Q2. Correct answer: D
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.
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.