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JF Webb. the Aetiology of Tropical Sprue As Seen in Hong Kong And

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JF Webb. the Aetiology of Tropical Sprue As Seen in Hong Kong And J R Army Med Corps: first published as 10.1136/jramc-118-03-02 on 1 January 1972. Downloaded from 119 THE AETIOLOGY OF TROPICAL SPRUE AS SEEN IN HONG KONG AND ITS RELATION TO COELIAC DISEASE Colonel J. F. WEBB, M.C., M.D., M.R.C.P.(Ed.), Late R.A.M.C. Cambridge Military Hospital, Aldershot SUMMARY: Over a period of twenty years the writer has been concerned in the study of tropical sprue and to a lesser extent, adult coeliac disease. The aetiology of coeliac disease is known, and Professor Booth in his Oliver-Sharpey lecture has suggested a hypothesis for the pathogenesis of gluten in that disease. Evidence is here presented that the production of oxidative rancidity in unsaturated cooking fats, exposed to the heat of a tropical humid atmosphere is aetiologically significant in tropical sprue as seeR in Hong Kong. It is believed that the toxic products of the rancid fat exert the same effect as gluteu does in coeliac disease. This paper discusses some possible aetiological factors in tropical sprue as seen in Hong Kong emphasising the ingestion of rancid fats as the main one. It indicates a Protected by copyright. close relationship between that disease and coeliac disease, suggesting that the main differences are:- The specific noxious factor causing the small intestinal cell damage, and In the case of coeliac disease, the relatively longer period of exposure to the noxious substance. It is based on the writer's experience of tropical sprue when he served in Hong Kong from 1950 to 1954, and 1958 to 1961 (Webb 1956, and Webb and Simpson 1966). In the intervening years he has had the opportunity of studying coeliac disease both in England and Germany (Webb and Reploh 1969). Since Dicke's (1950) classical observations in Holland it has been confirmed that coeliac disease, occurring in children http://militaryhealth.bmj.com/ and adults, is produced by gluten, which is found in wheat and rye flour, causing damage to the absorbing cell of the small intestine in certain individuals. Precisely why a normal dietary constituent should affect selected persons is not understood. A process by which this damage is effected has been suggested by Booth (1970) in his Oliver-Sharpey Lecture and it is this lecture which stimulated the author to put his thoughts on the aetiology of tropical sprue to paper, and in so doing indicate the relationship stated above. The similarity of the clinical features occurring in tropical sprue and coeliac disease which together form the majority of the causes of malabsorption is shown in Table I. Table I on October 2, 2021 by guest. Clinical features common to both coeliac disease and tropical sprue Feature Feature Diarrhoea Malnutrition Weight loss Megaloblastic anaemia Anorexia Low serum folate(B12 levels Lassitude Abnormal small intestine barium studies Glossitis Abnormality of the small intestine mucosa in the form of villous atrophy Steatorrhea (not so severe in sprue) J R Army Med Corps: first published as 10.1136/jramc-118-03-02 on 1 January 1972. Downloaded from J. }<~ Webb 120 The abnormality of the mucosa of the jejunum can be seen in biopsy specimens obtained by means of the Crosby capsule (Crosby and Kugler 1957). These specimens show in varying degree atro phy of the villi and abn ormalities of th e absorbing cells on the surface of the vilJi. T hese abnormalities are re versible by removal of the noxious substance from the diet, for example, gluten in the case of coeliac disease, and in th e case of tropical sprue recovery can be brought about by ad mission of the patient to hospital and treatment with foli c acid parenterally, or by mouth. 1n the author's experience of treating patients with tropical sprue, the response to treatment was accelerated when folic acid was accompanied by an antibiotic regime, but antibiotics when used alone \vere of no value and in some cases exacerbat ed the illness. Figure, I and 2 show a pati ent with tropical sprue before and after trealment and Protected by copyright. http://militaryhealth.bmj.com/ Figs. 1 and 2. A patient with tropical sprue before and after treatment. f igures 3 and 4 show the improvement in the severe glossitis in the same pat ient. This on October 2, 2021 by guest. patient demonstra ted the cl assical clinical features of tropical sprue and mega loblastic anaemia. He recovered on treatment within a few weeks and was fit for normal duty. Small intest ine biopsy techniques were not avai lable at the time this patient was studied. Figure 5 shmvs a patient who su.ffered fro m coeliac di sease diagnosed at the age of 17. She also demonstrated