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Barbero-Aznarez P, Perez-Tanoira R, Aguirre-Mollehuanca D, Trascasa-Caño A, Fortes-Alen J, Manzarbeitia-Arrambari F, Castillo-Alvarez J, Montoya-Bordon J, Petkova-Saiz E, Prieto-Perez L. Isolated central nervous system Whipple disease. Surg Neurol Int 2022; 13:477. [DOI: 10.25259/sni_591_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Whipple disease (WD) is an infection caused by Tropheryma whipplei, which might present in three different forms: classical, localized, and isolated in the central nervous system (CNS).
Methods:
We report the result of a systematic review of the literature on WD unusually presenting with exclusively neurological symptoms, including two previously unpublished cases. A description of two cases with isolated CNS WD was performed, as well as a literature search in Cochrane, Scielo, and PubMed.
Results:
Two male adult patients presented with exclusively neurological symptomatology. Both magnetic resonance imaging (MRI) showed an intracranial mass suggestive of brain tumor. The histopathological examination was consistent with WD, with no systemic involvement. In the review of the literature, 35 cases of isolated CNS WD were retrieved. The median age at diagnosis was 43.5 (IQR 31.5–51.5). In 13 patients, the MRI showed a brain mass consistent with a brain tumor. The most common finding in the biopsy was the periodic-acid Schiff-stained foamy macrophages. Only five cases presented the pathognomonic sign of oculomasticatory myorhythmia. Thirteen cases had an adverse outcome that resulted in death during follow-up, whereas another 13 improved. The other nine patients remained stable or presented moderate improvement.
Conclusion:
Isolated CNS WD is a rare disease that should be considered among the differential diagnosis of CNS mass lesions. Brain biopsy is necessary to establish the diagnosis. It is stressed in the literature that an extended antibiotic course is required to prevent relapses and to control the disease.
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Affiliation(s)
- Pablo Barbero-Aznarez
- Department of Neurosurgery, Instituto Clavel, San Francisco De Asis University Hospital, Madrid, Spain
| | - Ramon Perez-Tanoira
- Department of Microbiology, Principe de Asturias University Hospital, Madrid, Spain
| | | | | | - Jose Fortes-Alen
- Department of Pathology, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | | | | | | | | | - Laura Prieto-Perez
- Internal Medicine, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
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2
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Balducci C, Foresti S, Ciervo A, Mancini F, Nastasi G, Marzorati L, Gori A, Ferrarese C, Appollonio I, Peri AM. Primary Whipple disease of the Central Nervous System presenting with rhombencephalitis. Int J Infect Dis 2019; 88:149-151. [PMID: 31449925 DOI: 10.1016/j.ijid.2019.08.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 08/17/2019] [Accepted: 08/19/2019] [Indexed: 11/24/2022] Open
Abstract
Primary Whipple disease of the Central Nervous System is a rare entity whose outcome might be fatal if not promptly diagnosed and treated. Few cases are reported in the literature with heterogeneous clinical and radiological presentations which often make the diagnosis extremely challenging. We report a case of primary Whipple disease of the Central Nervous System presenting with rhombencephalitis in a female patient in immunosuppressive treatment for rheumatoid arthritis. We describe the management of our patient and discuss the features of this rare clinical entity.
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Affiliation(s)
- Claudia Balducci
- Department of Neurology, University of Milano-Bicocca, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Sergio Foresti
- Infectious Diseases Division, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Alessandra Ciervo
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Fabiola Mancini
- Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - Giulia Nastasi
- Department of Neurology, University of Milano-Bicocca, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Laura Marzorati
- Department of Neurology, University of Milano-Bicocca, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Andrea Gori
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy.
| | - Carlo Ferrarese
- Department of Neurology, University of Milano-Bicocca, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Ildebrando Appollonio
- Department of Neurology, University of Milano-Bicocca, San Gerardo Hospital, ASST Monza, Monza, Italy
| | - Anna Maria Peri
- Infectious Diseases Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, University of Milan, Italy
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3
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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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Damulin IV, Degterev DA. [Polyneuropathies in intestinal diseases]. Zh Nevrol Psikhiatr Im S S Korsakova 2017; 117:103-107. [PMID: 28884726 DOI: 10.17116/jnevro201711781103-107] [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: 11/17/2022]
Abstract
Different aspects of polyneuropathies (PN) developed due to the deficit of group B vitamins in intestinal diseases are considered. Neurological disturbances related to intestinal diseases are caused by malabsorption that leads to the deficit of some compounds extremely important for normal cell metabolism, pathological changes of mucous coat of the stomach and intestine and higher sensitivity to the plant protein gluten. Vitamin B12 deficit can lead to a number of neurological disturbances; patients with pernicious anemia most often develop myelopathy and PN. An increase in serum vitamin B1 concentration is identified in 30-80% of patients with alcoholism. However, vitamin B1 deficit is seen also in ulcer disease, chronic gastritis, acute pancreatitis, esophageal metastatic lesions as well as in primary tumors of the stomach and intestine. Demyelinating as well as axonal PN may develop in patients with enteropathy. Gluten intolerance is the most often cause of PN in pathological changes in the intestine Possibilities of clinical and paraclinical diagnosis of these disorders are analyzed.
