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Aguiar Ferreira A, Gomes P, Curvo-Semedo L, Donato P. Whipple's disease: imaging contribution for a challenging case. BMJ Case Rep 2020; 13:13/2/e233071. [PMID: 32047086 DOI: 10.1136/bcr-2019-233071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease is a rare and difficult-to-diagnose infectious disease, related to infection by gram-positive bacillum Tropheryma whipplei Clinical manifestations are very variable, but the classic form usually begins with recurring arthritis, followed several years later by non-specific abdominal symptoms, leading to late diagnosis. We present the case of a 52-year-old man who was admitted in the emergency department with an insidious clinical picture characterised by weight loss, abdominal pain, diarrhoea and arthralgias. An abdominal ultrasound was performed, showing findings suggestive of Whipple's disease, which, in conjunction with the clinical and laboratory findings, allowed the diagnosis to be correctly addressed. Upper endoscopy with duodenal biopsy revealed findings compatible with Whipple's disease, and the diagnosis was also confirmed through PCR techniques of blood. The patient was given antibiotic therapy, with rapid and substantial clinical improvement.
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Affiliation(s)
| | - Paula Gomes
- Medical Imaging, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Luís Curvo-Semedo
- Medical Imaging, Coimbra University Hospital Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Paulo Donato
- Medical Imaging, Coimbra University Hospital Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Kloek AT, Piet JR, Adriani KS. Pearls & Oy-sters: A rare presentation of Whipple disease: Still waters run deep. Neurology 2020; 94:e758-e761. [PMID: 32015179 DOI: 10.1212/wnl.0000000000008976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anne T Kloek
- From the Department of Neurology (A.T.K.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; Department of Neurology (J.R.P., K.S.A.), OLVG Hospital, Amsterdam; Department of Neurology (J.R.P., K.S.A.), Zaans Medisch Centrum, Zaandam; and Department of Viroscience (K.S.A.), Erasmus MC, Rotterdam, the Netherlands.
| | - Jurgen R Piet
- From the Department of Neurology (A.T.K.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; Department of Neurology (J.R.P., K.S.A.), OLVG Hospital, Amsterdam; Department of Neurology (J.R.P., K.S.A.), Zaans Medisch Centrum, Zaandam; and Department of Viroscience (K.S.A.), Erasmus MC, Rotterdam, the Netherlands
| | - Kirsten S Adriani
- From the Department of Neurology (A.T.K.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; Department of Neurology (J.R.P., K.S.A.), OLVG Hospital, Amsterdam; Department of Neurology (J.R.P., K.S.A.), Zaans Medisch Centrum, Zaandam; and Department of Viroscience (K.S.A.), Erasmus MC, Rotterdam, the Netherlands
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Sondhi AR, Platt KD, Gupta A. Fever, Diarrhea, and Weight Loss in a Man With Inflammatory Polyarthritis. JAMA 2020; 323:369-370. [PMID: 31904794 DOI: 10.1001/jama.2019.18724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Arjun R Sondhi
- Division of Gastroenterology, University of Michigan, Ann Arbor
| | - Kevin D Platt
- Division of Gastroenterology, University of Michigan, Ann Arbor
| | - Amit Gupta
- Division of Gastroenterology, University of Michigan, Ann Arbor
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Scheurwater MA, Verduin CM, van Dantzig JM. Whipple's endocarditis: a case report of a blood culture-negative endocarditis. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 3:1-6. [PMID: 31912002 PMCID: PMC6939820 DOI: 10.1093/ehjcr/ytz222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/04/2019] [Accepted: 11/21/2019] [Indexed: 12/17/2022]
Abstract
Background Whipple's disease is caused by Tropheryma whipplei and causes a self-limiting gastrointestinal infection. The majority of the population is an asymptomatic carrier, however, in some patients, it causes an invasive infection with for example arthritis, endocarditis, or involvement of the eyes. Case summary This case describes a man with long-lasting complaints of progressive dyspnoea caused by heart failure due to total destruction of the aortic and mitral valve as a result of T. whipplei endocarditis, diagnosed with serum polymerase chain reaction. The patient was treated with ceftriaxone and prolonged co-trimoxazole therapy and surgical replacement of the aortic and mitral valve. He was discharged to a rehabilitation centre. Discussion Tropheryma whipplei is one of the possible microorganisms classified as causing blood culture-negative endocarditis, with predominantly afebrile patients that do not fulfil the Dukes criteria, which makes it difficult to diagnose. Polymerase chain reaction is the cornerstone of the diagnosis. It requires long-term antibiotic treatment up to 12 months. It is recommended by the European Society of Cardiology to discuss treatment in an Endocarditis Team because Whipple's endocarditis has only rarely been described in the literature previously. Whipple's endocarditis has high mortality and relapse rates.
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Affiliation(s)
- Miriam A Scheurwater
- Department of Cardiology, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA Eindhoven, The Netherlands
| | - Cees M Verduin
- Department of Microbiology, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA Eindhoven, The Netherlands
| | - Jan-Melle van Dantzig
- Department of Cardiology, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA Eindhoven, The Netherlands
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Thornton CS, Wang Y, Köebel M, Bernard K, Burdz T, Maitland A, Ferraz JG, Beck PL, Ferland A. Another Whipple's triad? Pericardial, myocardial and valvular disease in an unusual case presentation from a Canadian perspective. BMC Cardiovasc Disord 2019; 19:312. [PMID: 31870305 PMCID: PMC6929430 DOI: 10.1186/s12872-019-1257-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 11/13/2019] [Indexed: 12/16/2022] Open
Abstract
Background Whipple’s disease is a clinically relevant multi-system disorder that is often undiagnosed given its elusive nature. We present an atypical case of Whipple’s disease involving pan-valvular endocarditis and constrictive pericarditis, requiring cardiac intervention. A literature review was also performed assessing the prevalence of atypical cases of Whipple’s disease. Case presentation A previously healthy 56-year-old male presented with a four-year history of congestive heart failure with weight loss and fatigue. Notably, he had absent gastrointestinal symptoms. He went on to develop pan-valvular endocarditis and constrictive pericarditis requiring urgent cardiac surgery. A clinical diagnosis of Whipple’s disease was suspected, prompting duodenal biopsy sampling which was unremarkable, Subsequently, Tropheryma whipplei was identified by 16S rDNA PCR on the cardiac valvular tissue. He underwent prolonged antibiotic therapy with recovery of symptoms. Conclusions Our study reports the first known case of Whipple’s disease involving pan-valvular endocarditis and constrictive pericarditis. A literature review also highlights this presentation of atypical Whipple’s with limited gastrointestinal manifestations. Duodenal involvement was limited and the gold standard of biopsy was not contributory. We also highlight the Canadian epidemiology of the disease from 2012 to 2016 with an approximate 4% prevalence rate amongst submitted samples. Routine investigations for Whipple’s disease, including duodenal biopsy, in this case may have missed the diagnosis. A high degree of suspicion was critical for diagnosis of unusual manifestations of Whipple’s disease.
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Affiliation(s)
- Christina S Thornton
- Division of Respirology, Department of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, AB, T2N 4N1, Canada.
| | - Yinong Wang
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.,Calgary Laboratory Services, Calgary, AB, Canada
| | - Martin Köebel
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, AB, Canada.,Calgary Laboratory Services, Calgary, AB, Canada
| | - Kathryn Bernard
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada.,Department of Medical Microbiology, University of Manitoba, Winnipeg, Canada
| | - Tamara Burdz
- National Microbiology Laboratory, Public Health Agency of Canada, Winnipeg, MB, Canada
| | - Andrew Maitland
- Division of Cardiac Surgery, University of Calgary, Calgary, AB, Canada
| | - Jose G Ferraz
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Paul L Beck
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, AB, Canada
| | - Andre Ferland
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
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Cardoso J, Gomes L, Santos S, Moreira H, Gomes P, Rua J, Fortuna J. Whipple's Disease: A Rare Cause of Malabsorption Syndrome. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2019; 27:283-289. [PMID: 32775551 DOI: 10.1159/000504760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Revised: 10/27/2019] [Indexed: 11/19/2022]
Abstract
Introduction Whipple's disease is a rare, chronic, systemic disease caused by the actinomycete Tropheryma whipplei. Clinical manifestations vary widely depending on the affected system, the most common being the digestive tract. Case Presentation The authors report the case of a 52-year-old man with malabsorption syndrome, diarrhea, marked weight loss, melanoderma, and visual and proprioception disorders. Periodic acid-Schiff staining of a proximal small bowel biopsy and peripheral-blood PCR identification of T. whipplei confirmed the disease. The patient was initially treated with intravenous ceftriaxone, followed by oral trimethoprim/sulfamethoxazole with significant clinical improvement. Conclusions This case is reported due to its rarity and the diagnostic challenge it presents. Although uncommon, Whipple's disease should be considered as a differential diagnosis of malabsorption syndrome due to its systemic impact and possible treatment with targeted antibiotic therapy.
