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Clinical manifestations of Whipple's disease mimicking rheumatic disorders. Reumatologia 2021; 59:104-110. [PMID: 33976464 PMCID: PMC8103404 DOI: 10.5114/reum.2021.105418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022] Open
Abstract
Whipple’s disease is a rare, chronic, systemic disorder caused by Tropheryma whipplei infection. The most common symptoms are weight loss, arthralgia, diarrhea and abdominal pain. Other organ involvement can also occur in the patients. Joint manifestations may mimic rheumatoid arthritis or spondyloarthritis. Arthalgia, arthritis, spondylodiscitis, bursitis and/or tenosynovitis are seen in the majority of the patients. This explains why some of the symptoms are misdiagnosed as those of rheumatic diseases. Understanding of Whipple’s disease is important for differential diagnostics of several rheumatic symptoms.
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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: 82] [Impact Index Per Article: 11.7] [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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Kwon JW, Hyun SJ, Han SH, Kim KJ, Jahng TA. Pyogenic Vertebral Osteomyelitis: Clinical Features, Diagnosis, and Treatment. KOREAN JOURNAL OF SPINE 2017; 14:27-34. [PMID: 28704905 PMCID: PMC5518432 DOI: 10.14245/kjs.2017.14.2.27] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/07/2017] [Accepted: 06/20/2017] [Indexed: 12/18/2022]
Abstract
Pyogenic vertebral osteomyelitis (PVO) may result in neurological deficits and sequelae, so early diagnosis and appropriate treatment are critical. Many previous studies on PVO exist, but our paper has aimed to comprehensively summarize the clinical aspects of PVO. Through review of the vast literature on the clinical research of PVO an overview of the clinical characteristics, diagnostic methods, treatment and prognosis is provided.
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Affiliation(s)
- Ji-Woong Kwon
- Neuro-Oncology Clinic, National Cancer Center, Goyang, Korea
| | - Seung-Jae Hyun
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Sang-Hyun Han
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Ki-Jeong Kim
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Tae-Ahn Jahng
- Department of Neurosurgery, Spine Center, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Lehmann P, Ehrenstein B, Hartung W, Dragonas C, Reischl U, Fleck M. PCR analysis is superior to histology for diagnosis of Whipple's disease mimicking seronegative rheumatic diseases. Scand J Rheumatol 2016; 46:138-142. [PMID: 27398638 DOI: 10.1080/03009742.2016.1183038] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVES The diagnosis of Whipple's disease (WD) is commonly confirmed by histology demonstrating Periodic Acid Schiff (PAS)-positive macrophages in the duodenal mucosa. Analysis of intestinal tissue or other specimens using polymerase chain reaction (PCR) is a more sensitive method. However, the relevance of positive PCR findings is still controversial. Therefore, we evaluated the relevance of histology and PCR findings to establishing the diagnosis of WD in a series of WD patients initially presenting with suspected rheumatic diseases. METHOD Between 2006 and 2014, 20 patients with seronegative rheumatic diseases tested positive for Tropheryma whipplei (Tw) by PCR and/or histology and were enrolled in a retrospective analysis of the diagnostic value of both procedures. RESULTS Seven of the 20 cases (35%) were diagnosed with 'classic' WD as indicated by PAS-positive macrophages. In the remaining 13 patients, the presence of Tw was detected by intestinal (n = 10) or synovial PCR analysis (n = 3). Two of the 20 patients (10%) with evidence of Tw did not respond to antibiotic therapy. They were not considered to suffer from WD. Therefore, relying only on histological findings of intestinal biopsies would have missed 11 (61%) of the 18 patients with WD in our cohort. In comparison, PCR of intestinal biopsies detected Tw-DNA in 14 (93%) of the 15 WD patients evaluated. Patients with a positive histology did not differ from PCR-positive patients with regard to sex, age, or duration of disease, but more often presented with gastrointestinal symptoms. CONCLUSIONS A substantial number of WD patients present without typical intestinal histology findings. Additional PCR analysis of intestinal tissue or synovial fluid increased the sensitivity of the diagnostic evaluation and should be considered particularly in patients presenting with atypical seronegative rheumatic diseases and a high-risk profile for WD.
