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Tropical Sprue in Children
GASTRO ENTEROLOGY
Copyright © 1969 by The Williams & Wilkins Co.
Vol. 56, No.3 Printed in U.S.A.
TROPICAL SPRUE IN CHILDREN A syndrome of idiopathic malabsorption V. I. MATHAN, M .D. (MADRAS), S. JOSEPH, M.B., B.S., AND S. J . BAKER, M .D. (MELBOURNE) Wellcome Research Unit and the Department of Medicine, Firm 1, Christian Medical College Hospital, Vellore , Madras State, India
A group of 20 South Indian children with tropical sprue is described. The disease occurs in endemic and epidemic forms, and there is no clinically detectable difference between the two. The disease in children is similar to that in adults, although the incidence among children in epidemics is lower. The children had multiple absorptive defects, radiological abnormalities, and histological changes in the jejunum. The effects of therapy are discussed and the importance of simple symptomatic therapeutic measures emphasized. The etiology is at present unknown and may be multiple. Diagnosis in an individual case is by exclusion of all other known causes of malabsorption. This condition should be considered in all children with chronic diarrhea in the tropics. Tropical sprue is recognized as a fairly common disease among adults living in certain parts of the tropics, but it is usually assumed that children are rarely, if ever, affected. I - 4 In studying epidemics of tropical sprue it was observed that children frequently developed an illness clinically identical with that occurring in adults. 5 - 8 A special study of the disease as it occurs in children was therefore undertaken. Received May 7, 1968. Accepted August 30, 1968. Address requests for reprints to: Dr. S. J . Baker, Wellcome Research Unit, Christian Medical College Hospital, Vellore 1, Madras State, India. The Wellcome Research Unit is supported by the Wellcome Trust in association with the World Health Organization. These studies were supported in part by Research Grant BSS-CDC-IND-4 . The authors wish to thank the Department of Pediatrics for referring cases 5, 7, and 8 for study; Professor C. J . G. Chacko for reporting on the intestinal biopsies; Mr. R. Tanner and Mr. J . Prabhakaran for help with the photography; and Dr. L. Ellenbogen, Lederle Laboratories, American Cyanamid Company, New York, for kindly supplying the intrinsic factor used in the tests.
Materials and Methods Twenty Indian children from the states of Madras and Andhra were admitted for detailed study in a metabolic ward. These children either presented at the hospital with diarrhea (cases 1 to 9) or were detected on field surveys in villages with tropical sprue (cases 10 to 20) and were willing to be admitted for study. During their stay in the hospital the children were fed either a standard hospital diet or a diet with low vitamin BI 2 and folate content. In either case, the daily fat intake was 50 g, except in a few patients, who were very ill at the time of admission and initially had to be maintained on parenteral therapy . In each case, at least three specimens of fresh stool were examined microscopically for evidence of parasitic infestation. Bacterial cultures of the stool for pathogenic organisms, including pathogenic Escherichia coli, were carried out in all cases. The fecal fat excretion was measured daily during the period of hospitalization by the method of van de Kamer et aL" and the results expressed as a 3-day running mean. Vitamin BI2 absorption was measured by the method of Heinle et aL Iu Xylose absorption was studied by estimating the urinary excretion of xylose for a 5-hr period following the oral administration of 5 g of
March 1969
D-xylose. Oral glucose tolerance tests were carried out giving 50 g of glucose and studying the rise in venous blood sugar. II Hematological studies were done by the methods described by Dacie. Il Serum vitamin BI2 and serum folate levels were determined by microbiological assay using Euglena gracilis Z strain 1" and Lactobacillus casei, I4 , 1; respectively, as the test organisms. Serum iron was determined by the method of Ramsay .Iti Bone marrow smears were stained for iron by the Prussian blue reaction, a known positive control being included in each batch of slides. Radiological examination of the small bowel was carried out using a stabilized barium preparation (Micropaque) . An image intensifier and television monitor was used to permit screening at very low millampereage so that detailed study of the small bowel was possible. 1 , Jejunal biopsies were done on 19 of the patients using a Crosby intestinal biopsy capsule. '" Biopsies were taken as soon as possible after admission to hospital, but in case 1 the procedure had to be postponed for 19 days owing to his very poor general conditon. In cases 9, 10, and 11 early biopsies were not obtained due to technical difficulties . Biopsy specimens were mounted on Gel-foam, studied under the dissecting microscope and then processed by routine histological methods and T A BLE
Case no,
Age at onset
Sex
Duration of symptoms
N orma l values
11
12 13 14 15 16 17 18 19 20
8 10 12 6 12 10 10 5 5 12 12 6 10 7 4 10 12 10
6 7 - - --
M M M M M M M M M ;V[ :'1 M M M F M F F M 1\1
stained with hematoxylin and eosin. Gastric biopsies were obtained in 8 children using Woods gastric biopsy tube .I" Gastric acid output was studied by the augmented histamine test."U The incidence of the epidemic form of the disease in children was obtained by a field study in North Arcot District.5 The full account of this study is being published elsewhere , but the details on the children in village P are included here for completeness. The health and nutrition of a village population similar to the ones from which these children came have been studied in detail. Zl - " 7
Results Studies on Hospitalized Children The age at the time of onset of the disease ranged from 4 to 12 years. There were 17 boys and 3 girls. Children 1 to 9 were apparently endemic cases and children 10 to 20 came , from villages affected by known epidemics of tropical sprue. There was no detectable difference between the two groups and they have therefore been considered together. The duration of symptoms ranged from 1 month to 5 years (table 1) . Symptomatology. In the majority of
1. A ge, sex , d uration , a nd absorption studies
yr
yr
1 2 3 4 5 6 ·7 8 9 10
557
TROPICAL SPRUE IN CHILDREN
6/ 12 5 3/12 6/ 12 4/ 12 2/ 12 1 1/12 2/ 12 2 3/ 12 3/12 1/ 12 1/ 12 1/12 6/ 12 1/ 52 4/ 12 5/ 12 5/ 12
- - - - - - - -- -
I I
I
I
1-- ---Vitamin Bl ~ absorption
Stoo l f a t
I
gm/ day
<5 18 14
21. 5 10 14
9 15 7 14 18 16 14 5 9 10 12
I
"g
' >0, 30 0 .17 0 .23 0.55 0.06 0.68 0.26 0.06 0 .02 0.42 0,25 0.09 0.22 0,22 0. 19 0 .50 0.05 0.19 0.14
11
17 26 11 - - - - _ .. -
-
X ylose e xcret ion
Glucose tolerance test maximu m rise
% fesf dose
mg %
>25 .0 1.4 12.6 15.8 13.0 8.0 28.0 7.4 6.6 14,8 25,0 11 .0 20.0
>25.0 23 .0 28 .2 11.4 18.7 21.6 50.0 4. 1 23.0 100.0 15 .0 21.0 8.8
17,0
24. 0
10.0 13.0 17 .0 7. 2 1:3.2
.. _ ----------
-
23.0 27.0 20 .5 33.4 42.0 - - - -- -
558
MATHAN ET AL.
cases, diarrhea was the first symptom. Fever, with, or prior to, the onset of diarrhea was present in 4 cases. The stools were usually semiformed or watery and initially contained blood and mucus in about half of the cases. Abdominal distension, loud borborygmi, anorexia, and vomiting were associated symptoms. However, the vomiting as well as the blood and mucus in the stool cleared up usually within 1 week. The majority had intermittent diarrhea, but in a few cases it was continuous. Abdominal distension, anorexia, and loud borborygmi persisted throughout. As the disease progressed, the children showed increasing lassitude, and symptoms of multiple deficiencies such as night blindness, glossitis, stomatitis, and anemia developed gradually. Physical examination at the time of admission. Most children had lost weight and 6 had become emaciated since the onset of diarrhea (fig. lA; his improvement following treatment is shown in fig IE) . Ten had dyspigmentation of the hair of recent
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ongm. Signs of dehydration were present in 5 cases and in 3 this was associated with dependent edema. In 2 cases, in association with severe anemia and hypoproteinemia, there was generalized anasarca. One child was apathetic and 2 were almost comatose. Signs of various deficiencies were present to some extent in all children (table 2). The most common finding on examination of the abdomen was distension (13 cases) due to gaseous dilation of the intestine. In addition, there was ascites in 3 of these children. Visible peristalsis was present in 3 cases. Bowel sounds were usually loud, prolonged and irregular. A mild degree of hepatic enlargement was found in 8 cases. Two children exhibited classical signs of bronchopneumonia. Stool examination. During the first week in the hospital the stools were usually mushy or watery in consistency. The stool volume was increased and ranged from 800 to 2000 cc per day. Mucus was present in the stools of 10 cases. Blood was visible in the stool in only 1 child who had
A FIG. 1. Case 1 (A) at time of admission, (B) at time of discharge 3 months later.
559
TROPICAL SPRUE IN CHILDREN
March 1969
asites by appropriate therapy, did not improve intestinal absorption in any case. Tests of intestinal absorption. The results are summarized in table 1. All of the patients had steatorrhea. The majority had defective xylose absorption (16/18) and many had defective glucose absorption (13/18). Vitamin B1 2 absorption was abnormal in 14 of the 18 in whom it was tested . When the test was repeated with intrinsic factor added, absorption was unchanged in 10 cases and improved in 2 others. TABLE 2. Findings on physical examination inHematology. Eight children had a hecluding signs of nutritional deficiency moglobin of 10 g per 100 ml or less. The values given in table 3 are those during Symptom No. of cases the first week in the hospital, after correction of dehydration. Examination of the Xerosis conjunctivae . . . . . . . . . . . . . .18. blood film usually showed morphological Altered bowel sounds. . ... . . . . . .. . .. 16 evidence of iron deficiency, and in some Abdominal distension. . . . . . . . . . . . . . 12 . Hair changes... . . . . . . . . . . . . . .. . . . . . 10 cases macrocytosis and hypersegmentation Stomatitis .... . .. .. . . . .... . . . . ... . " 9 of the polymorphs. Examination of bone Pallor... . .... . ... ... . . . .. .. . . . .... . 8 marrow smears showed megaloblastic eryBitots spots. . . . . . . . . . . . . . . . . . . . . . . . 7 thropoiesis in 12 cases. The remainder had Edema... . .. . .. . . . . . . . . . . ... . .. . . .. 6 normoblastic erythropoiesis with signs of Glossitis ... . . . ... .. .. . .... . . . .. . . " 5 iron deficiency. In no case was stainable Crazy pavementing of skin. . . . . . . . . 4 iron present in the marrow. Serum iron, Hyperpigmentation .. . .. . .. . .. . . . . " 3 and vitamin B1 2 levels are given in folate, Keratomalacia. . . . . . . . . . . . . . . . . . . . . . 2 table 3.
a prolapsed rectum. Thirteen patients had fat globules and half had parasitic infestation (Ancylostoma duodenale in 7, Ascaris lumbricoides in 4, Giardia lamblia in 2, and Entamoeba histolytica in 1) . In 2 out of 18 patients, enteropathogenic organisms were grown in culture of stool (Shigella fiexneri and pathogenic Escherichia coli, respectively). However, elimination of the infection, by antibiotics for a 2-week period, or eradication of the par-
3. Hematological fi ndin gs at the time of admission
TA BLE
Case no. - - -- -- -
Norma l v alues
I, Hemoglobin gm/ lOOml
:
I;"
3
11
5
14
4
13
I Packed cell I volume I
I
'7<.