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Affiliation(s)
- Joana Cardoso
- Department of Internal Medicine, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Lídia Gomes
- Department of Pneumology, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Sandra Santos
- Department of Internal Medicine, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Hélder Moreira
- Department of Anatomic Pathology, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Paula Gomes
- Department of Imagiology, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - João Rua
- Department of Internal Medicine, Coimbra University and Hospital Centre, Coimbra, Portugal
| | - Jorge Fortuna
- Department of Internal Medicine, Coimbra University and Hospital Centre, Coimbra, Portugal
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Tropheryma whipplei endocarditis presenting as chronic valvular disease: A case report and review of literature. HUMAN PATHOLOGY: CASE REPORTS 2019. [DOI: 10.1016/j.ehpc.2019.200321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Losa F, Firinu D, Deidda M, Costanzo G, del Giacco SR. Clinical pitfalls of leishmaniasis and Whipple's disease hidden behind systemic lupus erythematosus: A case series. Acta Microbiol Immunol Hung 2019; 66:377-385. [PMID: 31096758 DOI: 10.1556/030.66.2019.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease that can affect major organs possibly leading to life-threatening complications and appears with heterogeneous clinical picture. SLE could present with broad spectrum of clinical and laboratory features that can resemble those of other diseases, such as hemopoietic malignancies, infections, or immune-mediated disorders. Its complexity and protean features overlap with many other diseases, hindering the differential diagnosis. Rarely, true overlap with other diseases may occur. Herein, we report a case series of two patients affected by infectious diseases, namely visceral leishmaniasis and Whipple's disease (WD), intertwined with clinical or serological features of SLE. In both cases, several confounding factors have led to a delay in the diagnosis. Moreover, we first describe the persistent elevation of autoantibodies and a monoclonal gammopathy in a patient with WD. Awareness of unusual presentations of infections or other rare disorders, which may be encountered in clinical practice when taking care of SLE patients, is essential for timely diagnosis and treatment of potentially lethal diseases.
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Affiliation(s)
- Francesca Losa
- 1 Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital “Duilio Casula”, University of Cagliari, Monserrato (Cagliari), Italy
| | - Davide Firinu
- 1 Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital “Duilio Casula”, University of Cagliari, Monserrato (Cagliari), Italy
| | - Margherita Deidda
- 1 Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital “Duilio Casula”, University of Cagliari, Monserrato (Cagliari), Italy
| | - Giulia Costanzo
- 1 Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital “Duilio Casula”, University of Cagliari, Monserrato (Cagliari), Italy
| | - Stefano R. del Giacco
- 1 Department of Medical Sciences and Public Health and Unit of Allergy and Clinical Immunology, University Hospital “Duilio Casula”, University of Cagliari, Monserrato (Cagliari), Italy
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Whipple's Disease: Diagnostic Value of rpoB Gene PCR from Peripheral Blood Mononuclear Cells. Mol Diagn Ther 2019; 22:459-469. [PMID: 29882197 DOI: 10.1007/s40291-018-0339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Chronic infection with Tropheryma whipplei, known as Whipple's disease (WD), classically affects the gastrointestinal tract, but any organ system may be affected, and isolated manifestations occur. Reliable diagnosis based on a combination of periodic acid-Schiff (PAS) staining, T. whipplei-specific immunohistochemistry (IHC), and polymerase chain reaction (PCR) from duodenal biopsies may be challenging in cases without classical gastrointestinal infection, so the need for additional diagnostic materials is urgent. OBJECTIVE Our objective was to evaluate additional diagnostic possibilities for WD. METHODS We analyzed samples from 20 patients with WD and 18 control subjects in a prospective observational pilot study. In addition to WD diagnosis by PAS staining, T. whipplei-specific IHC and PCR of duodenal or extra intestinal tissues, whole EDTA blood, peripheral blood mononuclear cells (PBMCs) and PBMC fractions enriched with or depleted of cluster of differentiation (CD)-14+ cells were examined using T. whipplei rpoB gene PCR. RESULTS Tropheryma whipplei DNA was detected in 35 of 60 (58.3%) preparations from 16 of 20 patients with WD, most of whom lacked gastrointestinal signs and characteristic PAS-positive duodenal macrophages. CONCLUSION This study provides evidence for the potential suitability of blood, particularly PBMCs, as material to assist in the diagnosis of WD via rpoB gene real-time PCR. Thus, PCR from blood preparations can be helpful for diagnostic decision making in atypical cases of WD.
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García-Álvarez L, Sanz MM, Marín M, Fariñas MC, Montejo M, Goikoetxea J, Rodríguez García R, de Alarcón A, Almela M, Fernández-Hidalgo N, Alonso Socas MM, Goenaga MA, Navas E, Vicioso L, Oteo JA. Antimicrobial management of Tropheryma whipplei endocarditis: the Spanish Collaboration on Endocarditis (GAMES) experience. J Antimicrob Chemother 2019; 74:1713-1717. [PMID: 30789210 DOI: 10.1093/jac/dkz059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/16/2019] [Accepted: 01/18/2019] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Tropheryma whipplei has been detected in 3.5% of the blood culture-negative cases of endocarditis in Spain. Experience in the management of T. whipplei endocarditis is limited. Here we report the long-term outcome of the treatment of previously reported patients who were diagnosed with infective endocarditis (IE) caused by T. whipplei from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis Infecciosa en España (GAMES) and discuss potential options for antimicrobial therapy for IE caused by T. whipplei. PATIENTS AND METHODS Seventeen patients with T. whipplei endocarditis were recruited between 2008 and 2014 in 25 Spanish hospitals. Patients were classified according to the therapeutic regimen: ceftriaxone and trimethoprim/sulfamethoxazole, doxycycline + hydroxychloroquine and other treatment options. RESULTS Follow-up data were obtained from 14 patients. The median follow-up was 46.5 months. All patients completed the antibiotic treatment prescribed, with a median duration of 13 months. Six patients were treated with ceftriaxone and trimethoprim/sulfamethoxazole (median duration 13 months), four with doxycycline + hydroxychloroquine (median duration 13.8 months) and four with other treatment options (median duration 22.3 months). The follow-up after the end of the treatments was between 5 and 84 months (median 24 months). CONCLUSIONS All treatment lines were effective and well tolerated. Therapeutic failures were not detected during the treatment. None of the patients died or experienced a relapse during the follow-up. Only six patients received antibiotic treatment in accordance with guidelines. These data suggest that shorter antimicrobial treatments could be effective.
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Affiliation(s)
- Lara García-Álvarez
- Departamento de Enfermedades Infecciosas, Hospital Universitario San Pedro-Centro de investigación Biomédica de La Rioja (CIBIR), Logroño, Spain
| | - M Mercedes Sanz
- Departamento de Enfermedades Infecciosas, Hospital Universitario San Pedro-Centro de investigación Biomédica de La Rioja (CIBIR), Logroño, Spain
| | - Mercedes Marín
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Madrid, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - M Carmen Fariñas
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander, Spain
| | - Miguel Montejo
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Bilbao, Universidad del País Vasco, Bilbao, Spain
| | - Josune Goikoetxea
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Bilbao, Universidad del País Vasco, Bilbao, Spain
| | - Raquel Rodríguez García
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Oviedo, Universidad de Oviedo, Oviedo, Spain
| | - Arístides de Alarcón
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Manuel Almela
- Servicio de Microbiología y Parasitología, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Nuria Fernández-Hidalgo
- Servei de Malalties Infeccioses, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - M Mar Alonso Socas
- Servicio de Enfermedades Infecciosas, Hospital Universitario de Canarias, Tenerife, Spain
| | - Miguel A Goenaga
- Servicio de Enfermedades Infecciosas, Hospital Donostia, OSI Donostialdea, San Sebastián, Gipuzkoa, Spain
| | - Enrique Navas
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Luis Vicioso
- Servicio de Anatomía Patológica, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | - José A Oteo
- Departamento de Enfermedades Infecciosas, Hospital Universitario San Pedro-Centro de investigación Biomédica de La Rioja (CIBIR), Logroño, Spain
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Abstract
Whipple's disease is a rare, multisystem infection caused by the Gram-positive Tropheryma whippelii organism. In addition to neurological and rheumatological manifestations, this disease can result in significant gastrointestinal symptoms such as malabsorption, diarrhea, and weight loss. Given the diagnostic challenge and rare occurrence, a high index of suspicion is critical to prevent morbidity and mortality from this otherwise highly infectious disease transmitted via the fecal-oral route. We present a very rare but near-fatal case of hypovolemic shock secondary to protein-losing enteropathy and gastrointestinal bleeding from small bowel T. whippelii infection. Furthermore, the epidemiology, clinical presentation, diagnosis, and management of Whipple's disease is reviewed.
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Epidemiology of Whipple's Disease in the USA Between 2012 and 2017: A Population-Based National Study. Dig Dis Sci 2019; 64:1305-1311. [PMID: 30488239 PMCID: PMC6499665 DOI: 10.1007/s10620-018-5393-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 11/22/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prior studies on the epidemiology of Whipple's disease are limited by small sample size and case series design. We sought to characterize the epidemiology of Whipple's disease in the USA utilizing a large population-based database. METHODS We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of electronic health record data from 26 major integrated healthcare systems in the USA. We identified a cohort of patients with a diagnosis of Whipple's disease based on systemized nomenclature of medical terminology (SNOMED CT) codes. We calculated the overall and age-, race-, ethnicity, and gender-based prevalence of Whipple's disease and prevalence of associated diagnoses using univariate analysis. RESULTS A total of 35,838,070 individuals were active in the database between November 2012 and November 2017. Of these, 350 individuals had a SNOMED CT diagnosis of Whipple's disease, with an overall prevalence of 9.8 cases per 1 million. There was no difference in prevalence based on sex. However, prevalence of Whipple's disease was higher in Caucasians, non-Hispanics, and individuals > 65 years old. Individuals with a diagnosis of Whipple's disease were more likely to have associated diagnoses/findings of arthritis, CNS disease, endocarditis, diabetes, malignancy, dementia, vitamin D deficiency, iron deficiency, chemotherapy, weight loss, abdominal pain, and lymphadenopathy. CONCLUSIONS To our knowledge, this is the largest study to date examining the epidemiology of Whipple's disease. In this large population-based study, the overall prevalence of Whipple's disease in the USA is 9.8 cases per 1 million people. It affects men and women at similar rates and is more common in Caucasians, non-Hispanics, and people > 65 years old.
