Cases Of Sprue Research Articles

A Review of Current Evidence of Olmesartan Medoxomil Mimicking Symptoms of Celiac Disease

Objective: To review the evidence of an association between olmesartan medoxomil and symptoms mimicking celiac disease. Data Sources: Literature was searched in PubMed (1965-November 2013) using the key words or MeSH terms olmesartan, enteropathy, celiac disease, sprue, and diarrhea. References from the Food and Drug Administration (FDA) and Dipiro’s Pharmacotherapy eighth edition textbook were also reviewed. Data Synthesis: There have been recent implications of olmesartan medoxomil being linked to symptoms mimicking celiac disease. Investigators first identified the association in 22 patients who presented with presumed refractory celiac disease. Upon further evaluation, it was discovered that these symptoms improved when olmesartan was discontinued. In response to this report, additional case studies have been published. DeGaetani et al also further analyzed patients with seronegative villous atrophy from the Celiac Disease Center and found that olmesartan accounted for 22% of previously unclassified sprue cases. Conversely, the authors of the ROADMAP trial, which compared olmesartan to placebo, found no significant differences in the incidence of gastrointestinal adverse effects. Conclusions: There is growing evidence supporting the association between olmesartan and sprue-like symptoms; however, further research is warranted. These symptoms can be life threatening and clinicians should be aware of the potential association.

A presentation of latent tropical sprue in a Canadian hospital

Tropical sprue (TS) is a chronic diarrheal disease of unknown etiology characterized by malabsorption and small bowel mucosal abnormalities. TS affects residents of, and visitors to, endemic tropical regions. Rarely the disease may remain latent for several years, and to date, few cases of latent TS have been reported in Europe or North America. However, in our increasingly multicultural communities and in a 'global village' where travel is common, clinicians must maintain a high index of suspicion for TS in patients presenting with diarrhea and malabsorption who have traveled to endemic regions. TS may mimic common diarrheal diseases that are seen in developed nations, including celiac disease, Crohn's disease, bacterial overgrowth, and other infectious etiologies. Accordingly, once these more common etiologies have been ruled out, TS must be considered in patients presenting with diarrhea after travel to endemic regions. We present a unique Canadian case of latent TS, with a brief review of the diagnostic approach and treatment.

Celiac disease: India on the global map

Celiac disease: India on the global map

Sprue tropicale : à propos de 2 cas observés dans la région parisienne

Tropical sprue (TS) is a postinfective tropical malabsorption that occurs in tropical countries. TS is associated with a persisting colonization of the small-intestine lumen by enterotoxinogenic bacteria that cause subsequent enterocyte damage affecting all or part of the small-intestine. We report two cases of TS that occurred in inhabitants of Paris area returned from endemic areas. The first observation concerned a 76-year old woman admitted for anorexia, loss of 20 kg and anemia. The second observation concerned a 53-year old man referred for chronic diarrhea and loss of 40 kg within 4 years. In both cases, duodenal lesions consisted of subtotal and total villous atrophy with prominent infiltration of the damaged surface epithelium with lymphocytes and infiltrate of lymphocytes and plasma cells of the lamina propria. The two patients recovered under antibiotics, confirming the diagnosis of TS.

Lymphocytic gastritis--a rare disorder of the gastric mucosa

Lymphocytic gastritis, first described by Haot et al. in 1986, is a very rare form of gastritis (0.8-1.6% of cases) with unclear pathogenesis. On endoscopy, lymphocytic gastritis may present either a normal appearance, such as gastritis varioliformis with multiple elevated chronic erosions in the corpus and fundus, or as a giant fold gastritis in the corpus and fundus. This type of gastritis is diagnosed histologically based on an accumulation of intraepithelial lymphocytes (more than 25/100 epithelial cells) in the surface cells of the gastric mucosa. Its etiopathogenesis is currently thought to be a sprue-associated reaction or an atypical reaction to Helicobacter pylori infection. Some studies report the lymphocytic gastritis in almost 45% of cases of sprue, with the gastritis regressing in response to a gluten-free diet, while others report a correlation of lymphocytic gastritis with serologically and/or histologically confirmed H. pylori infection, with the lymphocytic gastritis being cured by H. pylori eradication treatment in a high percentage of the cases. It is possible that a similar abnormal immune reaction to an inflammatory agent underlies both pathological entities, sprue and lymphocytic gastritis--in the one case gluten and in the other H. pylori--which would mean that sprue-induced and H. pylori-induced forms of lymphocytic gastritis exist side by side.