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Affiliation(s)
- P Lehmann
- a Department of Rheumatology and Clinical Immunology , Asklepios Medical Centre , Bad Abbach , Germany
| | - B Ehrenstein
- a Department of Rheumatology and Clinical Immunology , Asklepios Medical Centre , Bad Abbach , Germany
| | - W Hartung
- a Department of Rheumatology and Clinical Immunology , Asklepios Medical Centre , Bad Abbach , Germany
| | - C Dragonas
- a Department of Rheumatology and Clinical Immunology , Asklepios Medical Centre , Bad Abbach , Germany
| | - U Reischl
- b Institute of Clinical Microbiology and Hygiene, University Medical Centre Regensburg , Regensburg , Germany
| | - M Fleck
- a Department of Rheumatology and Clinical Immunology , Asklepios Medical Centre , Bad Abbach , Germany.,c Department of Internal Medicine I , University Medical Centre Regensburg , Regensburg , Germany
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Ramos JM, Pasquau F, Galipienso N, Valero B, Navarro A, Martinez A, Rosas J, Gutiérrez A, Sanchez-Martínez R. Whipple's disease diagnosed during anti-tumor necrosis factor alpha treatment: two case reports and review of the literature. J Med Case Rep 2015. [PMID: 26215452 PMCID: PMC4522104 DOI: 10.1186/s13256-015-0632-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Introduction Whipple’s disease is a rare infectious disease caused by Tropheryma whipplei with protean clinical manifestations. This infection may mimic chronic inflammatory rheumatisms. Case presentation We report two cases of Whipple’s disease diagnosed in the context of an inflammatory disease with anti-tumor necrosis factor alpha failure. The first patient was a 58-year-old white man with psoriatic spondylarthritis, who was treated with adalimumab, etanercept, infliximab, tocilizumab and golimumab. The second was a 73-year-old white man with rheumatoid arthritis, who received treatment with infliximab, then etanercept and rituximab. Conclusions Whipple’s disease should be suspected in all patients diagnosed with chronic inflammatory rheumatism, partially controlled or not controlled by treatment with tumor necrosis factor alpha blockers, whose condition worsens after treatment.
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Affiliation(s)
- Jose M Ramos
- Department of Internal Medicine, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. .,Department of Medicine, Miguel Hernández University of Elche, Sant Joan d'Alacant, 03550, Spain. .,Servicio de Medicina Interna, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain.
| | - Francisco Pasquau
- Department of Internal Medicine, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain.
| | - Nora Galipienso
- Department of Internal Medicine, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain.
| | - Beatriz Valero
- Department of Internal Medicine, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain.
| | - Angela Navarro
- Department of Internal Medicine, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain.
| | - Agustín Martinez
- Department of Rheumatology, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain.
| | - José Rosas
- Department of Rheumatology, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain.
| | - Ana Gutiérrez
- Department of Gastroenterology, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain.
| | - Rosario Sanchez-Martínez
- Department of Internal Medicine, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain.
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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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Spondylodiscite et maladie de Whipple : une observation et revue de la littérature. Rev Med Interne 2014. [DOI: 10.1016/j.revmed.2014.03.158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Sparsa L, Fenollar F, Gossec L, Leone J, Pennaforte JL, Dougados M, Roux C. [Whipple disease revealed by anti-TNFα therapy]. Rev Med Interne 2012. [PMID: 23199973 DOI: 10.1016/j.revmed.2012.10.371] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Whipple disease is a rare infectious disease with protean clinical manifestations. This infection may mimic chronic inflammatory rheumatisms such as rheumatoid arthritis or spondylarthritis. In this context, introduction of a biotherapy after a diagnostic hesitation does not always lead to early complications. Sometimes, the clinical degradation follows an initial improvement, encouraging continuation of the immunosuppressive treatment and leading consequently to a greater diagnostic delay. CASE REPORTS We report two cases of Whipple disease diagnosed in the context of an inflammatory disease with anti-TNFα failure. The first patient was a 53-year-old man who presented with an axial and peripheral spondylarthritis who was treated with etanercept and adalimumab. The second was a 42-year-old man who received adalimumab and then etanercept for a peripheral spondylarthritis. CONCLUSION Whipple disease should be suspected in all patients who present with a chronic inflammatory rheumatism that is partially or not controlled with anti-TNFα therapy and who had persisting elevated acute phase reactants.
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Affiliation(s)
- L Sparsa
- Service de rhumatologie B, université Paris-Descartes, hôpital Cochin, AP-HP, Paris, France.