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Serra C, Privitera Hrustemovic H, Verardi FM. Bowel Ultrasound: No Longer a Cinderella of Bowel Imaging. Gastroenterology 2019; 156:1253-1254. [PMID: 30610867 DOI: 10.1053/j.gastro.2018.11.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/16/2018] [Accepted: 11/16/2018] [Indexed: 12/02/2022]
Affiliation(s)
- Carla Serra
- Department of Organ Failure and Transplantation, Sant'Orsola-Malpighi Hospital, Bologna, Italy
| | | | - Federico Maria Verardi
- Department of Organ Failure and Transplantation, Sant'Orsola-Malpighi Hospital, Bologna, Italy
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Beltrame A, Ragusa A, Perandin F, Formenti F, Fenollar F, Edouard S, Laroche M, Zavarise G, Doro F, Giorli G, Raoult D, Bisoffi Z. Tropheryma whipplei intestinal colonization in Italian and migrant population: a retrospective observational study. Future Microbiol 2019; 14:283-292. [PMID: 30855186 DOI: 10.2217/fmb-2018-0347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To obtain the first molecular epidemiological survey of Tropheryma whipplei intestinal colonization in Italy. Materials & methods: Retrospective, observational study to assess the prevalence of T. whipplei, the causative agent of Whipple's disease, in stool samples (real-time PCR) of patients attending the Center for Tropical Diseases (Italy) and risk factors associated. RESULTS Overall prevalence was 6.9% (85/1240). The younger age group showed a significantly higher rate than older age group (12.7 vs 5.9%, p = 0.002). The prevalence was 4.9% for Italians and 9.3% for migrants (p = 0.003). Among the latter, children less than 10 years had higher prevalence than older ones (17.3 vs 7.3%, p = 0.003). The young age, male gender and Giardia duodenalis and Entamoeba histolytica coinfection were risk factors. CONCLUSION Our study confirms an increased risk of acquiring T. whipplei infection during childhood, under poor sanitary conditions.
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Affiliation(s)
- Anna Beltrame
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Andrea Ragusa
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesca Perandin
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Fabio Formenti
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Florence Fenollar
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Sophie Edouard
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Maureen Laroche
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Giorgio Zavarise
- Paediatrics Department, IRCSS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesco Doro
- Paediatrics Department, IRCSS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Giovanni Giorli
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Didier Raoult
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Zeno Bisoffi
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy.,Department of Diagnostic & Public Health, University of Verona, P.le L. A. Scuro 10, 37134 Verona, Italy
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Le Goff M, Cornec D, Guellec D, Marhadour T, Devauchelle-Pensec V, Jousse-Joulin S, Herbette M, Cauvin JM, Le Guillou C, Renaudineau Y, Jamin C, Pers JO, Saraux A. Peripheral-blood b-cell subset disturbances in inflammatory joint diseases induced by Tropheryma whipplei. PLoS One 2019; 14:e0211536. [PMID: 30811404 PMCID: PMC6392227 DOI: 10.1371/journal.pone.0211536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/16/2019] [Indexed: 12/18/2022] Open
Abstract
Objective To look for abnormalities in circulating B-cell subsets in patients with rheumatic symptoms of Whipple’s disease (WD). Method Consecutive patients seen between 2010 and 2016 for suspected inflammatory joint disease were identified retrospectively. Results of standardized immunological and serological tests and of peripheral-blood B-cell and T-cell subset analysis by flow cytometry were collected. Patients with criteria suggesting WD underwent PCR testing for Tropheryma whipplei, and those with diagnosis of WD (cases) were compared to those without diagnosis (controls). We used ROC curve analysis to evaluate the diagnostic value of flow cytometry findings for WD. Results Among 2917 patients seen for suspected inflammatory joint disease, 121 had suspected WD, including 9 (9/121, 7.4%) confirmed WD. Proportions of T cells and NK cells were similar between suspected and confirmed WD, whereas cases had a lower proportion of circulating memory B cells (IgD-CD38low, 18.0%±9.7% vs. 26.0%±14.2%, P = 0.041) and higher ratio of activated B cells over memory B cells (4.4±2.0 vs. 2.9±2.2, P = 0.023). Among peripheral-blood B-cells, the proportion of IgD+CD27- naive B cells was higher (66.2%±18.2% vs. 54.6%±18.4%, P = 0.047) and that of IgD-CD27+ switched memory B cells lower (13.3%±5.7% vs. 21.4%±11.9%, P = 0.023), in cases vs. controls. The criterion with the best diagnostic performance was a proportion of IgD+CD27- naive B cells above 70.5%, which had 73% sensitivity and 80% specificity. Conclusion Our study provides data on peripheral-blood B-cell disturbances that may have implications for the diagnosis and pathogenetic understanding of WD.
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Affiliation(s)
- Maëlle Le Goff
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | - Divi Cornec
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Dewi Guellec
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | - Thierry Marhadour
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | - Valérie Devauchelle-Pensec
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Sandrine Jousse-Joulin
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Marion Herbette
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | | | | | - Yves Renaudineau
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Christophe Jamin
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Jacques Olivier Pers
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Alain Saraux
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
- * E-mail:
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Prudent E, Le Guenno G, Jonckheere S, Vankeerberghen A, Lepidi H, Angelakis E, Raoult D. Fluorescent in situ hybridization can be used as a complementary assay for the diagnosis of Tropheryma whipplei infection. Infection 2018; 47:317-321. [PMID: 30368732 DOI: 10.1007/s15010-018-1243-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/22/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Immunohistochemistry and Periodic acid-Schiff (PAS) staining have been routinely used for the diagnosis of Whipple's disease (WD). However, these methods present limitations. As a result, the last years, Fluorescence in situ hybridization (FISH) has been increasingly used as a complementary tool for the diagnosis of WD from various tissue samples. CASE REPORT In this study, we visualized, by FISH, Tropheryma whipplei within macrophages of a lymph node from a patient with WD. Moreover, we report in this study a patient with a pulmonary biopsy compatible with WD by PAS, immunostaining and FISH, although the specific molecular assays for T. whipplei were negative. Sequencing analysis of the 16S rDNA revealed a T. whipplei-related species with unknown classification. CONCLUSION FISH can be a valuable method for the detection of Tropheryma species in formalin-fixed paraffin-embedded tissues. FISH cannot replace the other already approved diagnostic techniques for WD, it can be used as a complementary tool and can provide supplementary information in a relatively short time.
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Affiliation(s)
- Elsa Prudent
- Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005, Marseille, France
| | - Guillaume Le Guenno
- Department of Internal Medicine, Hôpital Estaing, Centre, Hospitaliser Universitaire, Clermont-Ferrand, France
| | - Stijn Jonckheere
- Laboratory of Clinical Microbiology, OLV Hospital Aalst, Aalst, Belgium
| | | | - Hubert Lepidi
- Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005, Marseille, France
| | - Emmanouil Angelakis
- Aix Marseille Université, IRD, APHM, VITROME, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005, Marseille, France. .,Laboratory of Medical Microbiology, Hellenic Pasteur Institute, Athens, Greece.
| | - Didier Raoult
- Aix Marseille Université, IRD, APHM, MEPHI, IHU-Méditerranée Infection, 19-21 Boulevard Jean Moulin, 13005, Marseille, France
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Bally JF, Méneret A, Roze E, Anderson M, Grabli D, Lang AE. Systematic review of movement disorders and oculomotor abnormalities in Whipple's disease. Mov Disord 2018; 33:1700-1711. [DOI: 10.1002/mds.27419] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/20/2018] [Accepted: 03/25/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Julien F. Bally
- Movement Disorders Research Center, Toront Western Hospital; Toronto Ontario Canada
- Department of Neurology; University Hospitals of Geneva; Geneva Switzerland
| | - Aurélie Méneret
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Neurologie; Paris France
| | - Emmanuel Roze
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Neurologie; Paris France
| | - Melanie Anderson
- Library and Information Services; University Health Network; Toronto Ontario Canada
| | - David Grabli
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Neurologie; Paris France
| | - Anthony E. Lang
- Movement Disorders Research Center, Toront Western Hospital; Toronto Ontario Canada
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Isolated Knee Arthritis as Early and Only Symptom of Whipple's Disease. Case Rep Med 2018; 2018:3417934. [PMID: 29977302 PMCID: PMC5994299 DOI: 10.1155/2018/3417934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/18/2018] [Accepted: 05/07/2018] [Indexed: 12/17/2022] Open
Abstract
We report a case of isolated Whipple's disease involving the knee of a 64-year-old female patient who presented recurrent monoarthritis whose origin was not clear. Initially, the cause of the gradually invalidating symptoms was related to a meniscal lesion and a diffuse minor grade chondropathy, but pain and functional impairment suggested that more exams were needed. Biopsies were performed during arthroscopy. The histology showed highly inflammatory infiltrates with PAS staining negative for Tropheryma while PCR revealed the infection with Tropheryma whipplei. This, following the recommendation of a rheumatologist and infectious disease specialist, led to biopsies of the gastrointestinal tract and analysis of the cerebrospinal fluid that showed no other organ involvement. This confirms the scientific literature that an isolated monoarthritis without involvement of the gastrointestinal tract caused by this bacterium is rare but can occur as an early manifestation of potentially fatal systemic disease. Moreover, a review of the scientific literature showed the uncertainty about epidemiology of this rare disease, suggesting that more and specific data are required.
