis]] (but without any biliary involvement) | |||
:* [[Gastroenteritis]] usually resolves spontaneously within 14 days. | |||
* In [[immunocompromised]] patients: | |||
:* Disease is usually more severe and prolonged (especially in severly [[Immunocompromised|immunocomprmised patients]] with [[CD4|CD4 count]] < 100 cells/microL). | |||
:* [[Cryptosporidiosis]] may involve the [[biliary tract]] and the [[liver]]. | |||
:* [[Weight loss]] | |||
:* [[RUQ|Abdominal RUQ]] [[tenderness]] might be present if [[biliary]] or [[hepatic]] involvement is present. | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* Microscopic identification of the [[organism]] in the stool: The [[oocysts]] appear red on staining with modified acid fast staining | |||
* [[PCR]]: Most specific and sensitive diagnostic tool. [[PCR]] is expensive and used in limited cases. | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Cystoisospora belli|Cystoisosporiasis (isosporiasis)]]<ref name="pmid1889046">{{cite journal |vauthors=Current WL, Garcia LS |title=Cryptosporidiosis |journal=Clin. Microbiol. Rev. |volume=4 |issue=3 |pages=325–58 |year=1991 |pmid=1889046 |pmc=358202 |doi= |url=}}</ref> | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* [[Cystoisospora belli|Cystoisosporiasis]] is usually seen in [[Immunocompromised|immunocompromised patients]]. | |||
* [[Incubation period]] can last up to 2 weeks | |||
* [[Watery diarrhea]] that is profuse and foul smelling | |||
* Constitutional symptoms ([[headache]], [[Low-grade fever|low grade fever]], [[myalgia]] and [[malaise]]) | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* [[Isospora]] ova or parasites can be visualized on stool microscopic examination. | |||
* [[Endoscopy|Upper GI endoscopy]] may used for excluding other esophageal or gastric disease and obtaining specimens for histopathology. | |||
|- | |||
| style="padding: 5px 5px; background: #DCDCDC;font-weight: bold" | [[Tropical sprue]]<ref name="pmid1091526">{{cite journal |vauthors=Klipstein FA, Schenk EA |title=Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure |journal=Gastroenterology |volume=68 |issue=4 Pt 1 |pages=642–55 |year=1975 |pmid=1091526 |doi= |url=}}</ref> | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* History of travel to a tropical region (for a period more than a month) | |||
* [[Chronic diarrhea]] | |||
* [[Steatorrhea]] | |||
* Examination may show signs of [[vitamin deficiencies]] (eg [[glossitis]]) | |||
| style="padding: 5px 5px; background: #F5F5F5;" | | |||
* [[Megaloblastic anemia]] that might progress into [[pancytopenia]] | |||
* [[Hypoalbuminaemia]] | |||
* [[Vitamin D Deficiency|Vitamin D defeciency]] and [[hypocalcemia]] | |||
|} | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
Revision as of 18:26, 31 August 2017
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aravind Kuchkuntla, M.B.B.S[2]
Overview
Tropical sprue should be differentiated from diseases causing chronic diarrhea and malabsorption such as celiac disease, osmotic diarrhea and secretory diarrhea.
