|Penicillin G||2 million units intravenous every 4 hours for 14 days|
|Ceftriaxone||2 g intravenous daily for 14 days|
|Meropenem (if penicillin allergy)||1 g intravenous three times daily for 14 days|
|Trimethoprim–sulfamethoxazole (TMP–SMX)||160/800 mg twice daily for 12 months|
|Doxycycline (if sulfa allergy), plus Hydroxychloroquine||100 mg once daily oral, plus 200 mg three times daily for 12 months|
Tropical sprue (TS) is an acquired malabsorptive and likely infectious disease of unknown etiology that affects locals and travelers who reside in the tropics. Residence in the tropics for longer than a month with chronic diarrhea and nutritional deficiencies are the usual symptomatic hallmarks. Endemic areas include south Asia, Caribbean, Central America, and northern South America while sparing Africa and the Middle East. Most often it is a disease of local inhabitants; however, long-term visitors are also at risk. TS, initially described as a disease of low socioeconomic population, can also affect those with access to medical care, adequate hygiene, and nutritional diet. In North America and Europe, TS should be suspected in the long-term traveler after exclusion of common causes of chronic diarrhea and malabsorption.
Several theories for infectious mechanisms exist, but a specific organism has not been implicated. Patients with TS frequently report a preceding acute infectious diarrheal illness. This finding, in addition to a possible mechanism of small bowel injury explained by an overgrowth of aerobic coliform bacteria with resolution of symptoms after antibiotics, justifies an alternative nomenclature of TS: post-infective tropical malabsorption.
Patients suffer from chronic diarrhea related to malabsorption of fatty acids and carbohydrates, as well as bile salt-induced diarrhea from terminal ileal (TI) involvement. Loss of brush border enzymes (e.g. lactase), impaired fat absorption leading to steatorrhea, and nutrient deficiencies of primarily folate, vitamin D, and, as the disease progresses, B12 are commonly seen in TS. Macrocytic anemia from nutrient deficiency is commonly seen. Steatorrhea also leads to loss of fat-soluble vitamin absorption with subsequent vitamin deficiency clinical sequelae.