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69
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Secondary immune thrombocytopenia (ITP) as an initial presentation of Whipple's disease. IDCases 2018; 12:e4-e6. [PMID: 29942787 PMCID: PMC6010930 DOI: 10.1016/j.idcr.2017.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 11/28/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous autoimmune disease characterized by low platelet count that has been associated with a number of chronic infections but rarely described as a manifestation of Whipple’s disease (WD). We present a case of Whipple’s disease in a patient initially diagnosed with ITP. A 46-year old male in the fifth decade of life presented with presumed idiopathic ITP and was treated with several therapies including corticosteroids, rituximab, and thrombopoietin receptor agonists. Several years later, he developed weight loss and worsening arthralgias. He was found to have evidence of WD in a jejunal lymph node, the duodenum, and the cerebral spinal fluid (CSF). His diagnosis of WD, as a cause of secondary ITP, came a full 8 years after he was discovered to have thrombocytopenia and over 4 years after he was diagnosed with ITP. WD is an uncommon, multiorgan system disease caused by the actinomycete Tropheryma whipplei. Whipple’s disease presents a diagnostic challenge due to the wide array of possible presenting clinical manifestations, as well as a prolonged time course with separation of symptoms over many years. While T. whipplei is ubiquitous in the environment, few individuals develop clinical disease, raising the prospect that select immunodeficiencies, both singular or in combination, may play a role in infection. While rare, in the appropriate clinical setting, one should consider infection with T. whipplei in addition to other chronic infections as a cause of secondary ITP regardless of how long ago the diagnosis of ITP was made.
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70
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Brönnimann D, Vandenhende MA, Viallard JF. Gamma delta T cell expansion in Whipple's disease with muscular granulomatous vasculitis. Infection 2018; 46:573-576. [PMID: 29725938 DOI: 10.1007/s15010-018-1143-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/24/2018] [Indexed: 11/28/2022]
Abstract
Whipple's disease usually presents as chronic joint pain followed by digestive manifestations. However, many different presentations have been described in the literature. We report here the first proven case of muscular vasculitis related to Whipple's disease, associated with an expansion of circulating activated γδ T lymphocytes.
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Affiliation(s)
- Didier Brönnimann
- Department of Internal Medicine and Infectious Diseases, CHU Bordeaux, Hôpital Saint-André, 1 rue Jean Burguet, 33000, Bordeaux, France.
| | - Marie-Anne Vandenhende
- Department of Internal Medicine and Infectious Diseases, CHU Bordeaux, Hôpital Saint-André, 1 rue Jean Burguet, 33000, Bordeaux, France
| | - Jean-François Viallard
- Department of Internal Medicine and Infectious Diseases, CHU Bordeaux, Hôpital Haut Lévèque, 33600, Pessac, France
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Guérin A, Kerner G, Marr N, Markle JG, Fenollar F, Wong N, Boughorbel S, Avery DT, Ma CS, Bougarn S, Bouaziz M, Béziat V, Della Mina E, Oleaga-Quintas C, Lazarov T, Worley L, Nguyen T, Patin E, Deswarte C, Martinez-Barricarte R, Boucherit S, Ayral X, Edouard S, Boisson-Dupuis S, Rattina V, Bigio B, Vogt G, Geissmann F, Quintana-Murci L, Chaussabel D, Tangye SG, Raoult D, Abel L, Bustamante J, Casanova JL. IRF4 haploinsufficiency in a family with Whipple's disease. eLife 2018; 7:e32340. [PMID: 29537367 PMCID: PMC5915175 DOI: 10.7554/elife.32340] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Accepted: 03/12/2018] [Indexed: 12/19/2022] Open
Abstract
Most humans are exposed to Tropheryma whipplei (Tw). Whipple's disease (WD) strikes only a small minority of individuals infected with Tw (<0.01%), whereas asymptomatic chronic carriage is more common (<25%). We studied a multiplex kindred, containing four WD patients and five healthy Tw chronic carriers. We hypothesized that WD displays autosomal dominant (AD) inheritance, with age-dependent incomplete penetrance. We identified a single very rare non-synonymous mutation in the four patients: the private R98W variant of IRF4, a transcription factor involved in immunity. The five Tw carriers were younger, and also heterozygous for R98W. We found that R98W was loss-of-function, modified the transcriptome of heterozygous leukocytes following Tw stimulation, and was not dominant-negative. We also found that only six of the other 153 known non-synonymous IRF4 variants were loss-of-function. Finally, we found that IRF4 had evolved under purifying selection. AD IRF4 deficiency can underlie WD by haploinsufficiency, with age-dependent incomplete penetrance.
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Affiliation(s)
- Antoine Guérin
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Gaspard Kerner
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | | | - Janet G Markle
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
| | - Florence Fenollar
- Research Unit of Infectious and Tropical Emerging DiseasesUniversity Aix-Marseille, URMITE, UM63, CNRS 7278, IRD 198MarseilleFrance
| | - Natalie Wong
- Immunology DivisionGarvan Institute of Medical ResearchDarlinghurstAustralia
- St Vincent’s Clinical School, Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | | | - Danielle T Avery
- Immunology DivisionGarvan Institute of Medical ResearchDarlinghurstAustralia
- St Vincent’s Clinical School, Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Cindy S Ma
- Immunology DivisionGarvan Institute of Medical ResearchDarlinghurstAustralia
- St Vincent’s Clinical School, Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | | | - Matthieu Bouaziz
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Vivien Béziat
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Erika Della Mina
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Carmen Oleaga-Quintas
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Tomi Lazarov
- Immunology ProgramMemorial Sloan Kettering Cancer CenterNew YorkUnited States
- Ludwig CenterMemorial Sloan Kettering Cancer CenterNew YorkUnited States
| | - Lisa Worley
- Immunology DivisionGarvan Institute of Medical ResearchDarlinghurstAustralia
- St Vincent’s Clinical School, Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Tina Nguyen
- Immunology DivisionGarvan Institute of Medical ResearchDarlinghurstAustralia
- St Vincent’s Clinical School, Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Etienne Patin
- Human Evolutionary Genetics Unit, Department of Genomes and GeneticsInstitut PasteurParisFrance
- CNRS UMR2000ParisFrance
- Center of Bioinformatics, Biostatistics and Integrative BiologyInstitut PasteurParisFrance
| | - Caroline Deswarte
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Rubén Martinez-Barricarte
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
| | - Soraya Boucherit
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | | | - Sophie Edouard
- Research Unit of Infectious and Tropical Emerging DiseasesUniversity Aix-Marseille, URMITE, UM63, CNRS 7278, IRD 198MarseilleFrance
| | - Stéphanie Boisson-Dupuis
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
| | - Vimel Rattina
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
| | - Benedetta Bigio
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
| | | | - Frédéric Geissmann
- Immunology ProgramMemorial Sloan Kettering Cancer CenterNew YorkUnited States
- Ludwig CenterMemorial Sloan Kettering Cancer CenterNew YorkUnited States
- Weill Cornell Graduate School of Medical SciencesNew YorkUnited States
| | - Lluis Quintana-Murci
- Human Evolutionary Genetics Unit, Department of Genomes and GeneticsInstitut PasteurParisFrance
- CNRS UMR2000ParisFrance
- Center of Bioinformatics, Biostatistics and Integrative BiologyInstitut PasteurParisFrance
| | | | - Stuart G Tangye
- Immunology DivisionGarvan Institute of Medical ResearchDarlinghurstAustralia
- St Vincent’s Clinical School, Faculty of MedicineUniversity of New South WalesSydneyAustralia
| | - Didier Raoult
- Research Unit of Infectious and Tropical Emerging DiseasesUniversity Aix-Marseille, URMITE, UM63, CNRS 7278, IRD 198MarseilleFrance
| | - Laurent Abel
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
| | - Jacinta Bustamante
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
- Center for the Study of Primary ImmunodeficienciesAssistance Publique-Hôpitaux de Paris, Necker Hospital for Sick ChildrenParisFrance
| | - Jean-Laurent Casanova
- Laboratory of Human Genetics of Infectious Diseases, Necker BranchINSERM U1163ParisFrance
- Imagine InstituteParis Descartes UniversityParisFrance
- St. Giles Laboratory of Human Genetics of Infectious Diseases, Rockefeller BranchThe Rockefeller UniversityNew YorkUnited States
- Pediatric Hematology and Immunology UnitAssistance Publique-Hôpitaux de Paris, Necker Hospital for Sick ChildrenParisFrance
- Howard Hughes Medical InstituteNew YorkUnited States
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Lopes A, Santos AF, Alvarenga MJ, Mello E Silva A. Whipple's disease: a rare case of malabsorption. BMJ Case Rep 2018; 2018:bcr-2017-222955. [PMID: 29507019 DOI: 10.1136/bcr-2017-222955] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Whipple's disease is a chronic, rare, multisystemic, infectious entity, described for the first time in 1907. Its aetiological agent is the Gram-negative rod, Tropheryma whipplei, which was isolated for the first time in 2001 from a cardiac valve of a patient with endocarditis. We present the case of a 71-year-old man, who came into the emergency room complaining of anorexia, weakness, abdominal pain and diarrhoea with haematochezia and presented disseminated palpable purpuric lesions, predominantly in the lower limbs. The upper endoscopy showed a duodenal vasculitis and the biopsy of that location revealed aspects suggestive of Whipple's disease. We started him on antibiotics according to the recent orientations with progressive clinical and analytical improvement, although he developed an immune reconstitution syndrome, which lasted for 2 weeks.