Colonic lymphocytosis in patients with celiac sprue

We examined colonic biopsies from 39 patients with clinical and small bowel biopsy changes of celiac sprue. In 12 of 39 patients (31%), striking lymphocytic infiltration of the superficial colonic epithelium and chronic inflammation of the lamina propria were identified. These 12 cases had a mean of 30.4 lymphocytes per 100 superficial colonic epithelial cells, compared with means of 8.4 in sprue cases without colonic epithelial lymphocytosis, 4.8 in normal controls, and 32.4 in nine cases of lymphocytic colitis without concurrent celiac sprue. No case showed subepithelial collagen layer thickening. Four patients with celiac sprue and colonic lymphocytosis also had gastric biopsies; two showed gastric lymphocytosis. Intraepithelial lymphocytes at all sites were positive for the T-cell marker MT-1. These findings indicate that sprue-associated colonic lymphocytosis and lymphocytic colitis are histologically, quantitatively, and immunohistochemically indistinguishable, that the epithelial T-cell infiltration of celiac sprue occurs in glandular mucosa at all levels of the gastrointestinal tract, and that colonic subepithelial collagen deposition in patients with celiac sprue is an infrequent occurrence. These findings also suggest that gastrointestinal epithelial T-cell infiltration may be an immunologic response that is common in individuals sensitized to absorbed lumenal antigens, and that colonic lymphocytosis may occur as a reponse to a number of antigens, including gluten.

Tropical Sprue and Malnutrition in West Bengal : I. Intestinal Microflora and Absorption

Small bowel bacterial flora and absorptive function were studied in three groups of subjects; namely, patients with tropical sprue (15), patients with malnutrition without malabsorption (7), and normal individuals (13). Except for fat and B12 malabsorption, the tropical sprue and malnourished cases could not be differentiated by biochemical studies. Low serum folate, megaloblastic anemia, and reduced serum albumin were seen as frequently in both groups. Bacterial overgrowth of the upper small bowel was noted in all of the sprue cases; in five patients colonic bacteria were present in the stomach. The most consistent finding was an increase in numbers of coliforms. Four of seven malnourished patients also had coliforms in the upper bowel, but the concentrations were less than 104/ml. In normal individuals, coliforms could not be cultured from the stomach, duodenum, or jejunum. Bacterial populations in the small bowel declined during therapy in seven of nine sprue cases and one malnourished subject. Of six sprue patients treated with antibiotics, four showed dramatic improvement of fat and B12 absorption and decreased small bowel bacterial concentrations within 48 hr; resistant bacteria and antibiotic toxicity were responsible for the delayed response in two patients. Minimal abnormalities of the small bowel microflora were seen in two sprue patients in whom improvement in absorption could not be well correlated with changes in bacteriology. Thus, bacterial overgrowth of the small bowel was present in tropical sprue and to a lesser extent, in malnutrition, but the bacteria were interfering with absorption in 80% of the sprue cases and were acting as commensals in the malnourished individuals.

Immunoglobulins in serum and jejunal biopsies in non-tropical sprue.

Abstract A study has been made of 12 patients with non‐tropical sprue. Immunochemical determinations of serum IgG, IgA and IgM were carried out prior to gluten‐free diet (9 patients) and during treatment (10 patients). Immunofluorescent microscopy of jejunal biopsies from the same patients was performed prior to (10 cases) and during treatment (6 cases). Fluorescent antisera specifically reacting with IgG, IgA and IgM were applied and the cells containing these immunoglobulins were differentiated and quantitated accordingly.Serum IgM, which was decreased in untreated patients, was normalized during treatment. Serum levels of IgG and IgA were normal. In both treated and untreated cases of sprue increased numbers of cells containing IgG and IgM were found. The immunoglobulin levels of serum were not correlated to the area of cells containing the corresponding immunoglobulins.