I
!
I ;; I
37
35 44
~
~~
9 10 11 12
10
32
10 13 13 14 13
34 39
13 14
15 16 17 18
19 20
12 14
14 6 10 7
I
1-------Bone marrow
~~ :39 41
39 36 44 41 23
36 28
M egalobl as tic Normoblastic :Megaloblastic , M egalobl ast ic Megalobl astic No rmoblast ic M egalobl ast ic Megaloblas t ic Megaloblast ic lVl egaloblas ti c Megaloblastic M egalobl ast ic N ormobl as t ic Megaloblastic Normoblastic I :'IIegaloblast ic Normoblastic N ormoblastic Normoblastic N ormoblastic
I
\.
i~%i:
f~_,~U_l~_~' __
B I' 1_ _
a1b_~_~_in_
s_ e r_um _ ir_ on-l _ _
g/ I OO ",{
I'llg/ 1111
mlJ,g/ml
> 140 900 1000 65 400 248
>G .O 2. 5 :3. 0
>60 30
3.6
214
5 .0
148
3. 3 10 .0 13.0
20 35 60 28 24
-1. 2
3.0
40 280 66 80 136
11. 5
8 .0 7.7
140
190
510 144 200 640
480 312
4.6 4.5 I
.1 .2
4.0 3 .0
4.5 5.8
40
:3 .0 2.2 1. 3 3 .7 1. 9
3.5 2 .3
3 .9 2.7
55 50
45 64 38
3.9 3.9 3.9 3. 4 2 .2
2. 8 1.8
35
48 20 30 24
2.8 3.4 2.0 2.8 2 .3
560
MATHAN ET AL.
Serum albumin. The serum albumin determined during the first week after admission ranged from 1.3 to 3.9 g per 100 ml with a mean of 2.8 g per 100 ml (table 3).
Radiology. In 19 of the cases, barium meal examination showed one or more of the following small intestinal abnormalities-dilation, coarse mucosal pattern, and disordered peristalsis (fig. 2). The dilation was usually confined to the duodenum and jejunum, although occasionally it also involved the ileum. In one case the dilation was confined to the ileum. Coarsening of the mucosal pattern was found most frequently in the duodenum and jejunum (15 cases), but in 5 cases it extended into the ileum. Disordered peristalsis was most common in the upper small intestine, but in 2 cases it was present throughout. The most common finding was very slow peristalsis usually associated with abnormal to and fro "riding" or "churning" movements. In 2 cases, however, there was
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rapid peristalsis with shortened transit time. No evidences of strictures, blind loops, or fistulae were found in any case. Jejunal biopsy. Jejunal biopsy was performed in 16 patients soon after admission (table 4). The dissecting microscopic appearance showed leaf-like villi (fig. 3) in 8 of the cases, a convoluted (fig. 4) mucosa in 7, and a flat appearance in 1. The 3 patients in whom biopsy was delayed had leaf-like villi. On histological exami'lation, the height of the villi was reduced with varying degrees of glandular hypertrophy in all cases (fig. 5). In 8 cases partial villus atrophy (fig. 6) was present, and in 1 case there was total villus atrophy. There was an increase in the cellularity of the lamina propria in the majority of cases (figs. 6 and 7). The' cells were predominantly lymphocytes and plasma cells with occasional histiocytes. In 3 cases eosinophils were present in significant numbers. There was also an increase in the
FIG. 2. A, Barium meal, case 1, showing gross dilation of gas-filled loops of jejunum; B, barium meal, case 7, showing some dilation and very coarse mucosal pattern in jejunum.
TABLE
Bi~~~Y I ~z,s~f I
Case no.
--- ---
I
2
3 4 5 6 7 9 10 11 12 13
14 15 16 17 18 19
I
I
!
1 2 1 2 3 1 1 2 1 2 1 1 1 1 1 1 2 1 1 1 1 2 1 1 2 1
2 20
1
4. Biopsy findings
!
Dissection microscopic appearance I
Villus height
Lamina propria inftammaIinfiltration lium cell tory change
! Epithe-
--19 90 2 26 84 5 6 48 8 28 10 8 45
60 58 6 24 4 7 3 4 28 9 15 53 5 64 7
I
Convolutions Leaves and convolutions Flat cobblestone Convolutions Leaves Leaves Convolutions Leaves and convolutions Leaves Leaves Leaves Leaves Leaves Leaves Leaves Leaves Leaves Short fat leaves Convolutions Leaves and convolutions Convolutions Convolutions Leaves Convolutions Leaves an d convolutions Convolutions Convolutions Convolutions
cellular infiltration of the mucosal cells which in some cases was very marked (fig. 7).
561
TROPICAL SPRUE IN CHILDREN
March 1969
Gastric acid output. Augmented histamine tests were done in 15 cases. The maximal acid output in the posthistamine hour ranged from 0.2 to 10.3 mEq, with a mean of 4.1 mEq. Eight patients had values below 4.0 mEq. Gastric biopsy. Gastric biopsies were obtained in 8 cases. All biopsies were abnormal. Mild superficial gastritis was seen in 4 cases. Four other cases showed moderate infiltration with round cells and 3 of these had marked reduction in the glandular elements. Course in hospital. The period of hospitalization ranged from 10 days to 4 months. Diarrhea was controlled with ka-
Partial villus atrophy Reduced Total villus atrophy Partial villus atrophy Reduced Slightly reduced P artial villus atrop'hy Partial villus atrophy Slightly reduced Normal Slightly reduced Reduced Slightly reduced Partial villus atrophy Almost normal Partial villus atrophy Slightly reduced Partial villus atrophy Reduced Partial villus atrophy Partial villus atrophy Reduced Reduced Partial villus atrophy Normal Reduced Reduced Reduced
I
++ + +++ ++ + ++ ++ + + + + +++ + ++ + ++ + +++ ++ +++ +++ ++ ++ ++ 0
- --
++ + +++ +++ ++ ++ ++ ++ + + 0
++ + ++ + ++ ++ +++ ++ +++ +++ ++ ++ ++ 0
+++ +++ ++ +++ +++ +++
olin, or by code in phosphate, administered orally or by injection, as necessary. Dehydration, acidosis, hyponatremia, hypokalemia, and nutritional deficiencies (vitamin A, vitamin B 12 , folic acid, iron, and so forth) were appropriately corrected. In all cases, the diarrhea became less, anemia was corrected, and the patients gained weight and lost their edema (fig. IB). In addition, 6 patients had a 15-day course of antibiotics (tetracycline, chloramphenicol, and sulphamezathine each for a 5-day period in appropriate dosage according to weight) and 4 patients were given folic acid (pteroyl glutamic acid) tablets, 5 mg daily, for periods of 3 weeks or more (2 of these children also received antibiotics) (table 5). Fifteen patients were hospitalized long
562
MATHAN ET AL.
Vol . 56, No. 3
enough to study the effects of treatment on intestinal function. In 7 the steatorrhea had cleared up at the time of discharge. Four of these had only received symptomatic treatment for control of the diarrhea and had had no folic acid or antibiotics; the other 3 had been given antibiotics. However, in 4 others given antibiotics and in the 4 patients given high doses of folic acid, the steatorrhea persisted (table 5) . Ten out of 14 patients with an initial vitamin BI 2 absorptive defect were restudied at intervals. Three patients who received no specific therapy showed a spontaneous improvement of absorption. Of 6 patients who were given antibiotics, there was a prompt reversal of the absorptive defect (normal absorption in 5 days time) in 4, while in the other 2 it persisted unchanged (table 5). The xylose absorption became normal in 4 out of the 12 patients in whom it was FIG. 3. Dissecting microscopic appearance of restudied, but there was no correlation jejunal biopsy, case 3, showing leaf-like villi. between specific therapy and improvement in this test. In 7 cases initial and predischarge jejunal biopsies were done. All of the repeat biopsies showed some degree of improvement which varied from lessening of inflammatory change to return to normal appearance (table 4). Follow-up studies after discharge. Eleven patients has been followed up at home for periods up to 3 years. Except for occasional bouts of diarrhea 10 of them are still well. Two of them studied 6 months after discharge had no malabsorption. The 11th child has had recurrent diarrhea and at restudy 3 years after the original admission he still had persistent malabsoption.
FIG. 4. Dissecting microscopic appearance of jejunal biopsy, case 1, showing convoluted appearance.
Field Studies in Epidemic Sprue Village P, situated about 50 miles from Vellore had a population of 603, of whom 228 were below 12 years of age. Prior to September 1960 there were no people in the village suffering from chrnoic diarrhea, but in September cases of diarrhea began to occur in the village and reached a peak
.
March 1969
TROPICAL SPRUE IN CHILDREN
563
FIG. 5. Jejunal biopsy, case 3, showing slight shortening of villi and increase in glandular layer. Note that one leaf has been cut across at right angles to the longer axis giving a finger-like appearance. Others have been cut at different angles giving villi of different widths.
FIG. 6. Jejunal biopsy, case I, showing partial villus atrophy. Note marked increase in cellular infiltration of lamina propria, and distortion of surface mucosal cells.
incidence in November of the same year. Subsequently, the number of new cases diminished and none occurred after March 1961. Altogether, 58 children were affected
(32 males and 26 females). The age-specific attack rates in 2-year age groups are shown in figure 8. The attack rate in children was 25%, whereas in the adults it was
564
Vol. 56, No.3
MATHAN ET At.
FIG. 7. Oil immersion view of tip of a villus from jejunal biopsy, case 13, showing thickening of the basement membrane, disorganization and lymphocytic infiltration of the epithelial cells, and some distortion of the brush border. The marked cellular infiltration ofthe lamina propria is also clear. T "\BLE
5. Summary of treatment given to the cases during hospitalization and the effect on stool fat and . vitamin B12 absorption
I Case no.