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Affiliation(s)
- Ana Lopes
- Department of Medicina Interna, Hospital Egas Moniz, Lisbon, Portugal
| | - Ana Filipa Santos
- Department of Pneumologia, Hospital Egas Moniz, CHLO, Lisboa, Portugal
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Jarholm JA, Kristoffersen ES, Wohlleben C, Zarnovicky S, Faiz KW. Acute disseminated encephalomyelitis associated with debut of a late onset coeliac disease-a case report. Neurol Sci 2017; 39:799-801. [PMID: 29181653 DOI: 10.1007/s10072-017-3207-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 11/21/2017] [Indexed: 10/18/2022]
Affiliation(s)
| | - Espen Saxhaug Kristoffersen
- Department of Neurology, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway.
- Department of General Practice, Helsam, University of Oslo, Oslo, Norway.
| | - Christine Wohlleben
- Department of Neurology, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway
| | | | - Kashif Waqar Faiz
- Department of Neurology, Akershus University Hospital, PO Box 1000, 1478, Lørenskog, Norway
- Research Centre, Akershus University Hospital, Lørenskog, Norway
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Puri S, Shaikh AG. Basic and translational neuro-ophthalmology of visually guided saccades: disorders of velocity. EXPERT REVIEW OF OPHTHALMOLOGY 2017; 12:457-473. [PMID: 30774705 PMCID: PMC6377082 DOI: 10.1080/17469899.2017.1395695] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Saccades are rapid, yoked eye movements in an effort to direct a target over fovea. The complex circuitry of saccadic eye movements has been exhaustively described. As a result clinicians can elegantly localize the pathology if it falls on the neuraxis responsible for saccades. Traditionally saccades are studied with their quantitative characteristics such as amplitude, velocity, duration, direction, latency and accuracy. AREAS COVERED Amongst all subtypes, the physiology of the visually guided saccades is most extensively studied. Here we will review the basic and pertinent neuro-anatomy and physiology of visually guided saccade and then discuss common or classic disorders affecting the velocity of visually guided saccades. We will then discuss the basic mechanism for saccade slowing in these disorders. EXPERT COMMENTARY Prompt appreciation of disorders of saccade velocity is critical to reach appropriate diagnosis. Disorders of midbrain, cerebellum, or basal ganglia can lead to prolonged transition time during gaze shift and decreased saccade velocity.
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Affiliation(s)
- Sushant Puri
- Dept. of Neurology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio, United States
| | - Aasef G. Shaikh
- Dept. of Neurology, University Hospitals Cleveland Medical Center and Case Western Reserve University, Cleveland, Ohio, United States
- Daroff-DelOsso Ocular Motility Laboratory, Cleveland VA Medical Center, Cleveland, Ohio, United States
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Loiodice A, Losurdo G, Iannone A, Rossi R, Fiore MG, Piscitelli D. Transmission electron microscopy helpfulness in Whipple's disease masked by immunosuppressant therapy for arthritis. APMIS 2017; 126:92-96. [PMID: 29154446 DOI: 10.1111/apm.12782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/17/2017] [Indexed: 12/22/2022]
Abstract
A 61-year-old woman received a diagnosis of undifferentiated non-erosive arthritis in 2010 and assumed methotrexate and steroids in 2014. After 1 year, she experienced watery diarrhea, vomiting, fever, weight loss, and severe hypoalbuminemia, thus being admitted into our Unit. Esophagogastroduodenoscopy showed duodenal lymphangiectasia and duodenal biopsy samples several foamy PAS-positive macrophages and villous subtotal atrophy. Transmission electron microscope demonstrated several extracellular and intracellular rod-shaped bacteria (Tropheryma whipplei). Therefore, we diagnosed Whipple's disease. Our patient assumed doxycycline/hydroxychloroquine with prompt remission of gastrointestinal symptoms. At 1 year of follow-up, she was symptom-free, histological reassessment showed almost complete mucosal healing and transmission electron microscope demonstrated bacteria breaking/disappearance. The present report demonstrates that: (i) rheumatological manifestations are common onset symptoms of Whipple's disease; (ii) immunosuppressive therapy may delay the diagnosis and worsen clinical presentation; (iii) transmission electron microscopy for specific bacteria detection/disappearance is an helpful diagnostic tool, when available.
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Affiliation(s)
- Alessandra Loiodice
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Roberta Rossi
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Maria Grazia Fiore
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Domenico Piscitelli
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
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Epple HJ, Friebel J, Moos V, Troeger H, Krug SM, Allers K, Schinnerling K, Fromm A, Siegmund B, Fromm M, Schulzke JD, Schneider T. Architectural and functional alterations of the small intestinal mucosa in classical Whipple's disease. Mucosal Immunol 2017; 10:1542-1552. [PMID: 28176790 DOI: 10.1038/mi.2017.6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 01/10/2017] [Indexed: 02/04/2023]
Abstract
Classical Whipple's disease (CWD) affects the gastrointestinal tract and rather elicits regulatory than inflammatory immune reactions. Mechanisms of malabsorption, diarrhea, and systemic immune activation are unknown. We here analyzed mucosal architecture, barrier function, and immune activation as potential diarrheal trigger in specimens from 52 CWD patients. Our data demonstrate villus atrophy and crypt hyperplasia associated with epithelial apoptosis and reduced alkaline phosphatase expression in the duodenum of CWD patients. Electrophysiological and flux experiments revealed increased duodenal permeability to small solutes and macromolecules. Duodenal architecture and permeability ameliorated upon antibiotic treatment. Structural correlates for these alterations were concordant changes of membranous claudin-1, claudin-2, claudin-3, and tricellulin expression. Tumor necrosis factor-α and interleukin-13 were identified as probable mediators of epithelial apoptosis, and altered tight junction expression. Increased serum markers of microbial translocation and their decline following treatment corroborated the biological significance of the mucosal barrier defect. Hence, mucosal immune responses in CWD elicit barrier dysfunction. Diarrhea is caused by loss of absorptive capacity and leak flux of ions and water. Downregulation of tricellulin causes increased permeability to macromolecules and subsequent microbial translocation contributes to systemic inflammation. Thus, therapeutic strategies to reconstitute the mucosal barrier and control inflammation could assist symptomatic control of CWD.
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Affiliation(s)
- H-J Epple
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - J Friebel
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - V Moos
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - H Troeger
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - S M Krug
- Institute of Clinical Physiology/Nutritional Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - K Allers
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - K Schinnerling
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - A Fromm
- Institute of Clinical Physiology/Nutritional Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - B Siegmund
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - M Fromm
- Institute of Clinical Physiology/Nutritional Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - J D Schulzke
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany.,Institute of Clinical Physiology/Nutritional Medicine, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
| | - T Schneider
- Department of Gastroenterology, Rheumatology and Infectious Diseases, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Germany
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Clinical Manifestations, Treatment, and Diagnosis of Tropheryma whipplei Infections. Clin Microbiol Rev 2017; 30:529-555. [PMID: 28298472 DOI: 10.1128/cmr.00033-16] [Citation(s) in RCA: 83] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Whipple's disease is a rare infectious disease that can be fatal if left untreated. The disease is caused by infection with Tropheryma whipplei, a bacterium that may be more common than was initially assumed. Most patients present with nonspecific symptoms, and as routine cultivation of the bacterium is not feasible, it is difficult to diagnose this infection. On the other hand, due to the generic symptoms, infection with this bacterium is actually quite often in the differential diagnosis. The gold standard for diagnosis used to be periodic acid-Schiff (PAS) staining of duodenal biopsy specimens, but PAS staining has a poor specificity and sensitivity. The development of molecular techniques has resulted in more convenient methods for detecting T. whipplei infections, and this has greatly improved the diagnosis of this often missed infection. In addition, the molecular detection of T. whipplei has resulted in an increase in knowledge about its pathogenicity, and this review gives an overview of the new insights in epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of Tropheryma whipplei infections.