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Fenollar F, Keita AK, Buffet S, Raoult D. Intrafamilial circulation of Tropheryma whipplei, France. Emerg Infect Dis 2012; 18:949-55. [PMID: 22608161 PMCID: PMC3358147 DOI: 10.3201/eid1806.111038] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Tropheryma whipplei, which causes Whipple disease, has been detected in 4% of fecal samples from the general adult population of France. To identify T. whipplei within families, we conducted serologic and molecular studies, including genotyping, on saliva, feces, and serum from 74 relatives of 13 patients with classic Whipple disease, 5 with localized chronic T. whipplei infection, and 3 carriers. Seroprevalence was determined by Western blot and compared with 300 persons from the general population. We detected T. whipplei in 24 (38%) of 64 fecal samples and 7 (10%) of 70 saliva samples from relatives but found no difference between persons related by genetics and marriage. The same circulating genotype occurred significantly more often in families than in other persons. Seroprevalence was higher among relatives (23 [77%] of 30) than in the general population (143 [48%] of 300). The high prevalence of T. whipplei within families suggests intrafamilial circulation.
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Lagier JC, Fenollar F, Raoult D. De la maladie de Whipple aux infections à Tropheryma whipplei. Med Mal Infect 2010; 40:371-82. [DOI: 10.1016/j.medmal.2009.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 10/28/2009] [Indexed: 12/17/2022]
Affiliation(s)
- J-C Lagier
- Urmite CNRS-IRD UMR 6236, unité des Rickettsies, faculté de médecine, université de la Méditerranée, 27, boulevard Jean-Moulin, 13385 Marseille cedex 05, France
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Affiliation(s)
- Werner Zimmerli
- Basel University Medical Clinic Liestal, Kantonsspital, Liestal, Switzerland.
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Spoerl D, Bär D, Cooper J, Vogt T, Tyndall A, Walker UA. Multisegmental spondylitis due to Tropheryma whipplei: case report. Orphanet J Rare Dis 2009; 4:13. [PMID: 19493331 PMCID: PMC2697142 DOI: 10.1186/1750-1172-4-13] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2009] [Accepted: 06/03/2009] [Indexed: 12/18/2022] Open
Abstract
We report a patient who presented with inflammatory back pain due to multisegmental spondylitis. Following a vertebral biopsy which failed to detect an infectious organism, the patient was treated with etanercept, a tumor necrosis factor (TNF)-α inhibitor, for suspected undifferentiated spondyloarthritis. The back pain worsened and the spondylitic lesions increased. Only in a vertebral rebiopsy with polymerase chain reaction (PCR) amplification of Tropheryma whipplei, the causative agent of Whipple's disease was identified. Tropheryma whipplei should be considered as a cause of spondylitis even with multisegmental involvement and in the absence of gastrointestinal symptoms. In this clinical setting, routine PCR for Tropheryma whipplei from vertebral biopsies is recommended.
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Affiliation(s)
- David Spoerl
- Department of Rheumatology, University of Basel, Felix Platter Spital, Basel, Switzerland.
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Schneider T, Moos V, Loddenkemper C, Marth T, Fenollar F, Raoult D. Whipple's disease: new aspects of pathogenesis and treatment. THE LANCET. INFECTIOUS DISEASES 2008; 8:179-90. [PMID: 18291339 DOI: 10.1016/s1473-3099(08)70042-2] [Citation(s) in RCA: 218] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
100 years after its first description by George H Whipple, the diagnosis and treatment of Whipple's disease is still a subject of controversy. Whipple's disease is a chronic multisystemic disease. The infection is very rare, although the causative bacterium, Tropheryma whipplei, is ubiquitously present in the environment. We review the epidemiology of Whipple's disease and the recent progress made in the understanding of its pathogenesis and the biology of its agent. The clinical features of Whipple's disease are non-specific and sensitive diagnostic methods such as PCR with sequencing of the amplification products and immunohistochemistry to detect T whipplei are still not widely distributed. The best course of treatment is not completely defined, especially in relapsing disease, neurological manifestations, and in cases of immunoreconstitution after initiation of antibiotic treatment. Patients without the classic symptoms of gastrointestinal disease might be misdiagnosed or insufficiently treated, resulting in a potentially fatal outcome or irreversible neurological damage. Thus, we suggest procedures for the improvement of diagnosis and an optimum therapeutic strategy.
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Affiliation(s)
- Thomas Schneider
- Medical Department I, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
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Reyes R, Peris P, Feu F, Martínez-Ferrer À, Quera À, Guañabens N. Enfermedad de Whipple. Estudio de 6 casos. Med Clin (Barc) 2008; 130:219-22. [DOI: 10.1157/13116176] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Affiliation(s)
- Florence Fenollar
- Unité des Rickettsies, IFR 48, Centre National de la Recherche Scientifique UMR 6020, and Université de la Méditerranée, Faculté de Médecine, Marseille, France
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