Published: 2017-08-26

Tropical sprue in megaloblastic anemia

Yoganathan Chidambaram, Anith Kumar Mambatta, Sujith K. Sivaraj


Background: The causes of megaloblastic anemia may vary in different geographical regions. The aim of the present study is to evaluate the utilization of bone marrow examination and upper gastrointestinal endoscopy (UGIE) in megaloblastic anemia.

Methods: This was a cross-sectional descriptive study done on 50 patients (age ≥15years) of macrocytic anemia after applying inclusion and exclusion criteria. A bone marrow aspiration with biopsy and an UGIE with duodenal biopsy were performed in consented patients with evidence of megaloblastic anemia in the peripheral smear or Vitamin B12 deficiency or folate deficiency or both.

Results: Out of 50 cases, 38 patients had pure Vitamin B12 deficiency, 2 patients had pure folate deficiency and 5 patients had combined deficiency. Among 43 patients with vitamin B12 deficiency, only four (9.3%) were vegetarians and remaining 39 (90.7%) were having non-vegetarian diet. Bone marrow study was done in 29 patients (out of 50) and all of them were found to have megaloblastic erythropoiesis in the bone marrow. Thirty three out of 50 consented for UGIE and duodenal biopsy. Out of 33, 17 patients (51.5%) had features of tropical sprue in biopsy.

Conclusions: We found a high prevalence of tropical sprue in megaloblastic anemia due to Vitamin B12 and/or folate deficiency. We recommend that UGIE with deep duodenal biopsy should be considered in all patients with megaloblastic anemia to rule out tropical sprue in India.


Bone marrow study, Duodenal biopsy, Megaloblastic anemia, Tropical sprue, Upper gastrointestinal endoscopy

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Hoffbrand V, Provan D. ABC of clinical haematology. Macrocytic anaemias. BMJ. 1997;314:430-3.

Antony AC. Prevalence of cobalamin (vitamin B-12) and folate deficiency in India-audi alteram partem. Am J Clin Nutr. 2001;74:157-9.

Khanduri U, Sharma A, Joshi A. Occult cobalamin and folate deficiency in Indians. Natl Med J India. 2005;18:182-3.

Khanduri U, Sharma A. Megaloblastic anameia: prevalence and causative factors. Natl Med J India. 2007;20:172-5.

Sarode R, Garewal G, Marwaha N, Marwaha RK, Varma S, Ghosh K, et al. Pancytopenia in nutritional megaloblastic anaemia: a study from north-west India. Trop Geogr Med. 1989;41:331-6.

Haq S, Iqbal N, Fayyaz F, Tasneem A. Serum B12 and folate levels in patients with megaloblastic change in the bone marrow. Biomedica. 2012;28:35-9.

Unnikrishnan V, Dutta TK, Badhe BA, Bobby Z, Panigrahi AK. Clinico-aetiologic profile of macrocytic anemias with special reference to megaloblastic anemia. Indian J Hematol Blood Transfus. 2008;24:155-65.

Iqbal SP, Kakepoto GN, Iqbal SP. Vitamin B12 deficiency- a major cause of megaloblastic anaemia in patients attending a tertiary care hospital. J Ayub Med Coll Abbottabad. 2009;21:92-4.

Liggy A, Thomas T, Nambudiri H. Vitamin B12 status in a tertiary care center in central Gujarat. National J Community Med. 2012;3:414-6.

Kankonkar SR, Joshi SV, Tijoriwala SJ, Prabhu RV, Raikar SC, Kankonkar RC, et al. A study of Vitamin B12 deficiency in different diseases. Available at _110.htm.

Kumar R, Kalra SP, Kumar H, Anand AC, Madan N. Pancytopenia--a six-year study. J Assoc Physicians India. 2001;49:1078-81.

Jeejeebhoy KN, Desai HG, Borkar AV, Deshpande V, Pathare SM. Tropical malabsorption syndrome in West India. Am J Clin Nutr. 1968;21:994-1006.

Dutta AK, Balekuduru A, Chacko A. Spectrum of malabsorption in India-tropical sprue is still the leader. J Assoc Physicians India. 2011;59:420-2.

Ranjan P, Ghoshal UC, Aggarwal R, Pandey R, Misra A, Naik S, et al. Etiological spectrum of sporadic malabsorption syndrome in northern Indian adults at a tertiary hospital. Indian J Gastroenterol. 2004;23:94-8.