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78
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Heavener T, Thompson M, Patel C, Forrester L, Rawls D. An Unusual Presentation of Tropheryma Whipplei Infection. Proc (Bayl Univ Med Cent) 2017; 30:429-430. [DOI: 10.1080/08998280.2017.11930215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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79
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Peripheral T-Cell Reactivity to Heat Shock Protein 70 and Its Cofactor GrpE from Tropheryma whipplei Is Reduced in Patients with Classical Whipple's Disease. Infect Immun 2017; 85:IAI.00363-17. [PMID: 28559404 DOI: 10.1128/iai.00363-17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Accepted: 05/21/2017] [Indexed: 12/17/2022] Open
Abstract
Classical Whipple's disease (CWD) is characterized by the lack of specific Th1 response toward Tropheryma whipplei in genetically predisposed individuals. The cofactor GrpE of heat shock protein 70 (Hsp70) from T. whipplei was previously identified as a B-cell antigen. We tested the capacity of Hsp70 and GrpE to elicit specific proinflammatory T-cell responses. Peripheral mononuclear cells from CWD patients and healthy donors were stimulated with T. whipplei lysate or recombinant GrpE or Hsp70 before levels of CD40L, CD69, perforin, granzyme B, CD107a, and gamma interferon (IFN-γ) were determined in T cells by flow cytometry. Upon stimulation with total bacterial lysate or recombinant GrpE or Hsp70 of T. whipplei, the proportions of activated effector CD4+ T cells, determined as CD40L+ IFN-γ+, were significantly lower in patients with CWD than in healthy controls; CD8+ T cells of untreated CWD patients revealed an enhanced activation toward unspecific stimulation and T. whipplei-specific degranulation, although CD69+ IFN-γ+ CD8+ T cells were reduced upon stimulation with T. whipplei lysate and recombinant T. whipplei-derived proteins. Hsp70 and its cofactor GrpE are immunogenic in healthy individuals, eliciting effective responses against T. whipplei to control bacterial spreading. The lack of specific T-cell responses against these T. whipplei-derived proteins may contribute to the pathogenesis of CWD.
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80
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Braubach P, Lippmann T, Raoult D, Lagier JC, Anagnostopoulos I, Zender S, Länger FP, Kreipe HH, Kühnel MP, Jonigk D. Fluorescence In Situ Hybridization for Diagnosis of Whipple's Disease in Formalin-Fixed Paraffin-Embedded Tissue. Front Med (Lausanne) 2017; 4:87. [PMID: 28691008 PMCID: PMC5479881 DOI: 10.3389/fmed.2017.00087] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 06/07/2017] [Indexed: 12/12/2022] Open
Abstract
Whipple’s disease (WD) is a rare chronic systemic infection with a wide range of clinical symptoms, routinely diagnosed in biopsies from the small intestine and other tissues by periodic acid–Schiff (PAS) diastase staining and immunohistological analysis with specific antibodies. The aim of our study was to improve the pathological diagnosis of WD. Therefore, we analyzed the potential of fluorescence in situ hybridization (FISH) for diagnosing WD, using a Tropheryma (T.) whipplei-specific probe. 19 formalin-fixed paraffin-embedded (FFPE) duodenal biopsy specimens of 12 patients with treated (6/12) and untreated (6/12) WD were retrospectively examined using PAS diastase staining, immunohistochemistry, and FISH. 20 biopsy specimens with normal intestinal mucosa, Helicobacter pylori, or mycobacterial infection, respectively, served as controls. We successfully detected T. whipplei in tissue biopsies with a sensitivity of 83% in untreated (5/6) and 40% in treated (4/10) cases of WD. In our study, we show that FISH-based diagnosis of individual vital T. whipplei in FFPE specimens is feasible and can be considered as ancillary diagnostic tool for the diagnosis of WD in FFPE material. We show that FISH not only detect active WD but also be helpful as an indicator for the efficiency of antibiotic treatment and for detection of recurrence of disease when the signal of PAS diastase and immunohistochemistry lags behind the recurrence of disease, especially if the clinical course of the patient and antimicrobial treatment is considered.
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Affiliation(s)
- Peter Braubach
- Institute of Pathology, Hannover Medical School (MHH), Hanover, Germany
| | - Torsten Lippmann
- Institute of Pathology, Hannover Medical School (MHH), Hanover, Germany
| | - Didier Raoult
- Aix Marseille University, CNRS, IRD, INSERM, AP-HM, URMITE, IHU Méditerranée Infection, Marseille, France
| | - Jean-Christophe Lagier
- Aix Marseille University, CNRS, IRD, INSERM, AP-HM, URMITE, IHU Méditerranée Infection, Marseille, France
| | | | - Steffen Zender
- Department of Gastroenterology, Hepatology, and Endocrinology, Centre for Internal Medicine, Hannover Medical School (MHH), Hanover, Germany
| | | | | | | | - Danny Jonigk
- Institute of Pathology, Hannover Medical School (MHH), Hanover, Germany
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81
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Whipple's disease. J Neurol Sci 2017; 377:197-206. [DOI: 10.1016/j.jns.2017.01.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/16/2016] [Accepted: 01/15/2017] [Indexed: 11/24/2022]
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82
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Abstract
In the differential diagnostics of autoimmune-mediated rheumatic diseases, rheumatologists often have to consider infections (e. g. Lyme arthritis) or reactive diseases (e. g. reactive arthritis after urogenital bacterial infections). Furthermore, infections with an atypical presentation or caused by atypical pathogens (opportunistic infections) can complicate the immunosuppressive therapy of autoimmune diseases. For this purpose not only conventional microbiological culture methods but also PCR-based methods are increasingly being applied for the direct detection of pathogens in clinical specimens. The aim of this overview is to present commonly used PCR methods in the clinical practice of rheumatology and to describe their benefits and limitations compared to culture-based detection methods.
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Affiliation(s)
- B Ehrenstein
- Klinik und Poliklinik für Rheumatologie/Klinische Immunologie, Asklepios Klinikum Bad Abbach, 93077, Bad Abbach, Deutschland.
| | - U Reischl
- Institut für Klinische Mikrobiologie und Hygiene, Universitätsklinikum Regensburg (UKR), 93053, Regensburg, Deutschland
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83
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Abstract
Whipple's disease commonly presents as chronic diarrhea and abdominal pain. Ascites is an uncommon presentation of Whipple's disease. Here, we report a rare case of a 47-year-old male who presented with diarrhea and abdominal distention for three months. The physical examination was significant for ascites. Serum albumin was low and serum-to-ascites albumin gradient was < 1.1 g/dl. This suggested that ascites was less likely to be present due to portal hypertension. Enteroscopy showed erythematous duodenum and jejunum; biopsy was suggestive of periodic acid-Schiff stain (PAS) positive macrophages consistent with Whipple's disease. During the hospital course, the patient improved with intravenous (IV) ceftriaxone.
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84
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Management of adult infectious encephalitis in metropolitan France. Med Mal Infect 2017; 47:206-220. [PMID: 28336304 DOI: 10.1016/j.medmal.2017.01.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/23/2017] [Indexed: 02/06/2023]
Abstract
Infectious encephalitis is a severe disease leading to a high mortality and morbidity. The most frequent causes include Herpes simplex virus, Varicella Zoster virus, Listeria monocytogenes, and Mycobacterium tuberculosis. Urgent treatment is required (anti-infective therapy and nonspecific supportive care). The aim of this study was to define treatment strategy, empirical and after microbiological documentation at 48hours, through a systematic literature review.
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85
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Van Bockstal M, Hoorens A, Van den Bosch F, Creytens D, Verbeke S, Van Dorpe J. Whipple’s disease in granulomatous disguise: a challenging diagnosis with many histopathological pitfalls. Virchows Arch 2017; 470:465-468. [DOI: 10.1007/s00428-017-2084-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 01/21/2017] [Accepted: 01/30/2017] [Indexed: 12/19/2022]
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86
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Erythema Nodosum Leprosum-Like Lesions Are a Histopathologic Pattern in Whipple's Disease and a Sign of the Immune Reconstitution Inflammatory Syndrome: A Case Series and Review of the Literature. Am J Dermatopathol 2017; 39:259-266. [PMID: 28098596 DOI: 10.1097/dad.0000000000000641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inflammatory and subcutaneous nodules can arise in treated and untreated cases of Whipple disease (WD). The inflammatory immune reconstitution syndrome describes paradoxical clinical inflammatory worsening of a preexisting condition because of a return of immune function. Clinicopathologic examination of 4 patients with WD who presented with erythema nodosum leprosum (ENL)-like lesions and the findings of a systematic review of this phenomenon revealed that ENL-like lesions occurred in predominantly middle-aged male patients who suffered from WD, mostly on the legs. Patients showed a nonvasculitic, mostly septal panniculits with neutrophils, macrophages, and lymphocytes. Numerous bacteria-laden periodic acid-Schiff + macrophages and free bacilli were detected in the dermis, as well as subcutaneous septae and adipose lobules. These lesions occurred in both untreated and treated patients as part of inflammatory immune reconstitution syndrome. In conclusion, ENL-like lesions represent a characteristic histopathologic pattern associated with WD, which can occur in different contexts whenever there is a change in the immunological status of the patient. This change can be triggered by antimicrobial treatment, immunomodulatory and immunosuppressant therapy, or occur spontaneously, rarely.