Dysgammaglobulinaemia in tropical sprue.

Study of immunoglobulin levels in 16 Indian control subjects showed that, compared with a Danish control series, they had a significantly higher mean level of IgG, but not of IgA or IgM. By contrast, the IgG levels in eight patients with tropical sprue were decreased or low normal in six cases and raised in only one case. Two patients with tropical sprue had agamma-A-globulinaemia.Turnover studies with (125)I-labelled IgG showed a high rate of synthesis in three Indian controls and an appreciably reduced or low rate in seven of the eight cases of tropical sprue.

TETANY

ABSTRACT The purpose of this study was to investigate the tetanic predisposition and certain aspects of calcium metabolism in cases showing a vague disease picture, characterized mainly by the presence of visceral pains of unknown etiology, headaches, various neurovegetative symptoms, etc. The development of typical carpal cramps in Trousseau's or Trousseau-von Bonsdorff's test was regarded as a sign of a tetanic predisposition. In a total of several hundred cases of the type described above in which provocation tests were performed, the response was positive in 97. Spontaneous tetanic attacks occurred in 38 cases. On the basis of the calcium level the cases were classified in hypocalcaemic (20) and normocalcaemic (77). The latter were further divided into the following subgroups: cases with a history of thyroidectomy (7), neurogenous cases in which the disease picture was dominated by neurovegetative symptoms (26), idiopathic (42) and gastro-enterogenous (2). In addition, 18 cases of postoperative hypocalcaemic hypoparathyroidism were investigated in which the provocation test was positive in 16 and negative in two, notwithstanding a low serum calcium level. In this group spontaneous attacks occurred in 10 cases. Furthermore, in studies concerning calcium metabolism 41 control cases were used. In addition, Trousseau-von Bonsdorff's test was performed on 40 healthy subjects, all of whom responded negatively. The present investigation included determination of serum calcium and serum phosphorus and the excretion of calcium and phosphorus in the urine, intravenous calcium tolerance tests, parathyroid hormone tolerance tests and short-term AT 10 treatment for test purposes. This study was aided by a grant from the State Commission for Natural Sciences. The calcium excretion was less than 50 mg in practically all cases showing hypoparathyroidism, but also in one control case. In addition, an excretion of less than 50 mg a day was observed in one case of sprue and in one case of idiopathic tetany. The responses to the intravenous calcium tolerance test showed a wide variation, and it was concluded that this test is inadequate as an ordinary clinical routine test. The parathyroid hormone tolerance test gave a pathological response twice in one patient with postoperative hypoparathyroidism and in one case with normocalcaemia and a history of thyroidectomy. In many cases AT 10 therapy brought about a rapid and marked increase in calciuria, an excretion of as much as 800 mg a day being sometimes noted, although the changes in the blood were slight. This discrepancy in the response is emphasized and checking of the excretion of calcium, in addition to checking of the blood calcium, during AT 10 therapy is recommended. The clinical significance of the tetanic syndrome is discussed. In many cases the syndrome manifests itself only occasionally and under certain circumstances, but in others it may be grave enough to be called a disease. Patients with postoperative hypoparathyroidism constitute a separate group, in which the pathogenetic background seems to be clear. But it should be emphasized that there also are cases of postoperative hypoparathyroidism in which no signs of a tetanic predisposition can be elicited even by provocation. Latent tetany often seems to be associated with a vague disease picture. For the detection of a tetanic predisposition Trousseau-von Bonsdorff's test is very valuable. It may be added that during intravenous administration of calcium, exogenous 32P was found to be excreted in the urine in a different way than endogenous phosphorus.

Steatorrhea in tropical sprue patients in Puerto Rico.

