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Tropical sprue

Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

Synonyms: postinfective tropical malabsorption, idiopathic tropical malabsorption syndrome

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What is tropical sprue?

Tropical sprue is a malabsorptive disease of the small bowel, characterised by inflammation and villous flattening in the small intestine.

The symptoms and pathological appearance are similar to those of coeliac disease, but this is not an autoimmune condition and is considered most likely to be an infective one. The causative agent is, however, unclear, although it is probably bacterial.

Tropical sprue is seen in residents of, and visitors to, tropical areas and it tends to begin with an acute episode of diarrhoea, fever and malaise before settling into a more chronic presentation of steatorrhea, malabsorption, nutritional deficiency, anorexia, malaise and weight loss.

Folate deficiency is a significant part of the clinical picture. Tropical sprue was epidemic during World War II and caused one sixth of all Allied casualties in India and Southeast Asia.1

It is distinct from tropical enteropathy, an asymptomatic condition, defined by mild histological changes in the intestinal mucosa, which co-exists in endemic areas and is probably an adaptation to environmental factors.

How common is tropical sprue? (Epidemiology)

  • Tropical sprue usually occurs in residents of tropical or subtropical climates (less commonly, visitors), most often in developing countries.

  • The condition may not present until after they have left the area. The lag can be up to 10 years.

  • The incidence varies with geography.

  • It occurs mostly in Southeast Asia and the Caribbean but not in Jamaica.1

  • It remains the most common cause of malabsorption in India.2

  • There is no predilection for race or gender.

  • It tends to affect adults but can also occur in children.

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  • The aetiology is presumed to be infective but the exact cause remains elusive.

  • The exact nature of the infection, whether initiated or perpetuated by enterotoxic coliform bacteria, viruses or a combination of pathogens, is not clear.

  • Most commonly the condition only affects the upper small intestine although, more rarely, the stomach or colon can be involved.

Tropical sprue symptoms (presentation)

Tropical sprue ranges in severity from subclinical structural or functional deficiencies of the gastrointestinal mucosa to a full picture of malabsorption with diarrhoea, malnutrition and loss of weight. This variable clinical picture can be incomplete and typically consists of chronic diarrhoea, weight loss and vitamin deficiencies.1 However it may include:

  • Diarrhoea (acute or chronic).

  • Weight loss.

  • Malabsorption - deficiency of the following may occur:

    • Iron, folate and vitamin B12 - are the most common, and there may be signs such as, pallor or glossitis.

    • Vitamin A - with hyperkeratosis and skin scaliness.

    • Vitamin D and calcium - may cause abdominal pain, bone pain, weakness, tingling.

    • Vitamin K - risk of prolonged INR and haemorrhage.

  • Steatorrhoea.

  • Abdominal pain - may be mild and does not usually dominate the clinical picture.

  • Ankle oedema (hypoalbuminaemia).

  • Fatigue.

  • Fever.

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  • FBC - macrocytic anaemia with low folate and vitamin B12 levels in 60%.

  • Serum potassium, iron and albumin - all may be low due to malabsorption and diarrhoea.

  • Volume depletion is common - urea may be raised.

  • Vitamin D.

  • Calcium and phosphate may be abnormal, especially with low albumin.

  • Malabsorption of D-xylose - a dose of 25 g xylose is given by mouth and normal results are that urine contains at least 20 mg per 100 ml at one hour and a total of 4g excreted in five hours. (Normal renal function is needed.) Lower results suggest malabsorption.

  • Faecal fat measures - patients are fed a diet with high fat over 72 hours (80 to 100 g per day). A faecal fat exceeding 6 g a day is abnormal but steatorrhoea usually requires at least 15 g a day.

  • Check stool - for cysts, ova and parasites.

  • Consider bone densitometry - in appropriate patients.

  • Jejunal biopsy - this shows incomplete villous atrophy (as opposed to coeliac disease where there is complete villous atrophy).1

Differential diagnosis


  • If vitamin B12 levels are very low, B12 replacement must start prior to folate replacement, as otherwise the demands of the haemopoietic system may precipitate subacute combined degeneration of the cord.

  • Potassium supplements may also be needed as rapid utilisation occurs when haemopoiesis starts. Failure to supplement may account for the occasional sudden death seen at the start of treatment for severe B12 deficiency.

  • In children, delay in skeletal maturity, rickets, growth failure.

Tropical sprue treatment and management5

  • Fluid volume replacement (electrolytes and water).

  • Antibiotics - tetracycline is most often used and prolonged periods of treatment are necessary - eg, 6-12 months.6

  • Patients in southern India respond poorly to antibiotics.

  • Tetracycline is not used in children whose permanent teeth have not yet come through, and another broad-spectrum antibiotic is substituted.

  • In the USA, co-trimoxaxole is recommended although this drug is less commonly used in the UK.

  • Nutritional supplements - for example:

    • Folic acid - may need to be given parenterally at first if absorption is poor (but if very B12 deficient this must be replenished FIRST).

    • Vitamin B12 injections.

    • Oral iron may also be required, but iron and tetracycline should not be taken close to each other, as the tetracycline chelates the iron and neither is absorbed.

Monitoring treatment

Treatment is monitored by

  • Symptom improvement - eg, disappearance of anorexia with adequate B12 and folate replacement.

  • Weight gain.

  • Improvement of FBC and biochemical parameters.


  • Untreated, the disease runs a chronic, relapsing course.

  • Treatment is associated with a good prognosis.

Tropical sprue prevention

There is no established way to prevent the disease whilst visiting areas of risk. It seems sensible to observe safe practices regarding drinking water, peeling fruit and avoiding raw unpeeled vegetables, and this may minimise exposure to the causative agent.

Dr Mary Lowth is an author or the original author of this leaflet.

Further reading and references

  1. Ramakrishna BS, Venkataraman S, Mukhopadhya A; Tropical malabsorption. Postgrad Med J. 2006 Dec;82(974):779-87.
  2. Dutta AK, Balekuduru A, Chacko A; Spectrum of malabsorption in India--tropical sprue is still the leader. J Assoc Physicians India. 2011 Jul;59:420-2.
  3. Bhatnagar S, Gupta SD, Mathur M, et al; Celiac disease with mild to moderate histologic changes is a common cause of chronic diarrhea in Indian children. J Pediatr Gastroenterol Nutr. 2005 Aug;41(2):204-9.
  4. Baqai MT; Duodenal tuberculosis: delays and difficulties in diagnosis. J R Coll Physicians Edinb 2005; 35:330-331
  5. Ghoshal UC, Srivastava D, Verma A, et al; Tropical sprue in 2014: the new face of an old disease. Curr Gastroenterol Rep. 2014;16(6):391. doi: 10.1007/s11894-014-0391-3.
  6. Westergaard H; Tropical Sprue. Curr Treat Options Gastroenterol. 2004 Feb;7(1):7-11.

Article history

The information on this page is written and peer reviewed by qualified clinicians.

  • Next review due: 19 Aug 2028
  • 21 Aug 2023 | Latest version

    Last updated by

    Dr Colin Tidy, MRCGP

    Peer reviewed by

    Dr Pippa Vincent, MRCGP
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