"-- -- -
1 2 3 4 5 7 9 10 11 12 14 16 18 19 20
I
Total days in hospital
--
Days on which specific therapy was given
controlofl diarrhea
Antibiotics
! Folic acid
I
I Vitamin B" I
Stool fat
Initial
- -..- --
92 116 33 64 41 124 55 74 63 48 I 25 33 60 67 55
I
Initial Amount absorbed
hospital
g/24 hr
1-20 1-40 I 1-30 Ii ,
I I
2-5
7-67
102-120
28-41 30-122 16-38
14-30 I
32-47 I 10-25
I
10-26 43-58
I lOO-122
I I
30-48
i
I
43-58
I
I
!
I
45SC. The difference between these two attack rates is significant at the 0.5% level. The mean duration of symptoms in these cases, excluding those who died,
I
I
18 14 21 10 14 15 14 18 16 14 9 12 17 26 11
BI2
absorption
After treatment
Last
week in
I
1-80 1-98 1-33 1-30
1-18 1-18 1-50 1-33
I I
Vitamin
lO 4.5 9 3 8.5 7 14 4 8 4 4 4 9 7 5
I'g
0.17 0.23 0.55 0.06 0.68 0.06 0.42 0.25
I
0.09 0.22 0.19 0.05 0.19 0.14
Amount absorbed
Day tested
--- --I'g
0.27 0.43
77 lO4
0.57
32
0.12
120
0.38
30
0.47 0.85
38 15
0.58 0.19 0.31
31 58 45
was 3 months with a range of less than 1 month to over 4 years. These cases have been followed now for up to 6 years. Since the village was rela-
TROPICAL SPRUE IN CHILDREN
March 1969
565
did not publish detailed studies. Bahr 33 recorded the disease in an 8-year-old Tamil boy from Ceylon. Johnson and Breidigan34 described a 6-year-old American girl who contracted the disease in Madras State . MillerJ 5 reported an 11o ....-year-old English boy who became ill after ~ 30 returning home from Ceylon. On the basis o Z of published data, these 3 cases clinically ::I :t: resembled tropical sprue . However, by present standards they were inadequately Ill: investigated to substantiate the diagnosis. W .... Descriptions of 2 children with tropical 20 sprue have previously been published from this unit.3u, 37 Differential diagnosis. Tropical sprue may best be defined as a malabsorption syndrome of as yet unknown etiology oc:..: v curring in residents of, or visitors to, the ~ 10 tropics." 3 8,:1 9 The diagnosis can, there
~
~
~
~
~
566
MATHAN ET AL.
had levels indicative of severe depletion (less than 2 g per 100 ml) (table 3). In adults with tropical sprue, loss of albumin from the gastrointestinal tract has been reported by two groups40, 44 and there may be a reduction in serum albumino6 , 45 - 47 and the total exchangeable albumin pool. 44 The children reported in this paper, before the onset of their illness, did not have diets that were significantly different from that of the average village child. We believe, therefore, that the low serum albumin in these cases was due to a combination of defective absorption, increased exogenous loss, and reduced intake following the characteristic anorexia, rather than protein deficiency per se. There was also no evidence for any of the other known causes of malabsorption. All of these cases, therefore, had malabsorption of unknown etiology and must be grouped within the syndrome of tropical sprue. 47 Clinical features . The clinical picture of the disease in children is very similar to that observed in adults in South Inddia."' 7, 36, 47 The duration of symptoms ranged from 1 month to 5 years. The characteristic clinical symptoms were diarrhea, anorexia, abdominal distension, and loud borborygmi. This combination has given rise to its local vernacular name "Ubbu Mariyayee" meaning "visitation of the goddess of distension." It has been said that the presence of glossitis is essential for the diagnosis of sprue 3 However, many of the classical textbook features of tropical sprue such as glossitis, angular stomatitis, and anemia are the consequence of the deficiencies that occur as a result of the intestinal disease. Thus, the incidence and extent of these features will depend on the initial nutritional status, the dietary habits of the patient, and the severity and duration of the illness, and no one deficiency symptom can be considered as essential for the diagnosis. The incidence of nutritional deficiency in this group was much higher than in a control village population. 2i As an example, only 14% of the average vil-
Vol. 56, No . 3
lage children have xerosis conjunctivae while in this group 90% had it. A small proportion of patients may develop severe dehydration, hyponatremia, hypokalemia, and acidosis. This is the most common cause of death early in the course of the disease in untreated patients. In some patients, these fluid and electrolyte disturbances may be associated with diminished level of consciousness or coma as was observed in 2 of the cases in this study. Anemia is a common complication and may result from lack of iron, folic acid, or vitamin Bi2 or various combinations of these. Fifteen children in this series had serum folate levels below 6 /-lg per ml and 4 had serum vitamin Bi2 levels below 100 /-lg per ml. Two children (cases 1 and 2) had high serum vitamin Bi2 levels, presumably associated with liver dysfunction, which returned to normal with improvement in their general condition. A similar elevation of serum Bi2 levels has been seen in some adults with severe tropical sprue. Vitamin Bi2 malabsorption occurred in two-thirds of these children (table 1). The absorption of vitamin Bi2 in tropical sprue is usually not improved by giving additional intrinsic factor. However, the pathological changes are not entirely confined to the small bowel and there is also a gastric lesion producing varying degrees of atrophic gastritis with defective acid 48 and intrinsic factor secretion. 49 Occasionally, the gastric lesion may persist after the intestinal defect has improved; under such circumstances the absorption is normal when tested with additional intrinsic factor. The presence of such a gastric lesion in this group of cases is shown by the low acid output, the changes on gastric biopsy, and the improvement of vitamin Bi 2 absorption in 2 of the cases when the test dose was given with added intrinsic factor. The radiological findings in the children are identical to those found in adults with tropical sprue. The pathogenesis of the changes is not fully understood and they
March 1969
TROPICAL SPRUE IN CHILDREN
are not diagnostic. 5u No correlation between the radiological changes and other findings could be demonstrated. The major role of radiology is to exclude anatomical lesions of the small bowel which could produce secondary malabsorption. I 7. 50 The jejunal mucosa from these children showed a spectrum of changes in villus architecture from biopsies that were scarcely distinguishable from those found in control subjects38 to the appearance of total villus atrophy in one case. No definite correlation between the degree of abnormality and the clinical severity of the individual cases was possible . On examination of an isolated intestinal biopsy it is impossible to confirm the diagnosis of tropical sprue, although the studies of Schenk et al. 5 1 suggest that fat stains may be helpful in this regard. One important contribution of jejunal biopsy is to exclude conditions like lymphoma of the small bowel, intestinal lymphangiectasia, and Whipples disease. It is also useful in follow-up of cases when therapy with a gluten-free diet is being carried out to exclude celiac disease.52 Therapy. The most suitable therapy for patients with tropical sprue is still debated. It is claimed that antibiotics 39 • 53. 54 or folic acid 39 . 55. 56 will cause a remission in many cases of tropical sprue. However, the results in this group of children do not give unequivocal support to this concept. Controlling diarrhea and making up deficiencies of fluids, electrolytes, and other nutrients is the essential first step in treatment. As shown by some of the cases described here and elsewhere," 8. 36 the disease tends to remit without specific th~rapy. Therefore it is not possible to know whether the improvement noted in the steatorrhea, the xylose, absorption, and biopsy findings in the children in this study treated with folic acid or antibiotics would have occurred without the administration of these agents. However in 4 out of 6 cases the defect of vitamin BI 2 absorption was cured within 1 week by antibiotics, suggesting that in these cases this absorptive defect may have
567
been associated with bacterial invasion of the ileum. Studies in a larger series of cases are necessary for fuller evaluation of therapy. Epidemic sprue. Analysis of the cases studied in the metabolic ward shows no detectable differences between endemic and epidemic forms of the disease. The clinical features in the children of village P who were not admitted were similar to those observed in the hospitalized children. However, it is possible that a comparative study of a bigger number of patients might reveal difference such as have been observed in the incidence of vitamin BI 2 malabsorption in different groups of adults. 47 The lower incidence in children as compared with adults has been an unexplained but constant feature in all epidemics of sprue studied in this area. 5 - 8 The sex incidence among the children in the village was equal. The predominance of males in the hospitalized group is presumably a reflection of the greater readiness to seek medical aid for male children. The large numbers of deaths (32%) among the children in the village, where medical help was seldom availed of, contrasts markedly with a zero mortality in the hospital cases. This emphasizes the value and importance of even simple therapeutic measures. The long term follow up of the survivors in the village highlights the tendency of the disease to undergo spontaneous remISSIOn or cure, even though the individuals continue to live in the same environment and to eat the same diet. • Etiology . The primary lesion in tropical sprue appears to be damage to the intestinal mucosa. The etiology of this damage in children, as in adults, is unknown and may well be multiple. 4 7 It has been suggested that hypoproteinemia may cause intestinal damage and malabsorption. However, the evidence for this is not conclusive and severe hypoproteinemia associated with the nephrotic syndrome does not usually result in intestinal damage. 57 Nevertheless, it is pos-
568
MATHAN ET AL.
