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CHRONIC SPRUE IN MUMBAI - Its Clinical Presentation
JC PATEL*, SV JOSHI**, HL DHAR***
*Ex. Hon. Physician; **Technical Officer; ***Director, Medical Research Centre, Bombay Hospital Trust, Mumbai 400 020.
This report consists of findings of the vague symptoms, signs of nutritional deficiencies of vitamin B12, folic acid, B complex and iron. They seem to be due to either low/less availability in diet or deficient absorption. These findings have been labelled by us as Chronic but mild sprue syndrome most probably caused by earlier attacks of protozoal infection. The patients were treated with vitamin B12, folic acid, vitamin B complex, and/or iron resulting in the symptomatic improvement.
INTRODUCTION
Intestinal protozoal infections constitute a serious public health problem in India and particularly in the city of Mumbai. Helminthic infections are transmitted by food and water from unhygienic conditions prevailing in the city and later by auto-infection persisting in subacute or chronic form. High prevalence of infection is shown by reports published from Mumbai. [1-3] Even though it is known to produce morbidity, its relation to clinical manifestations as a result of intestinal infection in humans has not been adequately documented or highlighted and treated.
This effort of ours, is to bring to the notice of family/medical-practitioners of city of Mumbai of prevailing symptoms and signs of chronic protozoal and parasitic infection presenting in varied forms but not considered as cause.
The study, includes cases attending Bombay Hospital out patient department (OPD) with the symptoms of vague abdominal disturbances and consequent nutritional deficiency of vitamins (B complex), vitamin B12, folic acid and iron. Further it was planned to see, whether there is any correlation between the various deficiencies and protozol infection. Observations are based on clinical, haemotological and faecal examination of patients attending out patient department of Bombay Hospital.
MATERIAL AND METHODS
One thousand and sixteen patients constituting nearly 1/3rd of total 3000 cases (during 1997-1999) belonging to the working and lower middle class patients attending out-patient department (OPD) of one of the authors, at Bombay Hospital are analysed. Detailed history was taken and a thorough clinical examination was carried out. Stool examination and biochemical investigations were carried out prior and/or after attending Bombay Hospital OPD. Diagnosis was made on the basis of clinical history, examinations and investigations. They include symptoms pertaining to intestinal disturbances viz. irregular or loose stools, flatulence, leinteric (post-meal) colic and motion, post-meal heartburn and tender colon on palpation, pigmentation of the tongue, glossitis, dark pigmentation below the eyelid, loss of weight, paraesthesia and general lassitude. Because of epigastric leinteric colicky pain of colon after food, producing oesophageal regurgitation and heartburn.
RESULTS
Out of 1016 cases, 204 (20.6%) were clinically found to have nutritional deficiency. It was found that amongst various deficiencies vitamin B com plex factors was predominant (34.80%) followed by iron (19.61%), folic acid (13.23%), vitamin B-12 and folic acid (13.23%), B12-B6 (27.45%) and glossitis amenable to oral lactobacillus deficiency was seen only in 1.43% cases. Our assumption is due to improvement noticed with the above mentioned single or combination therapy.
There was multiplicity of vitamin and iron deficiencies e.g. either Vit. B complex + folic acid or Vit. B12 + iron in 7.75%. Vitamin B12 deficiency was associated with pigmentation of tongue in fifty per cent subjects coming from coastal population of Goa, Ratnagiri, Mangalore etc. Vitamin B12 deficiency was predominant in young (41.67%) compared to elderly (3.92%). However, elderly were more deficient in B complex (96.08%) than young subjects (26.11%).
CLINICAL FINDINGS OF NUTRITIONAL DEFICIENCIES
Common findings were tender colon (150), tingling numbness (56), glossitis (50), pain in abdomen (39), weakness (21), loss of appetite (17), chest pain (14), stomatitis (8), loss of weight (5), and giddiness (5) in patients with nutritional B complex deficiencies (23.78%). It is surprising to note that they never complained of loose motions but on questioning did mention about it some time in early period. Subsequent clinical examination revealed tenderness in part/whole of colon in most of the subjects. Number of cases complained of even heartburn, pain in epigastrium and flatulence (similar to GORD). This was considered due to chronic protozoal colitis persisted due to recurrent infection through orofaecal route. This might be suggestive of colitis leading to Tropical Sprue, a condition which probably changes bacterial flora and absorption causing either B-complex or B12 deficiency. Deficiency could be mainly due to presence of chronic protozoal infection revealed by subjective observation of and tender palpable colon. Those with tender colon were treated with anti-amoebic drugs along with vitamin B supplementation resulting in marked improvement. Our assumption of infection in colon was based on improvements with treatment of protozoal infection with B complex and/or vitamin B12.
The clinical findings included paraesthesia, numbness, tingling and numbness (27.25%). These symptoms were relieved by supplementation with injection of B12 + B6 + B1. Signs of glossitis (34.80%) as an evidence of redness of tip of the tongue. Angular stomatitis was also noticed in many of our patients.
Diagnosis of folic acid and vitamin B12 deficiency was considered by the presence of pigmentation as well as smoothness of tongue in 80% of patients. As mentioned earlier, deficiency of vitamin B complex, folic acid, iron and B12 was based on clinical examination and not by laboratory estimations. However, our assumption has been found to be correct to a large extent by the improvement of clinical signs and symptoms viz. improvement in general health, symptoms of glossitis, feeling of well being, weight gain, regularity in bowel movement and absence of symptoms like pain in epigastrium after food, heartburn, paraesthesia and glossitis. Administration of oral live lactobacillus controlled glossitis quicker compared to either oral folic acid or vitamin B complex. It seems that lactobacillus probably produces B12 in intestines. It definitely removes the fermentation by eliminating overgrowth of E. coli in small intestine.
Forty patients who had low haemoglobin levels were supplemented with iron. Those with MCV values were supplemented with iron.
Unlike textbooks, treatment for three days of protozoal infection, patients with tender colon, were treated with anti-amoebic drugs for a period of one month or repeated for further one month. Experience and explanation of textbook authors are from cold climate with good hygiene and for the acute attacks of dysentery. Because of the absence of this condition in the city and subacute/chronic infections, textbook treatment is not considered in our city.
DISCUSSION
This study has shown that in the city of Mumbai, multiple nutritional deficiencies are very common. It may be because of unrealised malabsorption of vitamins and iron in absence of villi in duodenum and jejunum due to overgrowth of E coli and other bacteria. Further change of diet in these lactovegetarians, during symptoms of indigestion adds to nutritional deficiencies. [4,5] Such deficiency was more prevalent in young as they eat food outside their own home compared to elderly. Nearly all of them had protozoal infection which might have been the cause of occurrence of malabsorption and subsequent nutritional deficiencies which we have considered as incipient sprue. [6] Second important finding of this study is nutritional microcytic anaemia which was diagnosed on the basis of MCV [7] due to lack of iron in food or deficient absorption. Many of these patients were carrying out their routine work in spite of the low Hb levels. Chief complaints in these cases were fatigue, fainting and weakness. Hyperpigmentation on tongue [8-10] was observed in 80% of B12 deficient subjects primarily belonging to coastal hilly areas.
ACKNOWLEDGEMENTS
We thank the chairman of Bombay Hospital Trust, Mr. Bharat Taparia and Medical Director, Dr. DP Vyas for allowing us to work in out patient department of the hospital. We also thank the OPD staff, nurses and others for assistance and the patients.
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