Title: Is "Megaloblastic Anemia", "Infectious"? What is tropical Sprue?

Abstract:

A 30 years old woman with resistant megaloblastic anemia, was referred to us for further diagnosis and investigation. According to peripheral blood smear, megaloblastic anemia had been diagnosed definitely with hypersegmented neutrophils and blood biochemistry revealed the severe serum Vitamin B12 deficiency and RBC, MCV was 115. The patient was pale and felt fatigue permanently and exact medical history showed that the patient's diet was desirable and she consumed all kinds of proteins and vitamins with sufficient meat, egg and vegetables intake .

It was the first sign of thinking about it is unusual case. In physical examination, we found muscle, bone tenderness and patient mentioned about her bone pain specially during night. Serum vitamin D level was very low and insufficient. We found osteoporosis based on bone densitometry and this  was second sign convinced us that this case is bizarre, "a 30 years old woman with osteoporosis ."

We returned to medical history again and found the gastrointestinal manifestation, that at first seemed irrelevant with megaloblastic anemia or osteoporosis, but it was a clue to consider GI tract as anatomical localization. The patient had diarrhea within 10 years with remission and relapse.

Along with intermittent abdominal cramp, we rapidly requested D-Gsylose test and it revealed malabsorption definitely. The patient had weight loss about 10kg during 5 years and after weight loss, she was 50 kg. thyroid, renal and hepatic tests was normal. We found steatodiarrehea in stool exam, so malabsorption was clear for us. We ruled out chronic pancreatitis and celiac disease with normal serum level of lipase, amylase, anti gliadin antibody and anti endomysial antibody. In addition, we found vitamin K deficiency with multiple bruises on her skin and body. Hence, we convinced to study intestine due to invasive procedures, so that, we ordered enteroscopy with biopsy. Biopsy reports consists of presence of inflammatory cells with lymphocyte predominance. With diagnosis of intestinal inflammation, with severe malabsorption and rule out of other diseases or conditions, our diagnosis was tropical sprue, that is probably infectious and with adequate antibiotic therapy, all GI manifestations was removed and patient felt completely well. With vitamin replacement therapy, the blood smear was revealed normal pattern. So, after treatment with antibiotics and biopsy report, we convinced that the diagnosis was tropical sprue .

We dedicate biopsy report and histological pattern and antibiotic therapy regimen in detail at oral presentation time .

Thanks and regards .

Mojtaba Mafi, MD, Study director.

Fateme Rezvani, bioinformatics, study manager.

Biography:

Dr. Mojtaba Mafi M.D., Medical Doctor/ Physician, graduated from Tehran university, School of Medicine with honor. I studied in neurosurgery ward and graduated with A score with thesis on Meningioma Brain Tumor during 6 years. With continuing my practice with special consideration on psychosomatic disorders, I completed many post graduate courses on health psychology, addiction medicine, sexual disorders therapy successfully. I passed many post graduate courses in Neuro, approved by Medical sciences university. As well, I have been passed post graduate courses on Nutrition, Gastroenterology and hepatology, Obesity treatment and diabetes approved by Tehran University of Medical sciences. I successfully passed more than 10 programs with certificates and membership in Iranian Association of Gastroenterology and Hepatology.