sible that there may be an as yet unrecognized specific deficiency or that general malnutrition may make a child more likely to develop sprue. It has been suggested also that intestinal damage may be caused by a toxin,58. 59 but there is as yet no good evidence in support of this hypothesis. It has also been proposed that sprue may be the result of an infection36 , 60, 61 and a steatorrheic enteritis of short duration has been described in children with a reovirus infection. 62 The occurrence of the disease in epidemics, the fever at the onset, the raised erythrocyte sedimentation rate, and the marked cellular infiltration of the intestinal mucosa could result from an infection. Various studies5 - 8. 36. 63 to date have failed to reveal any consistent bacterial or viral pathogens. However, these studies did not utilize all currently available techniques for the isolation of pathogenic agents and much more work needs to be done in this area before any answers can be given. REFERENCES 1. Fairley, N. H. 1939. Sprue, tropical. British Encyclopaedia of Medical Practice 11: 419436. Butterworth, London. 2. Trowel, H. G., and D. B. Jelliffe. 1958. Diseases of children in the subtropics and tropics. Edward Arnold, London. 3. Manson-Bahr, P. H. 1965. Mamon's tropical diseases, Ed. 16, p . 464-477. Cassell, London. 4. Gour, K. N. 1964. Diarrhea in infancy and childhood. Asian Paediatrics, p . 82-87. Asian Publishing House, Bombay. 5. Baker, S. J., V. I. Mathan, and 1. Joseph. 1962. Epidemiology of tropical sprue. Malabsorption Symposium . Proceedings of the 2nd World Congress of Gastroenterology, Munich, p. 46. Karger, Basel and New York. 6. Mathan, V. 1. , M. Ignatius, and S. J. Baker. 1966. A household epidemic of tropical sprue. Gut 7: 490-496. 7. Baker, S. J., and V. I. Mathan. 1968. Tropical sprue in South India. Roy. Coli. Phys . Lond. In press. 8. Mathan, V. 1., and S. J . Baker. 1968. Acomparative study of epidemic tropical sprue and other epidemics of diarrhea in South Indian villages. Amer. J. Clin. Nutr. In press. 9. van de Kamer, J. H., H. ten B. Huinink, and
Vol. 56, No . 3
H. A. Weyers. 1949. Rapid method for the determination of fat in the feces. J. Bioi. Chern. 177: 348-355. 10. Heinle, R. W., A. D. Welch, V. Scharf, G. C. Meacham, and W. H. Prusoff. 1952. Studies of excretion (and absorption) of C06 U labeled vitamin B12 in pernicious anemia . Tram. Assn. Amer. Phys. 65: 214-222. 11. Rajan, K. T., P. S. S. Rao, I. Ponnuswamy, and S. J. Baker. 1961. The oral glucose tolerance test in tropical malabsorption syndrome. Brit. Med. J . 1: 29-31. 12. Dacie, J. V. 1956. Practical haematology, Ed. 2. Churchill, London. 13. Hutner, S. H ., M .K. Bach and G. I. M. Ross. 1956. Sugar-containing basal medium for vitamin B12 assay with Euglena: application to body fluids. J. Protozool. 3: 101-112. 14. Baker, H., V. Herbert, O. Frank, I. Pasher, S. H. Hutner, L. F. Wasserman, and H. Sabotka. 1959. A microbiological method for detecting folic acid deficiency in man. Clin. Chern. 5: 275-280. 15. Waters, A. H., and D. L. Mollin, 1961. Studies on folic acid activity of human serum . J. Clin. Path. 14: 335-344. 16. Ramsay, W. N. M. 1957. The determination of iron in blood, plasma, or serum. Clin. Chim. Acta 2: 214-220. 17. Paterson, D. E., R. David, and S. J. Baker. 1965. Radio diagnostic problems in malabsorption. Brit.J. Radiol.38: 181-191. 18. Crosby, W. H., and H. Kugler. 1957. Intraluminal biopsy of the small intestine: the intra-' luminal biopsy capsule. Amer. J. Dig. Dis. 2: 236-241. 19. Wood, I. J ., K. R. Doig, R. Motteram, and A. Hughes. 1949. Gastric biospy: report of 55 biopsies using a new flexible gastric biopsy tube. Lancet 1: 18-21. 20. Kay, A. W. 1953, Effects of large doses of histamine on gastric excretion of HCl: an augmented histamine test. Brit. Med . J. 2: 77-80. 21. Rao, B. R. H., and P . S. S.Rao. 1958. General health and nutrition survey of the rural population in Pennathur. 1. The nutrition status survey. Ind. J . Med. Sci . 12: 705-717. 22. Rao, B. R. H. , and P. S. S. Rao. 1958. General health and nutrition survey of the rural population in Pennathur. II. A qualitative study on family meals. Ind. J. Med . Sci . 12: 718-725. 23. Rao, B. R. H., and P. S. S. Rao. 1958. General health and nutrition survey of the rural poplation in Pennathur. III. The quantitative dietary survey. Ind. J . Med. Sci . 12: 726-730. 24. Rao, B. R. H., P. S. S. Rao, and C. E. Klontz. General health and nutrition survey of the
March 1969
TROPICAL SPRUE IN CHILDREN
rural population in Pennathur. IV. Protein nutrition. Ind . J. Med. Sci. 13: 401-409. 25. Rao, B . R. H ., P . S. S. Rao, and C . E . Klontz. 1959. General helath and nutrition survey of of the rural population in Pennathur. V. Vitamin nutrition. Ind . J. Med . Sci. 13: 410-419. 26. Rao, B. R. H ., P . S .S. Rao, and S. J . Baker. 1959. General health and nutrition survey of the rural population in Pennathur. VI. Iron intake and iron deficiency anaemia. Ind . J. Med. Sci. 13: 584-592. 27. Rao, B. R . H., P . S . S. Rao, and C. E . Klontz. 1960. General health and nutrition survey of the rural population in Pennathur. VII. The health status survey. Ind. J. Med. Sci. 14: 175-182. 28. Porter, M . G., and J . D . Welsh. 1966. Review: current concepts of the malabsorption syndrome in children. J. Okla . Med . Assn. 59: 154- 163. 29. Anderson, C. M. 1966. Intestinal malabsorption in childhood. Arch. Dis. Child. 41: 571-596. 30. Gerrard, J. W., and M. C. Luboz. 1967. The malabsorption syndromes. Ped . Clin. N. Amer. 14: 73-91. 31. Visakorpi, J . K. , P . Immonen, and P. Kuitunen. 1967. Malabsorption syndrome in childhood. Acta Paed. Scand . 56: 1-9. 32. Sheehy, T . W. , and M. H . F. Floch. 1964. The small intestine, its function and diseases, p. 252. Harper and Row, New York. 33. Bahr, P. H. 1915. A report on researches on sprue in Ceylon 1912-1914, p. 122. University Press, Cambridge. 34. Johnson, J., and P . T. Breidigan, 1925. Tropical sprue in a child 6 years of age. Amer. J. Med . Sci . 170: 364-371. 35. Miller, R. 1934. A case of sprue commencing at the age of eleven and a half years. Trans. Roy. Soc. Trop . Med. Hyg. 28: 413-417. 36. Baker, S . J. 1957. Idiopathic tropical malabsorption. Ind . J. Med. Sci . 11: 687-703. 37. Mathew, K., M . Ignatius, Meenakshiammal, and S. J . Baker. 1964. Tropical sprue in children. Ind. Ped . 1: 271-275. 38. Baker, S . J., M . Ignatius, V. I. Mathan, S. K. Vaish, and C. C. Chacko. 1962. Intestinal biopsy in tropical sprue, p. 84-101. In G . E. W. Wolstenholme and M. P. Cameron [eds.}, Intestinal biopsy, Ciba Foundation Study Group No. 14. Churchill, London. 39. Klipstein, F. A. 1964. Tropical sprue in New York. Gastroenterology 47: 457-470. 40. Walia, B . N. S ., J . K. Sidhu, B. N . Tandon, O. P. Ghai, and S . Bhargava. 1966. Coeliac disease in North India. Brit. Med. J. 2: 12331234.
569
41. Brusner, 0., A. Reid, F. Minekeberg, A. Maccioni, and I. Centrerao. 1966. Jejunal biopsies in infant malnutrition: with special reference to mitotic index. Pediatrics 38: 605-612. 42. Mayoral, L. G., K. Tripathy, F. T. Garcia, S. Klahr, O. Bolanos, and J. Ghitis. 1967. Malabsorption in the tropics-a second look. 1. The role of protein malnutrition. Amer. J . Clin. Nutr. 20: 866-883 . 43. Rubini, M. E., T . W . Sheehy, W. H. Meroney, and J. Louro. 1961. Exudative enteropathy. II. Observations in tropical sprue. J. Lab. Clin. Med . 58: 902-907. 44. Vaish, S . K., M . Ignatius, and S. J . Baker. 1965. Albumin metabolism in tropical sprue. Quart. J . Med . 34: 15-32. 45. Perez Santiago, E., and C. E. Butterworth, Jr. 1957. Definition and diagnosis of sprue. Amer. J. Dig. Dis. 2: 225- 235. 46. Klipstein, F . A., I. M. Samloff, and E. A. Schenk. 1966. Tropical sprue in Haiti. Ann. Intern. Med . 64: 575-594. 47. Baker, S. J., and V. L Mathan. 1968. The syndrom of tropical sprue in South India. Amer. J. Clin. Nutr. In press. 48. Vaish, S. K., J. Sampath Kumar, R. Jacob, and S. J. Baker. 1965. Stomach in tropical sprue. Gut 6: 458-465. 49. Baker, S. J., and B. Richards. 1966. Experience in the assay of intrinsic factor in tropical sprue. J. Assn. Phys. Ind. 14: 100. 50. Paterson, D. E., and S. J . Baker. 1958. The radiological investigation of the small intestine in tropical idiopathic malabsorption. J. Fac. Radiol. 9: 183-194. 51. Schenk, E. A., I. M. Samloff, and F. A. Klipstein. 1965. Morphologic characteristics of jejunal biopsy in celiac disease and tropical sprue. Amer. J. Path . 47: 765-781. 52. Rubin, C. E., and W . O. Dobbins. 1965. Peroral biopsy of the small intestine. Gastroenterology 49: 676-697. 53. French, J . M. , R. Gaddie, and N. M . Smith. 1956. Tropical sprue: a study of 7 cases and their response to combined chemotherapy. Quart. J .Med. 25: 333-351. 54. Guerra, R., M . S. Wheby, and T. M. Bayless. 1965. Long term antibiotic therapy in tropical sprue. Ann. Intern. Med . 63: 619-634. 55. Suarez, R. M ., T . D . Spies, and R. M. Suarez, Jr. 1947. Use of folic acid in sprue . Ann. Intern. Med . 26: 643- 677. 56. Sheehy, T. W. , B. Baggs, E. Perez-Santiago, and M . H. Floch. 1962. Prognosis of tropical sprue: a study of the effect of folic acid on the intestinal aspects of acute and chronic sprue. Ann. Intern. Med . 57: 892-908.
570
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57. Jensen, H., S. Jarum, and J. P. Hart-Hansen. 1966. Gastrointestinal protein loss and intestinal function in the nephrotic syndrome. Nephron 3: 209- 220. 58. Ayrey, F. 1968. Outbreaks of sprue during the Burma Campaign. Trans . Roy. Soc. Trop. Med . Hyg. 41: 377- 406. 59. French, J . M. 1955. Aetiology and mechanism of steatorrhoea. Postgrad . Med . J. 31: 299-309. 60. Ashford, B. K. 1931. The relation of Monilia psilosis to tropical sprue and an evaluation of fermentation of sugar as a criterion for speci-
Vol. 56, No.3
ficity. Porto Rico J . Pub. H. Trop. Med. 6: 310-333. 61. Manson-Bahr, P. 1953. The causation of tropical sprue. Lancet 2: 389-391. 62. Sabin, A. N. 1956. The significance of viruses recovered from the intestinal tract of healthy infants and children. Ann. N. Y. Acad . Sci. 66: 226-230. 63. Bayless, T. M., A. Guardiola-Rotger, and M. S. Wheby. 1966. Tropical sprue: viral cultures of rectal swabs. Gastroenterology 51 : 32-35.