clinical fea tures similar to those of the patient described above \vith , in add itio n, marked bony derormities related to the osteodystrophy which presumablYr)esultcd fro111 lhe longer duration of her illness. J R Army Med Corps: first published as 10.1136/jramc-118-03-02 on 1 January 1972. Downloaded from 12 1 The Aetiology of Tropical Sprue as Seen in Hong Kong and ifS Re/ation fa Coeliac D isease Protected by copyright. http://militaryhealth.bmj.com/ on October 2, 2021 by guest. Fig. 5. A patient aged 17 years, suffer ing rrom Fig. 6. The same patient onc year after treatment. adult coeliac disease. Note the small !)taturc and She had improved in he ight and weight and breast limb deformity. development is clearly seen. J R Army Med Corps: first published as 10.1136/jramc-118-03-02 on 1 January 1972. Downloaded from J. F. Webb 122 Figure 6 shows the same patient after trealment wi lh a gluten free diet and sup­ portive therapy, which in this case extended over onc yea r. She had increased in height, gained weight, her periods had commenced and the development of secondary sex ual characteri stics ca n be seen in the photograph. Figures 7, 8 and 9 show the microscopic appearance of biopsy specimens taken during the course of treatment over onc year and demo nstrate reversion of the small intestine villi from "a ., flat" mucosa to near normal , over th e period of treatment. Figures 10 and I I show the macrosco pi c apl,earance of Ihe biopsy specimens al Ihe beginning and at the end of t.reatment. A sim il ar recovery of lhe small intestine vi ll i has been described in patients \vith tropical sprue in Hong Ko ng (Webb and Simpson 1966) and in patients seen in M al aya and Singapore, the same pattern has been described and beaulifully illust rated by England and O'Brien ( 1966). As noted above the author had a unique opportuni ty of stud ying the possible aetiological factors in tropical sprue as it occurred in Hong Kong, and the si milarity in the pat hogensis of coeliac disease and tropical spru e is the main subj ect of this paper. During 1950 to 195 1 an outbreak of acute tropica l spru e wh ich ass umed epidemic proportions occurred amongst Briti sh troops in H ong Kong (Rosenthal 1952 and Protected by copyright. Webb 1956) and since then tbe disease has been prese nt in the endemic fo rm described by Webb and Simpson (1966) . http://militaryhealth.bmj.com/ on October 2, 2021 by guest. Fig. 7. Thc prc·treatment microscopic appearance of the jejunum of the patient in Fig. 5. The flat cells on the surface of the villi with marked cellular infiltration can be seen. Fig . 8. The jejunal biopsy on the patient in Fig. 5 six mOlllhs after treatment showing the development of the villi . J R Army Med Corps: first published as 10.1136/jramc-118-03-02 on 1 January 1972. Downloaded from 123 The Aetiology of Tropical Spru.e as Seen in Hong Kong and its Relation to Coeliac Disease Fig. 9. The normal appearance of the villi in the jejunal biopsy of the patient in Fig. 5 onc year after treatment. Protected by copyright. http://militaryhealth.bmj.com/ on October 2, 2021 by guest. F ig. 10. The macroscopic appearance of the biopsy in Fig. 7 demonstrat ing the flat mucosal appearance. Fig. 11. The macroscopic appearance onc year after treatment demonstrating the growth of the villi. J R Army Med Corps: first published as 10.1136/jramc-118-03-02 on 1 January 1972. Downloaded from J. F. Webb 124 Hong Kong is a more or less enclosed community consisting of fairly clearly separated groups of people namely, Chinese residents forming the bulk of the population, European civilians, and members of the Armed Forces. The latter were the smallest group numbering about 16,000 with, in addition, a brigade of Gurkha troops, during each of the years 1951, 1952 and 1953. The Royal Air Force and Naval contingents were small compared to the Army and the majority of the patients seen were British soldiers. These soldiers rarely left the colony during their three-year tour and thus formed an excellent group for study. The civilian Chinese and European residents did not suffer from sprue, or at least it would appear so since enquiry indicated none were seen in the civilian hospitals or by civilian practitioners. Although these two latter groups experienced different conditions of living in regard to housing conditions and availability of refrigera­ tion facilities, they represented a reasonable control group with regard to climatic conditions, environment, and exposure to infectious diseases. Long residence and acdimatisation cannot be regarded as mitigating their value in this respect since these factors were considered to be of aeti·ological significance in the past by such authorities as Manson (1880) and Fairley (1936).
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