A 35-year-old man who recently returned from rural Philippines has 4 months of diarrhoea, steatorrhoea and megaloblastic anaemia. Duodenal biopsy shows partial villous atrophy with chronic inflammatory infiltrate. Anti-tTG antibodies are negative and symptoms did not improve on a gluten-free diet trial. What is the standard treatment?

• A Prednisolone taper over 8 weeks
• B Lifelong gluten-free diet
• C Albendazole single course
• D Tetracycline with folic acid for 3 to 6 months ✓

Explanation

Tropical sprue occurs in residents or visitors to endemic tropical areas and combines malabsorption with folate deficiency causing megaloblastic anaemia. Treatment is tetracycline (or doxycycline) plus folic acid for 3 to 6 months, with relapse possible after shorter courses. Negative anti-tTG and failure of gluten withdrawal exclude coeliac disease, and albendazole would treat giardiasis rather than sprue, killing both distractors.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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