Differentiating Tropical Sprue from other Diseases
Tropical sprue is a diagnosis of exclusion therefore it must be be differentiated from other diseases causing malabsorption such as: [1][2][3][4]
- Infectious causes
- Celiac disease
- Pancreatic insufficiency
- Osmotic diarrhea
- Secretory diarrhea
Approach to a Patient with Chronic Diarrhea
The following is an algorithm describing the approch to a patient with chronic diarrhea:
Classify diarrhea by the results of the stool analysis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stool osmotic gap >50 mOsm/kg | Stool osmotic gap <50 mOsm/kg | Fecal occult blood (+), WBC (+), lactoferrin (+), calprotectin(+) | Fecal fat (+) | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Osmotic diarrhea | Secretory diarrhea | Inflammatory diarrhea | Fatty diarrhea | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
• Check the pH of the stool | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Low pH • Evaluate for carbohydrate malabsorption | High pH • Evaluate for ingestion of magnesium or antacids • Evaluate for laxative abuse | 1. Exclude infection by any/combination of the following tests:
• Stool culture • Microscopic evaluation for ova and parasites • Stool antigen test for Giardia • Small bowel aspirate or breath H2 test to rule out bacterial overgrowth | 1. Exclude structural disease by any/combination of the following tests:
• Small bowel radiographs | 1. Exclude structural disease by any/combination of the following tests
• Small bowel radiographs | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
• Take a careful dietary history • Order breath H2 test (lactose), OR • Order lactase measurement in a mucosal biopsy | • Order stool alkanization test • Order chromatographic and chemical tests | 2. Exclude structural disease by any/combination of the following tests:
• Small bowel radiographs | 2. Exclude infection by any/combination of the following tests:
• Stool culture: Standard Aeromonas, Plesiomonas, Tuberculosis etc | 2. Exclude exocrine pancreatic insufficieny by any/combination of the following tests:
• Secretin test | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3. Order selective testing:
• Cholestyramine test for bile acid diarrhea • Plasma peptides (Gastrin, calcitonin, vasoactive intestinal polypeptide or somatostatin) • Urine (5-hydroxyindole acetic acid, metanephrine or histamine) • Others (TSH, ACTH stimulation test, serum protein electrophoresis or serum immunoglobulins) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Confirmatory diagnosis | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Yes | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Specific treatment per results and symptomatic treatment | Suspect Tropical sprue and initiate antibiotic therapy and folate supplementation | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Tropical sprue must be differentiated from other diseases that may cause chronic diarrhea, weight loss, and abdominal pain especially in immunocompromised patients.
Disease | Prominent clinical findings | Laboratory or radiological findings |
---|---|---|
Chronic giardiasis[5] |
|
|
Cryptosporidiosis[6] |
|
|
Cystoisosporiasis (isosporiasis)[7] |
|
|
Tropical sprue[8] |
|
|
References
- ↑ Dosanjh G, Pardi DS (2016). "Chronic unexplained diarrhea: a logical and cost-effective approach to assessment". Curr Opin Gastroenterol. 32 (1): 55–60. doi:10.1097/MOG.0000000000000232. PMID 26628100.
- ↑ Langenberg MC, Wismans PJ, van Genderen PJ (2014). "Distinguishing tropical sprue from celiac disease in returning travellers with chronic diarrhoea: a diagnostic challenge?". Travel Med Infect Dis. 12 (4): 401–5. doi:10.1016/j.tmaid.2014.05.001. PMID 24889052.
- ↑ Corinaldesi R, Stanghellini V, Barbara G, Tomassetti P, De Giorgio R (2012). "Clinical approach to diarrhea". Intern Emerg Med. 7 Suppl 3: S255–62. doi:10.1007/s11739-012-0827-4. PMID 23073866.
- ↑ Juckett G, Trivedi R (2011). "Evaluation of chronic diarrhea". Am Fam Physician. 84 (10): 1119–26. PMID 22085666.
- ↑ Thompson RC (2000). "Giardiasis as a re-emerging infectious disease and its zoonotic potential". Int. J. Parasitol. 30 (12–13): 1259–67. PMID 11113253.
- ↑ Sánchez-Vega JT, Tay-Zavala J, Aguilar-Chiu A, Ruiz-Sánchez D, Malagón F, Rodríguez-Covarrubias JA, Ordóñez-Martínez J, Calderón-Romero L (2006). "Cryptosporidiosis and other intestinal protozoan infections in children less than one year of age in Mexico City". Am. J. Trop. Med. Hyg. 75 (6): 1095–8. PMID 17172373.
- ↑ Current WL, Garcia LS (1991). "Cryptosporidiosis". Clin. Microbiol. Rev. 4 (3): 325–58. PMC 358202. PMID 1889046.
- ↑ Klipstein FA, Schenk EA (1975). "Enterotoxigenic intestinal bacteria in tropical sprue. II. Effect of the bacteria and their enterotoxins on intestinal structure". Gastroenterology. 68 (4 Pt 1): 642–55. PMID 1091526.