Copyright © 1969 by The Williams & Wilkins Co.
Vol. 56, No.3 Printed in U.S.A.
TROPICAL SPRUE IN CHILDREN A syndrome of idiopathic malabsorption V. I. MATHAN, M .D. (MADRAS), S. JOSEPH, M.B., B.S., AND S. J . BAKER, M .D. (MELBOURNE) Wellcome Research Unit and the Department of Medicine, Firm 1, Christian Medical College Hospital, Vellore , Madras State, India
A group of 20 South Indian children with tropical sprue is described. The disease occurs in endemic and epidemic forms, and there is no clinically detectable difference between the two. The disease in children is similar to that in adults, although the incidence among children in epidemics is lower. The children had multiple absorptive defects, radiological abnormalities, and histological changes in the jejunum. The effects of therapy are discussed and the importance of simple symptomatic therapeutic measures emphasized. The etiology is at present unknown and may be multiple. Diagnosis in an individual case is by exclusion of all other known causes of malabsorption. This condition should be considered in all children with chronic diarrhea in the tropics. Tropical sprue is recognized as a fairly common disease among adults living in certain parts of the tropics, but it is usually assumed that children are rarely, if ever, affected. I - 4 In studying epidemics of tropical sprue it was observed that children frequently developed an illness clinically identical with that occurring in adults. 5 - 8 A special study of the disease as it occurs in children was therefore undertaken. Received May 7, 1968. Accepted August 30, 1968. Address requests for reprints to: Dr. S. J . Baker, Wellcome Research Unit, Christian Medical College Hospital, Vellore 1, Madras State, India. The Wellcome Research Unit is supported by the Wellcome Trust in association with the World Health Organization. These studies were supported in part by Research Grant BSS-CDC-IND-4 . The authors wish to thank the Department of Pediatrics for referring cases 5, 7, and 8 for study; Professor C. J . G. Chacko for reporting on the intestinal biopsies; Mr. R. Tanner and Mr. J . Prabhakaran for help with the photography; and Dr. L. Ellenbogen, Lederle Laboratories, American Cyanamid Company, New York, for kindly supplying the intrinsic factor used in the tests.
Materials and Methods Twenty Indian children from the states of Madras and Andhra were admitted for detailed study in a metabolic ward. These children either presented at the hospital with diarrhea (cases 1 to 9) or were detected on field surveys in villages with tropical sprue (cases 10 to 20) and were willing to be admitted for study. During their stay in the hospital the children were fed either a standard hospital diet or a diet with low vitamin BI 2 and folate content. In either case, the daily fat intake was 50 g, except in a few patients, who were very ill at the time of admission and initially had to be maintained on parenteral therapy . In each case, at least three specimens of fresh stool were examined microscopically for evidence of parasitic infestation. Bacterial cultures of the stool for pathogenic organisms, including pathogenic Escherichia coli, were carried out in all cases. The fecal fat excretion was measured daily during the period of hospitalization by the method of van de Kamer et aL" and the results expressed as a 3-day running mean. Vitamin BI2 absorption was measured by the method of Heinle et aL Iu Xylose absorption was studied by estimating the urinary excretion of xylose for a 5-hr period following the oral administration of 5 g of
March 1969
D-xylose. Oral glucose tolerance tests were carried out giving 50 g of glucose and studying the rise in venous blood sugar. II Hematological studies were done by the methods described by Dacie. Il Serum vitamin BI2 and serum folate levels were determined by microbiological assay using Euglena gracilis Z strain 1" and Lactobacillus casei, I4 , 1; respectively, as the test organisms. Serum iron was determined by the method of Ramsay .Iti Bone marrow smears were stained for iron by the Prussian blue reaction, a known positive control being included in each batch of slides. Radiological examination of the small bowel was carried out using a stabilized barium preparation (Micropaque) . An image intensifier and television monitor was used to permit screening at very low millampereage so that detailed study of the small bowel was possible. 1 , Jejunal biopsies were done on 19 of the patients using a Crosby intestinal biopsy capsule. '" Biopsies were taken as soon as possible after admission to hospital, but in case 1 the procedure had to be postponed for 19 days owing to his very poor general conditon. In cases 9, 10, and 11 early biopsies were not obtained due to technical difficulties . Biopsy specimens were mounted on Gel-foam, studied under the dissecting microscope and then processed by routine histological methods and T A BLE
Case no,
Age at onset
Sex
Duration of symptoms
N orma l values
11
12 13 14 15 16 17 18 19 20
8 10 12 6 12 10 10 5 5 12 12 6 10 7 4 10 12 10
6 7 - - --
M M M M M M M M M ;V[ :'1 M M M F M F F M 1\1
stained with hematoxylin and eosin. Gastric biopsies were obtained in 8 children using Woods gastric biopsy tube .I" Gastric acid output was studied by the augmented histamine test."U The incidence of the epidemic form of the disease in children was obtained by a field study in North Arcot District.5 The full account of this study is being published elsewhere , but the details on the children in village P are included here for completeness. The health and nutrition of a village population similar to the ones from which these children came have been studied in detail. Zl - " 7
Results Studies on Hospitalized Children The age at the time of onset of the disease ranged from 4 to 12 years. There were 17 boys and 3 girls. Children 1 to 9 were apparently endemic cases and children 10 to 20 came , from villages affected by known epidemics of tropical sprue. There was no detectable difference between the two groups and they have therefore been considered together. The duration of symptoms ranged from 1 month to 5 years (table 1) . Symptomatology. In the majority of
1. A ge, sex , d uration , a nd absorption studies
yr
yr
1 2 3 4 5 6 ·7 8 9 10
557
TROPICAL SPRUE IN CHILDREN
6/ 12 5 3/12 6/ 12 4/ 12 2/ 12 1 1/12 2/ 12 2 3/ 12 3/12 1/ 12 1/ 12 1/12 6/ 12 1/ 52 4/ 12 5/ 12 5/ 12
- - - - - - - -- -
I I
I
I
1-- ---Vitamin Bl ~ absorption
Stoo l f a t
I
gm/ day
<5 18 14
21. 5 10 14
9 15 7 14 18 16 14 5 9 10 12
I
"g
' >0, 30 0 .17 0 .23 0.55 0.06 0.68 0.26 0.06 0 .02 0.42 0,25 0.09 0.22 0,22 0. 19 0 .50 0.05 0.19 0.14
11
17 26 11 - - - - _ .. -
-
X ylose e xcret ion
Glucose tolerance test maximu m rise
% fesf dose
mg %
>25 .0 1.4 12.6 15.8 13.0 8.0 28.0 7.4 6.6 14,8 25,0 11 .0 20.0
>25.0 23 .0 28 .2 11.4 18.7 21.6 50.0 4. 1 23.0 100.0 15 .0 21.0 8.8
17,0
24. 0
10.0 13.0 17 .0 7. 2 1:3.2
.. _ ----------
-
23.0 27.0 20 .5 33.4 42.0 - - - -- -
558
MATHAN ET AL.
cases, diarrhea was the first symptom. Fever, with, or prior to, the onset of diarrhea was present in 4 cases. The stools were usually semiformed or watery and initially contained blood and mucus in about half of the cases. Abdominal distension, loud borborygmi, anorexia, and vomiting were associated symptoms. However, the vomiting as well as the blood and mucus in the stool cleared up usually within 1 week. The majority had intermittent diarrhea, but in a few cases it was continuous. Abdominal distension, anorexia, and loud borborygmi persisted throughout. As the disease progressed, the children showed increasing lassitude, and symptoms of multiple deficiencies such as night blindness, glossitis, stomatitis, and anemia developed gradually. Physical examination at the time of admission. Most children had lost weight and 6 had become emaciated since the onset of diarrhea (fig. lA; his improvement following treatment is shown in fig IE) . Ten had dyspigmentation of the hair of recent
Vol . 56, No.3
ongm. Signs of dehydration were present in 5 cases and in 3 this was associated with dependent edema. In 2 cases, in association with severe anemia and hypoproteinemia, there was generalized anasarca. One child was apathetic and 2 were almost comatose. Signs of various deficiencies were present to some extent in all children (table 2). The most common finding on examination of the abdomen was distension (13 cases) due to gaseous dilation of the intestine. In addition, there was ascites in 3 of these children. Visible peristalsis was present in 3 cases. Bowel sounds were usually loud, prolonged and irregular. A mild degree of hepatic enlargement was found in 8 cases. Two children exhibited classical signs of bronchopneumonia. Stool examination. During the first week in the hospital the stools were usually mushy or watery in consistency. The stool volume was increased and ranged from 800 to 2000 cc per day. Mucus was present in the stools of 10 cases. Blood was visible in the stool in only 1 child who had
A FIG. 1. Case 1 (A) at time of admission, (B) at time of discharge 3 months later.
559
TROPICAL SPRUE IN CHILDREN
March 1969
asites by appropriate therapy, did not improve intestinal absorption in any case. Tests of intestinal absorption. The results are summarized in table 1. All of the patients had steatorrhea. The majority had defective xylose absorption (16/18) and many had defective glucose absorption (13/18). Vitamin B1 2 absorption was abnormal in 14 of the 18 in whom it was tested . When the test was repeated with intrinsic factor added, absorption was unchanged in 10 cases and improved in 2 others. TABLE 2. Findings on physical examination inHematology. Eight children had a hecluding signs of nutritional deficiency moglobin of 10 g per 100 ml or less. The values given in table 3 are those during Symptom No. of cases the first week in the hospital, after correction of dehydration. Examination of the Xerosis conjunctivae . . . . . . . . . . . . . .18. blood film usually showed morphological Altered bowel sounds. . ... . . . . . .. . .. 16 evidence of iron deficiency, and in some Abdominal distension. . . . . . . . . . . . . . 12 . Hair changes... . . . . . . . . . . . . . .. . . . . . 10 cases macrocytosis and hypersegmentation Stomatitis .... . .. .. . . . .... . . . . ... . " 9 of the polymorphs. Examination of bone Pallor... . .... . ... ... . . . .. .. . . . .... . 8 marrow smears showed megaloblastic eryBitots spots. . . . . . . . . . . . . . . . . . . . . . . . 7 thropoiesis in 12 cases. The remainder had Edema... . .. . .. . . . . . . . . . . ... . .. . . .. 6 normoblastic erythropoiesis with signs of Glossitis ... . . . ... .. .. . .... . . . .. . . " 5 iron deficiency. In no case was stainable Crazy pavementing of skin. . . . . . . . . 4 iron present in the marrow. Serum iron, Hyperpigmentation .. . .. . .. . .. . . . . " 3 and vitamin B1 2 levels are given in folate, Keratomalacia. . . . . . . . . . . . . . . . . . . . . . 2 table 3.
a prolapsed rectum. Thirteen patients had fat globules and half had parasitic infestation (Ancylostoma duodenale in 7, Ascaris lumbricoides in 4, Giardia lamblia in 2, and Entamoeba histolytica in 1) . In 2 out of 18 patients, enteropathogenic organisms were grown in culture of stool (Shigella fiexneri and pathogenic Escherichia coli, respectively). However, elimination of the infection, by antibiotics for a 2-week period, or eradication of the par-
3. Hematological fi ndin gs at the time of admission
TA BLE
Case no. - - -- -- -
Norma l v alues
I, Hemoglobin gm/ lOOml
:
I;"
3
11
5
14
4
13
I Packed cell I volume I
I
'7<.