Summary Fat-balance studies were carried out in twelve cases of tropical sprue in Puerto Rico and in two volunteer control subjects. The investigation involved determining by chemical analysis the total daily fat in a screening diet given over an eight-day period and the total daily fat eliminated in the feces during the same period. Steatorrhea, defined as a daily output of over 6 gm. of fat (fatty acids) in 24-hour stools, was observed in ten of the twelve cases studied and in neither of the control subjects.

Spruce vs. pancreatogenous steatorrhea; an evaluation of the small bowel study as an aid in differentiation.

The clinical and laboratory differentiation of the various causes of steatorrhea is often difficult. Recently interest has been aroused in the possibility of distinguishing sprue from pancreatogenous steatorrhea by roentgen examination. Numerous reports on this subject have appeared in the past two decades. Snell in 1939 (1) stated that it was not possible to make a distinction between these two conditions. Weber and Kirklin (2) are equally firm in their conclusion that the small bowel pattern of sprue cannot be distinguished from that of pancreatogenous steatorrhea. This might be said to represent the majority opinion today. Bjerkelund and Husebye (1950), on the contrary, believe that there are characteristics in the small bowel pattern that permit this differentiation (3). Weigen, Pendergrass, Ravdin, and Machella, in two experimental studies on dogs in 1952 (4) and 1953 (5), reinforced the affirmative side of the argument. These workers in the first of their studies extirpated the pancreas, and in the second ligated the pancreatic duct. They demonstrated that the two procedures did not alter the small bowel pattern in the dog. Golden (6), in 1941 wrote: “As far as can be determined now, the presence or absence of pancreatic enzymes makes no difference in the small intestinal pattern.” The published experience of the last two decades reveals two leading causes for steatorrhea. These are sprue and pancreatic intestinal enzyme deficiency. Three basic classifications of steatorrhea are generally accepted: a. Idiopathic, as seen in sprue and severe deficiency states. b. Pancreatogenous, resulting from a deficiency of pancreatic intestinal enzyme. Intrinsic inflammatory or neoplastic disease, duct obstruction, and extirpative surgery are the chief causes. c. Symptomatic, the result of obstruction of small bowel lacteals by neoplastic or inflammatory processes. This is a heterogeneous group, including amyloid disease, lymphoma, Whipple's disease, regional enteritis, and others. Reference to these classifications is found in two symposia by Ricketts, Maimon and Knowlton (7), and Durant and Zibold (8). Bjerkelund and Husebye (3), and Pearson (9) have also contributed. The present report will be concerned only with the idiopathic and pancreatogenous types, and will pertain only to the small bowel pattern of adults. Zwerling and Nelson (10) have demonstrated the inconstancy of this pattern in the normal pediatric group. Material This report is based upon small bowel studies in 19 cases of sprue, compared with those in 10 cases of pancreatogenous steatorrhea. These cases were seen on the Medical and Surgical Services of Duke Hospital during the last twenty-three years.

Fundamental concepts in the diagnosis of sprue.