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87
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Acute and Chronic Meningitis. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00019-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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88
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89
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Henriques MSDM, da Paz AR, Gaertner ABP, Melo CIS, Filgueiras PL, Jerome RA. Deep Vein Thrombosis as Initial Manifestation of Whipple Disease. Case Rep Gastroenterol 2016; 10:640-645. [PMID: 27920655 PMCID: PMC5126608 DOI: 10.1159/000452206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 10/03/2016] [Indexed: 01/19/2023] Open
Abstract
Introduction Wipple disease (WD) is a rare chronic disease caused by the bacillus Tropheryma whipplei. Constitutive, rheumatologic, gastrointestinal, cardiac, cerebral, lymphatic, cutaneous, and ophthalmological signs are possible systemic symptoms. However, thrombotic manifestations are rarely described as “stroke-like syndrome” or arterial thrombosis. Diagnosis is based on clinical manifestations and pathological examination. Laboratory findings may include anemia, leukocytosis, and thrombocytosis. Objective We report a case of venous thrombosis as initial manifestation of WD. Case Report We describe the case of a 53-year-old male with iliofemoral vein thrombosis followed by intermittent diarrhea, loss of appetite, abdominal distension, and bloating. A mild malnutrition state with a weight loss of 13 kg, pallor (+/4 +), presence of lower-limb edema (+/4 +), and hypertympanic distended abdomen occurred. Laboratory tests on admission revealed anemia, positive inflammatory activity tests, and normal coagulation. Endoscopic examination showed villous edema with white dotted infiltrates in the second duodenal portion and intestinal lymphangiectasia in the terminal ileum. Pathological examination revealed numerous macrophages with positive periodic acid-Schiff inclusions. Venous Doppler ultrasound showed extensive deep thrombosis on the left lower limb and recanalization of the femoral vein in the right lower limb. The patient was treated with ceftriaxone and enoxaparin sodium, which led to an improvement of gastrointestinal and thrombosis symptoms. Comments Hypercoagulability, endothelial damage, vasculitis, and blood stasis are present in T. whipplei infection, which are associated with the activation of inflammatory mechanisms as well as procoagulant and thromboembolic events. WD should be part of the differential diagnosis of diseases that cause venous thrombosis of unknown origin.
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90
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Tsarfati EM, Sutherland R. Whipple's disease. Br J Hosp Med (Lond) 2016; 77:C82-5. [PMID: 27269764 DOI: 10.12968/hmed.2016.77.6.c82] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- E M Tsarfati
- Medical Microbiology Registrar in the Department of Clinical Microbiology, Royal Infirmary of Edinburgh, Edinburgh
| | - R Sutherland
- Consultant Infectious Diseases in the Regional Infectious Diseases Unit, Western General Hospital, Edinburgh EH4 2XU
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91
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Sunnapwar A, Menias CO, Ojili V, Policarpio Nicolas M, Katre R, Gangadhar K, Nagar A. Abdominal manifestations of histiocytic disorders in adults: imaging perspective. Br J Radiol 2016; 89:20160221. [PMID: 27332519 DOI: 10.1259/bjr.20160221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Histiocytic disorders (HDs) are a diverse group of diseases characterized by pathologic infiltration of normal tissues by cells of the mononuclear phagocyte system. The spectrum of these diseases ranges from treatable infectious diseases to rapidly progressive, life-threatening conditions. Although they are rare and difficult diagnoses, HDs can be diagnosed with the help of clinical and laboratory analyses, imaging features and tissue biopsy. The clinicopathology and imaging spectrum of select entities belonging to this disorder are presented in this review.
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Affiliation(s)
- Abhijit Sunnapwar
- 1 University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Vijaynadh Ojili
- 1 University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Rashmi Katre
- 1 University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | | | - Arpit Nagar
- 4 Ohio State University, Wexner Medical Center, Columbus, OH, USA
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92
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Whipple's disease without gastrointestinal symptoms: a challenging diagnosis. J Neurol 2016; 263:1657-8. [PMID: 27272955 DOI: 10.1007/s00415-016-8184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/27/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
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93
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García-Álvarez L, Sanz MM, Marín M, Fariñas M, Montejo M, Goikoetxea J, Rodríguez García R, de Alarcón A, Almela M, Fernández-Hidalgo N, Alonso Socas MDM, Goenaga MÁ, Navas E, Vicioso L, Oteo JA. Tropheryma whipplei endocarditis in Spain: Case reports of 17 prospective cases. Medicine (Baltimore) 2016; 95:e4058. [PMID: 27368042 PMCID: PMC4937956 DOI: 10.1097/md.0000000000004058] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Tropheryma whipplei endocarditis is an uncommon condition with very few series and <90 cases reported in the literature. The aim of the study was to analyze the epidemiological, clinical, and outcome characteristics of 17 cases of T. whipplei endocarditis recruited in our country from a multicentric cohort from 25 Spanish hospitals from the Spanish Collaboration on Endocarditis-Grupo de Apoyo al Manejo de la Endocarditis infecciosa en España.From a total of 3165 cases included in the cohort, 14.2% were diagnosed of blood culture negative endocarditis (BCNE) and 3.5% of these had T. whipplei endocarditis. This condition was more frequent in men. The average age was 60.3 years. Previous cardiac condition was present in 35.3% of the cases. The main clinical manifestation was cardiac failure (76.5%) while fever was only present in the 35.3%. Ecocardiography showed vegetations in 64.7% of patients. Surgery was performed in all but 1 cases and it allowed the diagnosis when molecular assays were performed. A broad range rRNA 16S polymerase chain reaction was used for first instance in all laboratories and different specific targets for T. whipplei were employed for confirmation. A concomitant Whipple disease was diagnosed in 11.9% of patients. All patients received specific antimicrobial treatment for at least 1 year, with no relapse and complete recovery.T. whipplei endocarditis is an uncommon condition with an atypical presentation that must be considered in the diagnosis of BCNE. The prognosis is very good when an appropriate surgical management and antimicrobial-specific treatment is given.
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Affiliation(s)
- Lara García-Álvarez
- Departamento de Enfermedades Infecciosas, Hospital San Pedro-Centro de Investigación Biomédica de La Rioja (CIBIR)
| | | | - Mercedes Marín
- Servicio de Microbiología Clínica y Enfermedades Infecciosas, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid
| | - MªCarmen Fariñas
- Servicio de Enfermedades Infecciosas, Hospital Universitario Marqués de Valdecilla, Universidad de Cantabria, Santander
| | - Miguel Montejo
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Universidad del País Vasco
| | - Josune Goikoetxea
- Unidad de Enfermedades Infecciosas, Hospital Universitario de Cruces, Bilbao
| | - Raquel Rodríguez García
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Universidad de Oviedo, Oviedo
| | - Arístides de Alarcón
- Unidad de Gestión Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen del Rocío, Sevilla
| | - Manuel Almela
- Servicio de Microbiología y Parasitología, Hospital Clinic de Barcelona, Barcelona
| | - Núria Fernández-Hidalgo
- Servicio de Enfermedades Infecciosas, Hospital Universitario Vall d’Hebron, Universidad Autónoma de Barcelona, Barcelona
| | | | - Miguel Ángel Goenaga
- Servicio de Enfermedades Infecciosas, Hospital Universitario Donosti, San Sebastián
| | - Enrique Navas
- Servicio de Enfermedades Infecciosas, Hospital Universitario Ramón y Cajal, Madrid
| | - Luis Vicioso
- Servicio de Anatomía Patológica, Hospital Clínico Universitario Virgen de la Victoria, Málaga, Spain
| | - José Antonio Oteo
- Departamento de Enfermedades Infecciosas, Hospital San Pedro-Centro de Investigación Biomédica de La Rioja (CIBIR)
- Correspondence: José A. Oteo, Departamento de Enfermedades Infecciosas, Hospital San Pedro-CIBIR, C/Piqueras 98-7a NE, 26006 Logroño (La Rioja), Spain ()
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94
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Schäfer VS, Fleck M, Ehrenstein B, Peters AK, Hartung W. Impact of esophagogastroduodenoscopy and ileocolonoscopy on diagnosis and therapy in patients with rheumatic diseases-a retrospective cohort study. Mod Rheumatol 2016; 26:594-7. [PMID: 26529497 DOI: 10.3109/14397595.2015.1112466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Many rheumatic diseases as well as their medications may cause gastrointestinal (GI) pathologies; in addition, some primary GI diseases may contribute or lead to rheumatic disease manifestations. The aim of this study is to analyze the clinical relevance of esophagogastroduodenoscopy (EGD) and ileocolonoscopy (IC) in patients suffering from inflammatory rheumatic diseases. METHODS A retrospective chart review was performed for all rheumatological inpatients who underwent EGD and/or IC within 2 years. RESULTS Within 2 years, 456 patients (261 female, 195 male) underwent 752 endoscopic investigations of the GI tract (419 EGDs and 333 ICs). Of all patients, 152 (33.3%) did not report any GI complaints. However, 28 of these asymptomatic patients (18.4%) suffered from esophagitis, a gastric ulcer could be identified in 20 patients (13%), whereas unspecific colitis was diagnosed in 19 patients (12.5%). In addition, 14 patients (9.2%) suffered from clinically unapparent Crohn's disease and two patients from Whipple's disease. In one patient with polymyalgia rheumatica, colon cancer was diagnosed. Altogether 304 patients reported GI complaints. Of these, 292 (39%) endoscopic investigations had impact on the final diagnosis or therapeutic strategy. The antirheumatic medication or the concomitant medication was changed in 18% of the patients due to the endoscopic findings; in 29 patients (6.5%) the initially clinically presumed diagnosis had to be corrected. In 70 patients (15%) with an undefined rheumatic diagnosis prior to endoscopy, endoscopic findings were decisive to establish the final diagnosis. CONCLUSION EGD and IC have a high diagnostic impact on patients with rheumatic diseases presenting with or without concomitant GI symptoms.