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Affiliation(s)
- I V Damulin
- Sechenov First Moscow State Medical University, Moscow, Russia; Moscow Clinical Research Center, Moscow, Russia
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5
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Zalonis I, Christidi F, Potagas C, Rentzos M, Evdokimidis I, Kararizou E. Central Nervous System Involvement as Relapse in Undiagnosed Whipple's Disease with Atypical Symptoms at Onset. Open Neurol J 2015; 9:21-3. [PMID: 26191089 PMCID: PMC4503830 DOI: 10.2174/1874205x01509010021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2014] [Revised: 03/10/2015] [Accepted: 05/25/2015] [Indexed: 11/22/2022] Open
Abstract
Whipple's disease (WD) is a rare systemic disease caused by the gram-positive bacillus Tropheryma Whipplei and mostly characterized by arthralgias, chronic diarrhea, weight loss, fever and abdominal pain. Central Nervous System involvement is not uncommon and it may precede other disease manifestations, appear after treatment and improvement of gastrointestinal signs or rarely be the only WD symptom. We report a case in a middle-aged male with unexplained neurological signs and symptoms which were presented as relapse of previously undiagnosed WD with atypical symptoms at onset. After diagnosis confirmation, the patient was appropriately treated which resulted in improvement of major symptoms.
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Affiliation(s)
- Ioannis Zalonis
- Department of Neurology, Aeginition Hospital, Medical School, Athens National & Kapodistrian University, 72-74 Vas. Sofias Avenue, Athens, 115 28, Greece
| | - Foteini Christidi
- Department of Neurology, Aeginition Hospital, Medical School, Athens National & Kapodistrian University, 72-74 Vas. Sofias Avenue, Athens, 115 28, Greece
| | - Constantin Potagas
- Department of Neurology, Aeginition Hospital, Medical School, Athens National & Kapodistrian University, 72-74 Vas. Sofias Avenue, Athens, 115 28, Greece
| | - Michalis Rentzos
- Department of Neurology, Aeginition Hospital, Medical School, Athens National & Kapodistrian University, 72-74 Vas. Sofias Avenue, Athens, 115 28, Greece
| | - Ioannis Evdokimidis
- Department of Neurology, Aeginition Hospital, Medical School, Athens National & Kapodistrian University, 72-74 Vas. Sofias Avenue, Athens, 115 28, Greece
| | - Evangelia Kararizou
- Department of Neurology, Aeginition Hospital, Medical School, Athens National & Kapodistrian University, 72-74 Vas. Sofias Avenue, Athens, 115 28, Greece
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Marth T. Systematic review: Whipple's disease (Tropheryma whipplei infection) and its unmasking by tumour necrosis factor inhibitors. Aliment Pharmacol Ther 2015; 41:709-24. [PMID: 25693648 DOI: 10.1111/apt.13140] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/10/2015] [Accepted: 02/04/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND The classical form of Whipple's disease (WD), clinically characterised by arthropathy, diarrhoea and weight loss, is rare. Recently, other more frequent forms of Tropheryma whipplei infection have been recognised. The clinical spectrum includes an acute, self-limiting disease in children, localised forms affecting cardiac valves or the central nervous system without intestinal symptoms, and asymptomatic carriage of T. whipplei which is found in around 4% of Europeans. Genomic analysis has shown that T. whipplei represents a host-dependent or opportunistic bacterium. It has been reported that the clinical course of T. whipplei infection may be influenced by medical immunosuppression. AIM To identify associations between immunomodulatory treatment and the clinical course of T. whipplei infection. METHODS A PubMed literature search was performed and 19 studies reporting on immunosuppression, particularly therapy with tumour necrosis factor inhibitors (TNFI) prior to the diagnosis in 41 patients with Whipple?s disease, were evaluated. RESULTS As arthritis may precede the diagnosis of WD by many years, a relevant percentage (up to 50% in some reports) of patients are treated with immunomodulatory drugs or with TNFI. Many publications report on a complicated Whipple?s disease course or T. whipplei endocarditis following medical immunosuppression, particularly after TNFI. Standard diagnostic tests such as periodic acid-Schiff stain used to diagnose Whipple?s disease often fail in patients who are pre-treated by TNFI. CONCLUSIONS In cases of doubt, Whipple?s disease should be excluded before therapy with TNFI. The fact that immunosuppressive therapy contributes to the progression of T. whipplei infection expands our pathogenetic view of this clinical entity.
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Affiliation(s)
- T Marth
- Division of Internal Medicine, Krankenhaus Maria Hilf, Daun, Germany
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Maresi E, Argo A, Portelli F, Busardò FP, Raoult D, Lepidi H. Rare occurrence of Whipple Disease in a young female patient with a fatal outcome. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2013. [DOI: 10.1016/j.ejfs.2013.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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