I
!
I ;; I
37
35 44
~
~~
9 10 11 12
10
32
10 13 13 14 13
34 39
13 14
15 16 17 18
19 20
12 14
14 6 10 7
I
1-------Bone marrow
~~ :39 41
39 36 44 41 23
36 28
M egalobl as tic Normoblastic :Megaloblastic , M egalobl ast ic Megalobl astic No rmoblast ic M egalobl ast ic Megaloblas t ic Megaloblast ic lVl egaloblas ti c Megaloblastic M egalobl ast ic N ormobl as t ic Megaloblastic Normoblastic I :'IIegaloblast ic Normoblastic N ormoblastic Normoblastic N ormoblastic
I
\.
i~%i:
f~_,~U_l~_~' __
B I' 1_ _
a1b_~_~_in_
s_ e r_um _ ir_ on-l _ _
g/ I OO ",{
I'llg/ 1111
mlJ,g/ml
> 140 900 1000 65 400 248
>G .O 2. 5 :3. 0
>60 30
3.6
214
5 .0
148
3. 3 10 .0 13.0
20 35 60 28 24
-1. 2
3.0
40 280 66 80 136
11. 5
8 .0 7.7
140
190
510 144 200 640
480 312
4.6 4.5 I
.1 .2
4.0 3 .0
4.5 5.8
40
:3 .0 2.2 1. 3 3 .7 1. 9
3.5 2 .3
3 .9 2.7
55 50
45 64 38
3.9 3.9 3.9 3. 4 2 .2
2. 8 1.8
35
48 20 30 24
2.8 3.4 2.0 2.8 2 .3
560
MATHAN ET AL.
Serum albumin. The serum albumin determined during the first week after admission ranged from 1.3 to 3.9 g per 100 ml with a mean of 2.8 g per 100 ml (table 3).
Radiology. In 19 of the cases, barium meal examination showed one or more of the following small intestinal abnormalities-dilation, coarse mucosal pattern, and disordered peristalsis (fig. 2). The dilation was usually confined to the duodenum and jejunum, although occasionally it also involved the ileum. In one case the dilation was confined to the ileum. Coarsening of the mucosal pattern was found most frequently in the duodenum and jejunum (15 cases), but in 5 cases it extended into the ileum. Disordered peristalsis was most common in the upper small intestine, but in 2 cases it was present throughout. The most common finding was very slow peristalsis usually associated with abnormal to and fro "riding" or "churning" movements. In 2 cases, however, there was
Vol. 56, No.3
rapid peristalsis with shortened transit time. No evidences of strictures, blind loops, or fistulae were found in any case. Jejunal biopsy. Jejunal biopsy was performed in 16 patients soon after admission (table 4). The dissecting microscopic appearance showed leaf-like villi (fig. 3) in 8 of the cases, a convoluted (fig. 4) mucosa in 7, and a flat appearance in 1. The 3 patients in whom biopsy was delayed had leaf-like villi. On histological exami'lation, the height of the villi was reduced with varying degrees of glandular hypertrophy in all cases (fig. 5). In 8 cases partial villus atrophy (fig. 6) was present, and in 1 case there was total villus atrophy. There was an increase in the cellularity of the lamina propria in the majority of cases (figs. 6 and 7). The' cells were predominantly lymphocytes and plasma cells with occasional histiocytes. In 3 cases eosinophils were present in significant numbers. There was also an increase in the
FIG. 2. A, Barium meal, case 1, showing gross dilation of gas-filled loops of jejunum; B, barium meal, case 7, showing some dilation and very coarse mucosal pattern in jejunum.
TABLE
Bi~~~Y I ~z,s~f I
Case no.
--- ---
I
2
3 4 5 6 7 9 10 11 12 13
14 15 16 17 18 19
I
I
!
1 2 1 2 3 1 1 2 1 2 1 1 1 1 1 1 2 1 1 1 1 2 1 1 2 1
2 20
1
4. Biopsy findings
!
Dissection microscopic appearance I
Villus height
Lamina propria inftammaIinfiltration lium cell tory change
! Epithe-
--19 90 2 26 84 5 6 48 8 28 10 8 45
60 58 6 24 4 7 3 4 28 9 15 53 5 64 7
I
Convolutions Leaves and convolutions Flat cobblestone Convolutions Leaves Leaves Convolutions Leaves and convolutions Leaves Leaves Leaves Leaves Leaves Leaves Leaves Leaves Leaves Short fat leaves Convolutions Leaves and convolutions Convolutions Convolutions Leaves Convolutions Leaves an d convolutions Convolutions Convolutions Convolutions
cellular infiltration of the mucosal cells which in some cases was very marked (fig. 7).
561
TROPICAL SPRUE IN CHILDREN
March 1969
Gastric acid output. Augmented histamine tests were done in 15 cases. The maximal acid output in the posthistamine hour ranged from 0.2 to 10.3 mEq, with a mean of 4.1 mEq. Eight patients had values below 4.0 mEq. Gastric biopsy. Gastric biopsies were obtained in 8 cases. All biopsies were abnormal. Mild superficial gastritis was seen in 4 cases. Four other cases showed moderate infiltration with round cells and 3 of these had marked reduction in the glandular elements. Course in hospital. The period of hospitalization ranged from 10 days to 4 months. Diarrhea was controlled with ka-
Partial villus atrophy Reduced Total villus atrophy Partial villus atrophy Reduced Slightly reduced P artial villus atrop'hy Partial villus atrophy Slightly reduced Normal Slightly reduced Reduced Slightly reduced Partial villus atrophy Almost normal Partial villus atrophy Slightly reduced Partial villus atrophy Reduced Partial villus atrophy Partial villus atrophy Reduced Reduced Partial villus atrophy Normal Reduced Reduced Reduced
I
++ + +++ ++ + ++ ++ + + + + +++ + ++ + ++ + +++ ++ +++ +++ ++ ++ ++ 0
- --
++ + +++ +++ ++ ++ ++ ++ + + 0
++ + ++ + ++ ++ +++ ++ +++ +++ ++ ++ ++ 0
+++ +++ ++ +++ +++ +++
olin, or by code in phosphate, administered orally or by injection, as necessary. Dehydration, acidosis, hyponatremia, hypokalemia, and nutritional deficiencies (vitamin A, vitamin B 12 , folic acid, iron, and so forth) were appropriately corrected. In all cases, the diarrhea became less, anemia was corrected, and the patients gained weight and lost their edema (fig. IB). In addition, 6 patients had a 15-day course of antibiotics (tetracycline, chloramphenicol, and sulphamezathine each for a 5-day period in appropriate dosage according to weight) and 4 patients were given folic acid (pteroyl glutamic acid) tablets, 5 mg daily, for periods of 3 weeks or more (2 of these children also received antibiotics) (table 5). Fifteen patients were hospitalized long
562
MATHAN ET AL.
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enough to study the effects of treatment on intestinal function. In 7 the steatorrhea had cleared up at the time of discharge. Four of these had only received symptomatic treatment for control of the diarrhea and had had no folic acid or antibiotics; the other 3 had been given antibiotics. However, in 4 others given antibiotics and in the 4 patients given high doses of folic acid, the steatorrhea persisted (table 5) . Ten out of 14 patients with an initial vitamin BI 2 absorptive defect were restudied at intervals. Three patients who received no specific therapy showed a spontaneous improvement of absorption. Of 6 patients who were given antibiotics, there was a prompt reversal of the absorptive defect (normal absorption in 5 days time) in 4, while in the other 2 it persisted unchanged (table 5). The xylose absorption became normal in 4 out of the 12 patients in whom it was FIG. 3. Dissecting microscopic appearance of restudied, but there was no correlation jejunal biopsy, case 3, showing leaf-like villi. between specific therapy and improvement in this test. In 7 cases initial and predischarge jejunal biopsies were done. All of the repeat biopsies showed some degree of improvement which varied from lessening of inflammatory change to return to normal appearance (table 4). Follow-up studies after discharge. Eleven patients has been followed up at home for periods up to 3 years. Except for occasional bouts of diarrhea 10 of them are still well. Two of them studied 6 months after discharge had no malabsorption. The 11th child has had recurrent diarrhea and at restudy 3 years after the original admission he still had persistent malabsoption.
FIG. 4. Dissecting microscopic appearance of jejunal biopsy, case 1, showing convoluted appearance.
Field Studies in Epidemic Sprue Village P, situated about 50 miles from Vellore had a population of 603, of whom 228 were below 12 years of age. Prior to September 1960 there were no people in the village suffering from chrnoic diarrhea, but in September cases of diarrhea began to occur in the village and reached a peak
.
March 1969
TROPICAL SPRUE IN CHILDREN
563
FIG. 5. Jejunal biopsy, case 3, showing slight shortening of villi and increase in glandular layer. Note that one leaf has been cut across at right angles to the longer axis giving a finger-like appearance. Others have been cut at different angles giving villi of different widths.
FIG. 6. Jejunal biopsy, case I, showing partial villus atrophy. Note marked increase in cellular infiltration of lamina propria, and distortion of surface mucosal cells.
incidence in November of the same year. Subsequently, the number of new cases diminished and none occurred after March 1961. Altogether, 58 children were affected
(32 males and 26 females). The age-specific attack rates in 2-year age groups are shown in figure 8. The attack rate in children was 25%, whereas in the adults it was
564
Vol. 56, No.3
MATHAN ET At.
FIG. 7. Oil immersion view of tip of a villus from jejunal biopsy, case 13, showing thickening of the basement membrane, disorganization and lymphocytic infiltration of the epithelial cells, and some distortion of the brush border. The marked cellular infiltration ofthe lamina propria is also clear. T "\BLE
5. Summary of treatment given to the cases during hospitalization and the effect on stool fat and . vitamin B12 absorption
I Case no.