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Affiliation(s)
- Valentin Sebastian Schäfer
- a Medical Centre for Rheumatology and Clinical Immunology , Immanuel Clinic Berlin-Buch , Berlin , Germany
| | - Martin Fleck
- b Department of Rheumatology and Clinical Immunology , Asklepios Medical Center Bad Abbach , Bad Abbach , Germany , and.,c Department of Internal Medicine (I) , University Medical Center Regensburg , Regensburg , Germany
| | - Boris Ehrenstein
- b Department of Rheumatology and Clinical Immunology , Asklepios Medical Center Bad Abbach , Bad Abbach , Germany , and
| | - Ann-Kathrin Peters
- b Department of Rheumatology and Clinical Immunology , Asklepios Medical Center Bad Abbach , Bad Abbach , Germany , and
| | - Wolfgang Hartung
- b Department of Rheumatology and Clinical Immunology , Asklepios Medical Center Bad Abbach , Bad Abbach , Germany , and
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95
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Deglycosylation of Tropheryma whipplei biofilm and discrepancies between diagnostic results during Whipple's disease progression. Sci Rep 2016; 6:23883. [PMID: 27025850 PMCID: PMC4812295 DOI: 10.1038/srep23883] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 03/15/2016] [Indexed: 12/17/2022] Open
Abstract
Whipple’s disease is a systemic infectious disease associated with the bacterium Tropheryma whipplei. Numerous reports have presented puzzling discrepancies between diagnosis methods. We addressed this confusion using fluorescent in situ hybridization and immunofluorescence assays to evaluate 34 duodenal biopsies and 1 lymph node biopsy from Whipple’s patients. We showed the presence of bacteria in both CK20+ epithelial cells and CD68+ macrophages. Bacteria are found embedded in a biofilm hindering the detection of T. whipplei. Only after treatment of biopsies by glycosidases, co-localization of T. whipplei RNA/DNA with bacterial proteins was restored. Moreover, using 13 bronchoalveolar lavages and 7 duodenal biopsies, we found that hydrolysis of the biofilm weakened the bacteria, facilitated bacterial DNA extraction and improved the sensitivity of qPCR detection by up to 1000x opening new perspectives for diagnostic and scientific approaches.
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96
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Abstract
Whipple's disease is a rare infection caused by Tropheryma whipplei, a Gram-negative Bacillus usually found in macrophages of the lamina propria of the small intestine. The typical clinical manifestations of classic Whipple's disease are diarrhea, weight loss, malabsorption, abdominal pain, and arthralgia. The disease's laboratory diagnosis is currently based on duodenal biopsy. Treatment generally includes primary therapy for 2 weeks with intravenous antibiotics capable of reaching high levels in the cerebrospinal fluid, such as ceftriaxone, usually followed by treatment with oral cotrimoxazole for 1 year. Early diagnosis should enable appropriate treatment and improves the prognosis, and prolonged antibiotic treatment often leads to complete remission. Our case report focuses on a 72-year-old man who had been passing watery stools for 1-2 months, accompanied by low-grade fever. He reported profound asthenia, a weight loss of about 3 kg, and loss of appetite. Thirty years earlier (in 1984), he had been working as a horse keeper at a University Department of Agricultural and Veterinary Studies, where he had contracted Whipple's disease. Laboratory tests and microbiological studies led to a diagnosis of recurrent Whipple's disease. Esophagogastroduodenoscopy was performed under deep sedation. Biopsy samples obtained from the stomach and duodenum were stained with hematoxylin and eosin, Giemsa, and periodic acid-Schiff to identify any accumulation of typical periodic acid-Schiff-positive macrophages in the lamina propria. A specific quantitative real-time PCR assay using specific oligonucleotide probes for targeting repeated sequences of Tropheryma whipplei was also performed to detect its DNA in the duodenum samples.
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Nay J, Menias CO, Mellnick VM, Balfe DM. Gastrointestinal manifestations of systemic disease: a multimodality review. ACTA ACUST UNITED AC 2016; 40:1926-43. [PMID: 25548008 DOI: 10.1007/s00261-014-0334-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Systemic diseases have many different presentations, including imaging findings in the bowel. Recognizing the imaging findings in these diseases is important in making the correct diagnosis. Although certain imaging features overlap, knowledge of specific findings along with the clinical presentation aid in narrowing the differential or in making an imaging diagnosis. The pictorial review will focus on the gastrointestinal manifestations of systemic diseases, including amyloidosis, angiotensin converter enzyme inhibitor-induced angioedema, celiac sprue, distal intestinal obstruction syndrome, graft-versus-host disease, hemolytic uremic syndrome, hemophilia, Henoch-Schönlein purpura, intestinal lymphangiectasia, mastocytosis, scleroderma, systemic lupus erythematosus, Wegener's granulomatosis, and Whipple's disease. The aforementioned diseases can be subdivided based upon the underlying process leading to the disease. The diseases discussed are categorized into autoimmune, infiltrative, treatment related, congenital/hereditary, and infectious etiologies.
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Affiliation(s)
- John Nay
- Washington University School of Medicine Mallinckrodt Institute of Radiology, 510 S. Kingshighway Blvd, Saint Louis, MO, 63110, USA,
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Marth T, Moos V, Müller C, Biagi F, Schneider T. Tropheryma whipplei infection and Whipple's disease. THE LANCET. INFECTIOUS DISEASES 2016; 16:e13-22. [PMID: 26856775 DOI: 10.1016/s1473-3099(15)00537-x] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 12/01/2015] [Accepted: 12/11/2015] [Indexed: 12/12/2022]
Abstract
Recent advances in medical microbiology, epidemiology, cellular biology, and the availability of an expanded set of diagnostic methods such as histopathology, immunohistochemistry, PCR, and bacterial culture have improved our understanding of the clinical range and natural course of Tropheryma whipplei infection and Whipple's disease. Interdisciplinary and transnational research activities have contributed to the clarification of the pathogenesis of the disorder and have enabled controlled trials of different treatment strategies. We summarise the current knowledge and new findings relating to T whipplei infection and Whipple's disease.
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Affiliation(s)
- Thomas Marth
- Division of Internal Medicine, Krankenhaus Maria Hilf, Daun, Germany.
| | - Verena Moos
- Charité-University Medicine Berlin, Campus Benjamin Franklin, Division of Infectious Diseases, Berlin, Germany
| | - Christian Müller
- University Clinic of Internal Medicine III, Allgemeines Krankenhaus Vienna, Vienna, Austria
| | - Federico Biagi
- First Department of Internal Medicine, IRCCS Foundation Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Thomas Schneider
- Charité-University Medicine Berlin, Campus Benjamin Franklin, Division of Infectious Diseases, Berlin, Germany
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100
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García-Álvarez L, Pérez-Matute P, Blanco JR, Ibarra V, Oteo JA. High prevalence of asymptomatic carriers of Tropheryma whipplei in different populations from the North of Spain. Enferm Infecc Microbiol Clin 2015; 34:340-5. [PMID: 26585816 DOI: 10.1016/j.eimc.2015.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 09/09/2015] [Accepted: 09/16/2015] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Tropheryma whipplei is the causative agent of Whipple disease. T. whipplei has also been detected in asymptomatic carriers with a very different prevalence. To date, in Spain, there are no data regarding the prevalence of T. whipplei in a healthy population or in HIV-positive patients, or in chronic fatigue syndrome (CFS). Therefore, the aim of this work was to assess the prevalence of T. whipplei in stools in those populations. METHODS Stools from 21 HIV-negative subjects, 65 HIV-infected, and 12 CFS patients were analysed using real time-PCR. HIV-negative and positive subjects were divided into two groups, depending on the presence/absence of metabolic syndrome (MS). Positive samples were sequenced. RESULTS The prevalence of T. whipplei was 25.51% in 98 stool samples analysed. Prevalence in HIV-positive patients was significantly higher than in HIV-negative (33.8% vs. 9.09%, p=0.008). Prevalence in the control group with no associated diseases was 20%, whereas no positive samples were observed in HIV-negative patients with MS, or in those diagnosed with CFS. The prevalence observed in HIV-positive patients without MS was 30.35%, and with MS it was 55.5%. The number of positive samples varies depending on the primers used, although no statistically significant differences were observed. CONCLUSIONS There is a high prevalence of asymptomatic carriers of T. whipplei among healthy and in HIV-infected people from Spain. The role of T. whipplei in HIV patients with MS is unclear, but the prevalence is higher than in other populations.
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Affiliation(s)
- Lara García-Álvarez
- Infectious Diseases Department, Hospital San Pedro-Center for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Patricia Pérez-Matute
- Infectious Diseases Department, Hospital San Pedro-Center for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - José Ramón Blanco
- Infectious Diseases Department, Hospital San Pedro-Center for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Valvanera Ibarra
- Infectious Diseases Department, Hospital San Pedro-Center for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - José Antonio Oteo
- Infectious Diseases Department, Hospital San Pedro-Center for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain.
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