Article1 January 1954FUNDAMENTAL CONCEPTS IN THE DIAGNOSIS OF SPRUERAFAEL RODRIGUEZ-MOLINA, F.A.C.P.RAFAEL RODRIGUEZ-MOLINA, F.A.C.P.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-40-1-33 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptSprue is a chronic, wasting disease which, in the light of modern medical science, is classified among the deficiency states. Medical literature during the past 20 years has not significantly altered the basic concepts about sprue. Recent observations, however, have contributed materially to a better understanding of the etiologic factors, diagnostic criteria and effective treatment of this interesting syndrome.1, 2, 3, 4In the earlier writings5, 6great importance was ascribed to the differential diagnosis between sprue and addisonian or pernicious anemia of temperate climates. Mainly through the work of Castle, Rhoads and associates, we now consider these conditions closely...Bibliography1. CastleRhoadsLawsonPayne WBCPHAGC: Etiology and treatment of sprue; observations on patients in Puerto Rico and subsequent experiments on animals, Arch. Int. Med. 56: 627-699 (Oct.) 1935. CrossrefGoogle Scholar2. CastleMinot WBGK: Pathological physiology and clinical description of the anemias, 1936, Oxford University Press, New York. Google Scholar3. Suarez RM: Clinical and hematological review of sprue based on the study of 150 cases, Ann. Int. Med. 12: 529, 1938. LinkGoogle Scholar4. Rodriguez-Molina R: Sprue in Puerto Rico: clinical study of 100 cases, Puerto Rico J. Pub. Health and Trop. Med. 17: 134-151 (Dec.) 1941. Google Scholar5. Ashford BK: A clinical investigation of tropical sprue, Bol. Asoc. med. de Puerto Rico 21: 1-26 (Mar.) 1923. Google Scholar6. Serra A: The relation of sprue to pernicious anemia, with a report on blood changes in 45 cases of sprue, Am. J. Trop. Med. 9: 49, 1929. CrossrefGoogle Scholar7. RomeroVizcarrondoRodriguez-Molina CARR: Treatment of sprue with folinic acid: report of nine cases, Am. J. M. Sc. 224: 9-22 (July) 1952. CrossrefMedlineGoogle Scholar8. Asenjo CF: Criteria for assessing fat absorption in normal subjects and sprue patients, Am. J. Trop. Med. and Hyg. 1: 344-352 (Mar.) 1952. CrossrefMedlineGoogle Scholar9. Thaysen TE: Nontropical sprue; a study in idiopathic steatorrhea (translated by Hans Andersen), 1932, Levin and Munksgaard, Copenhagen. Google Scholar This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: San Juan, Puerto Rico*Presented at the Thirty-Fourth Annual Session of the American College of Physicians, Atlantic City, New Jersey, April 13, 1953. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics Cited byFolate in Tropical SprueAcute quadriparesis with muscle spasms related to electrolyte disturbances in steatorrheaRegarding the Definition of Tropical SprueCurrent Views on Tropical Sprue and a Comparison to Nontropical SprueNeuromuscular disease in patients with steatorrhoea.Tropical sprue and intussusception: An unusual associationThe structural and functional status of the liver in tropical sprueGastroenterology 1 January 1954Volume 40, Issue 1Page: 33-41KeywordsPernicious anemia Issue Published: 1 January 1954 PDF downloadLoading ...

Criteria for assessing fat absorption in normal subjects and sprue patients.

Summary 1. The literature dealing with absorption and excretion of fecal fat by normal subjects and sprue patients is reviewed. 2. In a series of 41 sprue patients and 19 normal subjects studied by us, in which the percentage of fat in dried feces was exclusively determined, only 29.2 per cent of the sprue and 5.3 per cent of the normals had more than 30 per cent fat in the dried feces. The limitations of this procedure for evaluating fat loss in normal subjects and sprue cases is discussed. 3. In another series, percentage fat in dried feces as well as percentage fat absorption, were determined in 7 normal and 7 sprue cases receiving similar care. The percentage of fat in dried feces indicated that 2 out of the 7 sprue cases suffered from abnormal fat absorption. On the other hand, the percentage fat absorption disclosed that 5 out of the 7 patients had definite signs of abnormal fat absorption. One of the 2 remaining sprue cases was a very early case. After repeated studies it always showed normal absorption. The other was a frank clinical case of sprue, which could not be properly evaluated because of low intake of fat. Daily fecal fat excretion of all the sprue cases averaged 12.5 gm., a value significantly higher than that obtained for the normals. None of the 7 normal subjects treated in a way similar to the sprue patients showed any signs of abnormal fat absorption either when the percentage of fat in dried feces or the percentage of fat absorption was used as an index to assess this condition. The daily fecal fat excretion of the normal group averaged 4 gm. 4. In both sprue and normal subjects the partition of the fecal fat was as follows: the split fat of the sprue group was slightly higher than the normals; the neutral fat was nearly the same as the normals, and the unsaponifiable matter was about half as large as the normals. The possible significance of these results is discussed.

