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Chapter 16

Tropical Sprue; Kwashiorkor

Sprue, both tropical and nontropical, has been a subject of great interest to the medical community ever since it was initially described over 200 years ago. It is of interest despite the fact that it is unknown in many parts of the world and, even where endemic (primarily India, Southeast Asia and the Caribbean), it affects relatively few of the population compared with the millions who suffer from parasitic and other tropical diseases. It has undoubtedly held a continuing fascination for physicians because of the challenge of its etiology, which is still unsolved despite decades of laboratory research and clinical investigations. In the process, it has become an extremely significant disease because it is a classical example of a malabsorptive process, and has shed considerable light on intestinal physiology and on other malabsorption syndromes.

The name "sprue" is derived from the Dutch word "sprouw" which means stomatitis. The disease was first described by William Hillary in 1759 from the island of Barbados in the West Indies. It had been known for some time, following the discovery of new lands in the 15th and 16th centuries and their subsequent colonization, that some of the Europeans who came to live on these tropical islands of the Americas were afflicted with a new disease. This disease, subsequently known as tropical sprue, was soon recognized in established European communities in India, Ceylon and the Dutch East Indies as well. In addition to expatriates residing in endemic areas for more than 1 year, the disease has affected many British and American troops and their families while previously on duty in India, Burma and the Far East.

It is now known that the condition occurs primarily in the tropics in those areas with a high rainfall, and that it affects the indigenous populations as well as Caucasians, Chinese and other immigrants. It is rare throughout Africa, although there are cases reported from Nigeria, Central and South Africa, Uganda and the Sudan. For more than a century, tropical sprue has been recognized as affecting people living in certain villages and houses (sprue houses). It is seen in adults of both sexes much more often than in children, and may affect both civilian and military populations. It has become a disease of some importance in tropical warfare, as it can affect soldiers suffering from other intestinal disorders who must subsist for long periods on rations deficient in folic acid. It may follow as a sequel to epidemics of acute gastroenteritis.


Tropical malabsorption. Postinfective malabsorption. Tropical enteropathy. Tropical diarrhea. Military diarrhea. Cachectic diarrhea. Hill diarrhea. Ceylon sore mouth. White flux. Diarrhea alba. Cochin China diarrhea. Psilosis. Aphthae tropical. Sp: Esprue tropical. Fr:Sprue (stéatorrhée) tropique. Ger: Tropische Sprue.


Tropical sprue is a primary malabsorption syndrome that runs a chronic relapsing course. It is characterized by a sore tongue, flatulent indigestion, diarrhea with steatorrhea, progressive weight loss and cachexia. It is associated with a macrocytic anemia and megaloblastic bone marrow, and with histological and radiological changes in the small bowel. Its etiology remains unknown. Klipstein in 1971 described the disorder thusly (modified by Cook, 1984): "A chronic disorder acquired in endemic tropical areas that is characterized by abnormalities of small bowel structure and function that become progressively more severe, eventually leading to the development of nutritional deficiencies, and are either ameliorated or cured by treatment with folic acid and/or tetracycline".

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