DDSEP® 8 Quick Quiz

DDSEP® 9 Quick Quiz Question 2

Publish date: February 28, 2020

An 18-year-old woman presents for evaluation of chronic diarrhea, fatigue, and abdominal cramping. She was recently in Puerto Rico for 6 months visiting family and returned a few weeks ago. Her labs are significant for a hemoglobin of 11 g/L with an MCV of 109 fL. Her albumin is 3.6 g/dL. She had stool studies which ruled out infection, including parasites. TtG IgA and total IgA were within normal limits. EGD with multiple duodenal biopsies showed villous blunting with increased intraepithelial lymphocytes.

What is the preferred treatment for this patient?

Gluten-free diet

Ceftriaxone IV followed by Bactrim PO

Low FODMAP diet

Tetracycline and folic acid

Rifaxmin

Q2. Correct answer: D


Rationale

This patient has tropical sprue based on her travel to an endemic country, negative celiac serologies, labs revealing a macrocytic anemia and low albumin and characteristic histology (villous blunting, increased intraepithelial lymphocytes). Treatment is with tetracycline and folate. Diagnosis of tropical sprue is ultimately confirmed by a response to treatment. A gluten-free diet is not appropriate, as the patient does not have celiac disease, confirmed by normal celiac serologies. Ceftriaxone IV followed by Bactrim PO is the correct treatment for Whipple's disease. A diet low in fermentable oligo-, di-, and monosaccharides and polyols (FODMAPs) is beneficial treatment in some patients with IBS with abdominal bloating or pain. Rifaximin is the correct treatment for small intestine bacterial overgrowth or IBS-D.


References

1. Brown IS, Bettington A, Bettington M, Rosty C. Tropical sprue: revisiting an underrecognized disease. Am J Surg Pathol. 2014;38:666.
2. Shah VH, Rotterdam H, Kotler DP, et al. All that scallops is not celiac disease. Gastrointest Endosc. 2000;51:717.

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