"-- -- -
1 2 3 4 5 7 9 10 11 12 14 16 18 19 20
I
Total days in hospital
--
Days on which specific therapy was given
controlofl diarrhea
Antibiotics
! Folic acid
I
I Vitamin B" I
Stool fat
Initial
- -..- --
92 116 33 64 41 124 55 74 63 48 I 25 33 60 67 55
I
Initial Amount absorbed
hospital
g/24 hr
1-20 1-40 I 1-30 Ii ,
I I
2-5
7-67
102-120
28-41 30-122 16-38
14-30 I
32-47 I 10-25
I
10-26 43-58
I lOO-122
I I
30-48
i
I
43-58
I
I
!
I
45SC. The difference between these two attack rates is significant at the 0.5% level. The mean duration of symptoms in these cases, excluding those who died,
I
I
18 14 21 10 14 15 14 18 16 14 9 12 17 26 11
BI2
absorption
After treatment
Last
week in
I
1-80 1-98 1-33 1-30
1-18 1-18 1-50 1-33
I I
Vitamin
lO 4.5 9 3 8.5 7 14 4 8 4 4 4 9 7 5
I'g
0.17 0.23 0.55 0.06 0.68 0.06 0.42 0.25
I
0.09 0.22 0.19 0.05 0.19 0.14
Amount absorbed
Day tested
--- --I'g
0.27 0.43
77 lO4
0.57
32
0.12
120
0.38
30
0.47 0.85
38 15
0.58 0.19 0.31
31 58 45
was 3 months with a range of less than 1 month to over 4 years. These cases have been followed now for up to 6 years. Since the village was rela-
TROPICAL SPRUE IN CHILDREN
March 1969
565
did not publish detailed studies. Bahr 33 recorded the disease in an 8-year-old Tamil boy from Ceylon. Johnson and Breidigan34 described a 6-year-old American girl who contracted the disease in Madras State . MillerJ 5 reported an 11o ....-year-old English boy who became ill after ~ 30 returning home from Ceylon. On the basis o Z of published data, these 3 cases clinically ::I :t: resembled tropical sprue . However, by present standards they were inadequately Ill: investigated to substantiate the diagnosis. W .... Descriptions of 2 children with tropical 20 sprue have previously been published from this unit.3u, 37 Differential diagnosis. Tropical sprue may best be defined as a malabsorption syndrome of as yet unknown etiology oc:..: v curring in residents of, or visitors to, the ~ 10 tropics." 3 8,:1 9 The diagnosis can, there
~
~
~
~
~
566
MATHAN ET AL.
had levels indicative of severe depletion (less than 2 g per 100 ml) (table 3). In adults with tropical sprue, loss of albumin from the gastrointestinal tract has been reported by two groups40, 44 and there may be a reduction in serum albumino6 , 45 - 47 and the total exchangeable albumin pool. 44 The children reported in this paper, before the onset of their illness, did not have diets that were significantly different from that of the average village child. We believe, therefore, that the low serum albumin in these cases was due to a combination of defective absorption, increased exogenous loss, and reduced intake following the characteristic anorexia, rather than protein deficiency per se. There was also no evidence for any of the other known causes of malabsorption. All of these cases, therefore, had malabsorption of unknown etiology and must be grouped within the syndrome of tropical sprue. 47 Clinical features . The clinical picture of the disease in children is very similar to that observed in adults in South Inddia."' 7, 36, 47 The duration of symptoms ranged from 1 month to 5 years. The characteristic clinical symptoms were diarrhea, anorexia, abdominal distension, and loud borborygmi. This combination has given rise to its local vernacular name "Ubbu Mariyayee" meaning "visitation of the goddess of distension." It has been said that the presence of glossitis is essential for the diagnosis of sprue 3 However, many of the classical textbook features of tropical sprue such as glossitis, angular stomatitis, and anemia are the consequence of the deficiencies that occur as a result of the intestinal disease. Thus, the incidence and extent of these features will depend on the initial nutritional status, the dietary habits of the patient, and the severity and duration of the illness, and no one deficiency symptom can be considered as essential for the diagnosis. The incidence of nutritional deficiency in this group was much higher than in a control village population. 2i As an example, only 14% of the average vil-
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lage children have xerosis conjunctivae while in this group 90% had it. A small proportion of patients may develop severe dehydration, hyponatremia, hypokalemia, and acidosis. This is the most common cause of death early in the course of the disease in untreated patients. In some patients, these fluid and electrolyte disturbances may be associated with diminished level of consciousness or coma as was observed in 2 of the cases in this study. Anemia is a common complication and may result from lack of iron, folic acid, or vitamin Bi2 or various combinations of these. Fifteen children in this series had serum folate levels below 6 /-lg per ml and 4 had serum vitamin Bi2 levels below 100 /-lg per ml. Two children (cases 1 and 2) had high serum vitamin Bi2 levels, presumably associated with liver dysfunction, which returned to normal with improvement in their general condition. A similar elevation of serum Bi2 levels has been seen in some adults with severe tropical sprue. Vitamin Bi2 malabsorption occurred in two-thirds of these children (table 1). The absorption of vitamin Bi2 in tropical sprue is usually not improved by giving additional intrinsic factor. However, the pathological changes are not entirely confined to the small bowel and there is also a gastric lesion producing varying degrees of atrophic gastritis with defective acid 48 and intrinsic factor secretion. 49 Occasionally, the gastric lesion may persist after the intestinal defect has improved; under such circumstances the absorption is normal when tested with additional intrinsic factor. The presence of such a gastric lesion in this group of cases is shown by the low acid output, the changes on gastric biopsy, and the improvement of vitamin Bi 2 absorption in 2 of the cases when the test dose was given with added intrinsic factor. The radiological findings in the children are identical to those found in adults with tropical sprue. The pathogenesis of the changes is not fully understood and they
March 1969
TROPICAL SPRUE IN CHILDREN
are not diagnostic. 5u No correlation between the radiological changes and other findings could be demonstrated. The major role of radiology is to exclude anatomical lesions of the small bowel which could produce secondary malabsorption. I 7. 50 The jejunal mucosa from these children showed a spectrum of changes in villus architecture from biopsies that were scarcely distinguishable from those found in control subjects38 to the appearance of total villus atrophy in one case. No definite correlation between the degree of abnormality and the clinical severity of the individual cases was possible . On examination of an isolated intestinal biopsy it is impossible to confirm the diagnosis of tropical sprue, although the studies of Schenk et al. 5 1 suggest that fat stains may be helpful in this regard. One important contribution of jejunal biopsy is to exclude conditions like lymphoma of the small bowel, intestinal lymphangiectasia, and Whipples disease. It is also useful in follow-up of cases when therapy with a gluten-free diet is being carried out to exclude celiac disease.52 Therapy. The most suitable therapy for patients with tropical sprue is still debated. It is claimed that antibiotics 39 • 53. 54 or folic acid 39 . 55. 56 will cause a remission in many cases of tropical sprue. However, the results in this group of children do not give unequivocal support to this concept. Controlling diarrhea and making up deficiencies of fluids, electrolytes, and other nutrients is the essential first step in treatment. As shown by some of the cases described here and elsewhere," 8. 36 the disease tends to remit without specific th~rapy. Therefore it is not possible to know whether the improvement noted in the steatorrhea, the xylose, absorption, and biopsy findings in the children in this study treated with folic acid or antibiotics would have occurred without the administration of these agents. However in 4 out of 6 cases the defect of vitamin BI 2 absorption was cured within 1 week by antibiotics, suggesting that in these cases this absorptive defect may have
567
been associated with bacterial invasion of the ileum. Studies in a larger series of cases are necessary for fuller evaluation of therapy. Epidemic sprue. Analysis of the cases studied in the metabolic ward shows no detectable differences between endemic and epidemic forms of the disease. The clinical features in the children of village P who were not admitted were similar to those observed in the hospitalized children. However, it is possible that a comparative study of a bigger number of patients might reveal difference such as have been observed in the incidence of vitamin BI 2 malabsorption in different groups of adults. 47 The lower incidence in children as compared with adults has been an unexplained but constant feature in all epidemics of sprue studied in this area. 5 - 8 The sex incidence among the children in the village was equal. The predominance of males in the hospitalized group is presumably a reflection of the greater readiness to seek medical aid for male children. The large numbers of deaths (32%) among the children in the village, where medical help was seldom availed of, contrasts markedly with a zero mortality in the hospital cases. This emphasizes the value and importance of even simple therapeutic measures. The long term follow up of the survivors in the village highlights the tendency of the disease to undergo spontaneous remISSIOn or cure, even though the individuals continue to live in the same environment and to eat the same diet. • Etiology . The primary lesion in tropical sprue appears to be damage to the intestinal mucosa. The etiology of this damage in children, as in adults, is unknown and may well be multiple. 4 7 It has been suggested that hypoproteinemia may cause intestinal damage and malabsorption. However, the evidence for this is not conclusive and severe hypoproteinemia associated with the nephrotic syndrome does not usually result in intestinal damage. 57 Nevertheless, it is pos-
568
MATHAN ET AL.