Folic acid and fat absorption in the sprue syndrome

1. 1. Fat balance tests using the method of Cookeet al. (1946) were carried out before and after treatment with folic acid in four cases of tropical sprue and one case of non-tropical sprue. 2. 2. No significant improvement in fat absorption was detected, though the patient's appetite and sense of well being improved during treatment. 3. 3. The failure of folic acid to improve fat absorption in tropical sprue and the reported efficiency of yeast preparations raises problems as to the mechanism responsible for this effect.

Studies on adrenal function in sprue: preliminary report.

EVER since Verzar (1) suggested the possibility of adrenocortical hypofunction as an etiologic factor in celiac disease of children and adults, many investigators have speculated about a similar possibility for sprue. Investigation of this theory has not been undertaken until now in our institution because all efforts have been concentrated on the therapeutic angle. The only pertinent information we could find was a personal statement by Koppisch who, in a review of 1,400 consecutive autopsies, found 17 cases of sprue. The duration of the disease could not be ascertained in 5 cases. In the others it varied from four months to five years. Histologic sections were available from 13 of these cases, alterations being found in all but one, which was normal. The periadrenal fat showed serous atrophy, generally advanced. The cortical lipoids had undergone depletion and the zona glomerulosa and fasciculata were atrophic. This condition was most marked in the superficial portions of the cortex, where the cords of cells were usually very narrow. The interstitial tissue of the atrophied parts was broadened by edema. In the case with the most advanced atrophy there was actual loss of portions of the cords of cells, which had been replaced by very loose and edematous areolar tissue. These alterations were not specific, since they resembled those found in other cases of cachexia.

OBSERVATIONS ON THE EFFECT OF AN ANIMAL PROTEIN FACTOR CONCENTRATE ON PERSONS WITH THE MACROCYTIC ANEMIA OF PERNICIOUS ANEMIA, OF NUTRITIONAL MACROCYTIC ANEMIA AND OF SPRUE, AND ON PERSONS WITH NUTRITIONAL GLOSSITIS

Abstract The intramuscular injection of animal protein factor concentrate to 5 cases of pernicious anemia in relapse, 4 cases of nutritional macrocytic anemia in relapse, and 3 cases of tropical sprue in relapse was followed by a positive hematologic response in each case as is illustrated in figures 1, 2, and 4, respectively. The parenteral administration of this material to 3 patients with nutritional glossitis unassociated with anemia was followed by the disappearance of the redness and soreness of the tongue.

A Comparison of Pteroylglutamic Acid and Liver Extract Maintenance Therapy in Sprue

THE effects of synthetic folic acid in sprue have been studied by several groups of investigators. Both Darby et al.1 and Suarez and his associates2 reported that the substance had a prompt and dramatic clinical and hematologic effect with remissions comparable or superior to that which follows liver therapy. A daily dose of 2.5 to 5 mg. was considered to be adequate although in many cases the periods of observation were brief. Davidson and his co-workers,3 on the other hand, treated 10 cases of sprue with folic acid with only moderately good hematologic results, noting that macrocytosis persisted.The present . . .

A case of Sprue in the later childhood treated with folic acid

SUMMARYA case of typical sprue in a boy fourteen years of age is described. Treated with folic acid, 5 mg 5 times a day for three days, after that 5 mg 3 times a day. Prompt increasing of weight but no change of the blood‐picture besides an increase of the reticulocytes. Discharged in a very good general condition without any symptoms of his illness.

A Case of Sprue Maintained on Folic Acid

Numerous observers have reported the treatment of macrocytic anemias with folic acid with the return of the blood to normal. Several (1–6) have found that the macrocytic anaemia of sprue was similarly improved. But so far, no one has reported the effect of folic acid in the maintenance of sprue over many months. For this reason, the fact that five milligrams of folic acid by mouth daily has been sufficient to maintain an old case of sprue in continued health for over one year, should be recorded.Case History. Diarrhoea commenced in 1924, twelve years after two periods of service in the Philippines. At first the diarrhoea was caused by acids like stewed tomatoes, and could be controlled by a rigid diet, but during a third tour in the Philippines in 1925–1928, the diarrhoea of a watery character became continuous, and following an episode of sore mouth which lasted only one week, the diagnosis of sprue was made.