sible that there may be an as yet unrecognized specific deficiency or that general malnutrition may make a child more likely to develop sprue. It has been suggested also that intestinal damage may be caused by a toxin,58. 59 but there is as yet no good evidence in support of this hypothesis. It has also been proposed that sprue may be the result of an infection36 , 60, 61 and a steatorrheic enteritis of short duration has been described in children with a reovirus infection. 62 The occurrence of the disease in epidemics, the fever at the onset, the raised erythrocyte sedimentation rate, and the marked cellular infiltration of the intestinal mucosa could result from an infection. Various studies5 - 8. 36. 63 to date have failed to reveal any consistent bacterial or viral pathogens. However, these studies did not utilize all currently available techniques for the isolation of pathogenic agents and much more work needs to be done in this area before any answers can be given. REFERENCES 1. Fairley, N. H. 1939. Sprue, tropical. British Encyclopaedia of Medical Practice 11: 419436. Butterworth, London. 2. Trowel, H. G., and D. B. Jelliffe. 1958. Diseases of children in the subtropics and tropics. Edward Arnold, London. 3. Manson-Bahr, P. H. 1965. Mamon's tropical diseases, Ed. 16, p . 464-477. Cassell, London. 4. Gour, K. N. 1964. Diarrhea in infancy and childhood. Asian Paediatrics, p . 82-87. Asian Publishing House, Bombay. 5. Baker, S. J., V. I. Mathan, and 1. Joseph. 1962. Epidemiology of tropical sprue. Malabsorption Symposium . Proceedings of the 2nd World Congress of Gastroenterology, Munich, p. 46. Karger, Basel and New York. 6. Mathan, V. 1. , M. Ignatius, and S. J. Baker. 1966. A household epidemic of tropical sprue. Gut 7: 490-496. 7. Baker, S. J., and V. I. Mathan. 1968. Tropical sprue in South India. Roy. Coli. Phys . Lond. In press. 8. Mathan, V. 1., and S. J . Baker. 1968. Acomparative study of epidemic tropical sprue and other epidemics of diarrhea in South Indian villages. Amer. J. Clin. Nutr. In press. 9. van de Kamer, J. H., H. ten B. Huinink, and
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H. A. Weyers. 1949. Rapid method for the determination of fat in the feces. J. Bioi. Chern. 177: 348-355. 10. Heinle, R. W., A. D. Welch, V. Scharf, G. C. Meacham, and W. H. Prusoff. 1952. Studies of excretion (and absorption) of C06 U labeled vitamin B12 in pernicious anemia . Tram. Assn. Amer. Phys. 65: 214-222. 11. Rajan, K. T., P. S. S. Rao, I. Ponnuswamy, and S. J. Baker. 1961. The oral glucose tolerance test in tropical malabsorption syndrome. Brit. Med. J . 1: 29-31. 12. Dacie, J. V. 1956. Practical haematology, Ed. 2. Churchill, London. 13. Hutner, S. H ., M .K. Bach and G. I. M. Ross. 1956. Sugar-containing basal medium for vitamin B12 assay with Euglena: application to body fluids. J. Protozool. 3: 101-112. 14. Baker, H., V. Herbert, O. Frank, I. Pasher, S. H. Hutner, L. F. Wasserman, and H. Sabotka. 1959. A microbiological method for detecting folic acid deficiency in man. Clin. Chern. 5: 275-280. 15. Waters, A. H., and D. L. Mollin, 1961. Studies on folic acid activity of human serum . J. Clin. Path. 14: 335-344. 16. Ramsay, W. N. M. 1957. The determination of iron in blood, plasma, or serum. Clin. Chim. Acta 2: 214-220. 17. Paterson, D. E., R. David, and S. J. Baker. 1965. Radio diagnostic problems in malabsorption. Brit.J. Radiol.38: 181-191. 18. Crosby, W. H., and H. Kugler. 1957. Intraluminal biopsy of the small intestine: the intra-' luminal biopsy capsule. Amer. J. Dig. Dis. 2: 236-241. 19. Wood, I. J ., K. R. Doig, R. Motteram, and A. Hughes. 1949. Gastric biospy: report of 55 biopsies using a new flexible gastric biopsy tube. Lancet 1: 18-21. 20. Kay, A. W. 1953, Effects of large doses of histamine on gastric excretion of HCl: an augmented histamine test. Brit. Med . J. 2: 77-80. 21. Rao, B. R. H., and P . S. S.Rao. 1958. General health and nutrition survey of the rural population in Pennathur. 1. The nutrition status survey. Ind. J . Med. Sci . 12: 705-717. 22. Rao, B. R. H. , and P. S. S. Rao. 1958. General health and nutrition survey of the rural population in Pennathur. II. A qualitative study on family meals. Ind. J. Med . Sci . 12: 718-725. 23. Rao, B. R. H., and P. S. S. Rao. 1958. General health and nutrition survey of the rural poplation in Pennathur. III. The quantitative dietary survey. Ind. J . Med. Sci . 12: 726-730. 24. Rao, B. R. H., P. S. S. Rao, and C. E. Klontz. General health and nutrition survey of the
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TROPICAL SPRUE IN CHILDREN
rural population in Pennathur. IV. Protein nutrition. Ind . J. Med. Sci. 13: 401-409. 25. Rao, B . R. H ., P . S. S. Rao, and C . E . Klontz. 1959. General helath and nutrition survey of of the rural population in Pennathur. V. Vitamin nutrition. Ind . J. Med . Sci. 13: 410-419. 26. Rao, B. R. H ., P . S .S. Rao, and S. J . Baker. 1959. General health and nutrition survey of the rural population in Pennathur. VI. Iron intake and iron deficiency anaemia. Ind . J. Med. Sci. 13: 584-592. 27. Rao, B. R . H., P . S . S. Rao, and C. E . Klontz. 1960. General health and nutrition survey of the rural population in Pennathur. VII. The health status survey. Ind. J. Med. Sci. 14: 175-182. 28. Porter, M . G., and J . D . Welsh. 1966. Review: current concepts of the malabsorption syndrome in children. J. Okla . Med . Assn. 59: 154- 163. 29. Anderson, C. M. 1966. Intestinal malabsorption in childhood. Arch. Dis. Child. 41: 571-596. 30. Gerrard, J. W., and M. C. Luboz. 1967. The malabsorption syndromes. Ped . Clin. N. Amer. 14: 73-91. 31. Visakorpi, J . K. , P . Immonen, and P. Kuitunen. 1967. Malabsorption syndrome in childhood. Acta Paed. Scand . 56: 1-9. 32. Sheehy, T . W. , and M. H . F. Floch. 1964. The small intestine, its function and diseases, p. 252. Harper and Row, New York. 33. Bahr, P. H. 1915. A report on researches on sprue in Ceylon 1912-1914, p. 122. University Press, Cambridge. 34. Johnson, J., and P . T. Breidigan, 1925. Tropical sprue in a child 6 years of age. Amer. J. Med . Sci . 170: 364-371. 35. Miller, R. 1934. A case of sprue commencing at the age of eleven and a half years. Trans. Roy. Soc. Trop . Med. Hyg. 28: 413-417. 36. Baker, S . J. 1957. Idiopathic tropical malabsorption. Ind . J. Med. Sci . 11: 687-703. 37. Mathew, K., M . Ignatius, Meenakshiammal, and S. J . Baker. 1964. Tropical sprue in children. Ind. Ped . 1: 271-275. 38. Baker, S . J., M . Ignatius, V. I. Mathan, S. K. Vaish, and C. C. Chacko. 1962. Intestinal biopsy in tropical sprue, p. 84-101. In G . E. W. Wolstenholme and M. P. Cameron [eds.}, Intestinal biopsy, Ciba Foundation Study Group No. 14. Churchill, London. 39. Klipstein, F. A. 1964. Tropical sprue in New York. Gastroenterology 47: 457-470. 40. Walia, B . N. S ., J . K. Sidhu, B. N . Tandon, O. P. Ghai, and S . Bhargava. 1966. Coeliac disease in North India. Brit. Med. J. 2: 12331234.
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41. Brusner, 0., A. Reid, F. Minekeberg, A. Maccioni, and I. Centrerao. 1966. Jejunal biopsies in infant malnutrition: with special reference to mitotic index. Pediatrics 38: 605-612. 42. Mayoral, L. G., K. Tripathy, F. T. Garcia, S. Klahr, O. Bolanos, and J. Ghitis. 1967. Malabsorption in the tropics-a second look. 1. The role of protein malnutrition. Amer. J . Clin. Nutr. 20: 866-883 . 43. Rubini, M. E., T . W . Sheehy, W. H. Meroney, and J. Louro. 1961. Exudative enteropathy. II. Observations in tropical sprue. J. Lab. Clin. Med . 58: 902-907. 44. Vaish, S . K., M . Ignatius, and S. J . Baker. 1965. Albumin metabolism in tropical sprue. Quart. J . Med . 34: 15-32. 45. Perez Santiago, E., and C. E. Butterworth, Jr. 1957. Definition and diagnosis of sprue. Amer. J. Dig. Dis. 2: 225- 235. 46. Klipstein, F . A., I. M. Samloff, and E. A. Schenk. 1966. Tropical sprue in Haiti. Ann. Intern. Med . 64: 575-594. 47. Baker, S. J., and V. L Mathan. 1968. The syndrom of tropical sprue in South India. Amer. J. Clin. Nutr. In press. 48. Vaish, S. K., J. Sampath Kumar, R. Jacob, and S. J. Baker. 1965. Stomach in tropical sprue. Gut 6: 458-465. 49. Baker, S. J., and B. Richards. 1966. Experience in the assay of intrinsic factor in tropical sprue. J. Assn. Phys. Ind. 14: 100. 50. Paterson, D. E., and S. J . Baker. 1958. The radiological investigation of the small intestine in tropical idiopathic malabsorption. J. Fac. Radiol. 9: 183-194. 51. Schenk, E. A., I. M. Samloff, and F. A. Klipstein. 1965. Morphologic characteristics of jejunal biopsy in celiac disease and tropical sprue. Amer. J. Path . 47: 765-781. 52. Rubin, C. E., and W . O. Dobbins. 1965. Peroral biopsy of the small intestine. Gastroenterology 49: 676-697. 53. French, J . M. , R. Gaddie, and N. M . Smith. 1956. Tropical sprue: a study of 7 cases and their response to combined chemotherapy. Quart. J .Med. 25: 333-351. 54. Guerra, R., M . S. Wheby, and T. M. Bayless. 1965. Long term antibiotic therapy in tropical sprue. Ann. Intern. Med . 63: 619-634. 55. Suarez, R. M ., T . D . Spies, and R. M. Suarez, Jr. 1947. Use of folic acid in sprue . Ann. Intern. Med . 26: 643- 677. 56. Sheehy, T. W. , B. Baggs, E. Perez-Santiago, and M . H. Floch. 1962. Prognosis of tropical sprue: a study of the effect of folic acid on the intestinal aspects of acute and chronic sprue. Ann. Intern. Med . 57: 892-908.
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57. Jensen, H., S. Jarum, and J. P. Hart-Hansen. 1966. Gastrointestinal protein loss and intestinal function in the nephrotic syndrome. Nephron 3: 209- 220. 58. Ayrey, F. 1968. Outbreaks of sprue during the Burma Campaign. Trans . Roy. Soc. Trop. Med . Hyg. 41: 377- 406. 59. French, J . M. 1955. Aetiology and mechanism of steatorrhoea. Postgrad . Med . J. 31: 299-309. 60. Ashford, B. K. 1931. The relation of Monilia psilosis to tropical sprue and an evaluation of fermentation of sugar as a criterion for speci-
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ficity. Porto Rico J . Pub. H. Trop. Med. 6: 310-333. 61. Manson-Bahr, P. 1953. The causation of tropical sprue. Lancet 2: 389-391. 62. Sabin, A. N. 1956. The significance of viruses recovered from the intestinal tract of healthy infants and children. Ann. N. Y. Acad . Sci. 66: 226-230. 63. Bayless, T. M., A. Guardiola-Rotger, and M. S. Wheby. 1966. Tropical sprue: viral cultures of rectal swabs. Gastroenterology 51 : 32-35.