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Schönfeld L, Scheumann G, Jöckel J. [Endocarditis and ischemic stroke of rare cause]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2024; 65:840-842. [PMID: 38483553 DOI: 10.1007/s00108-024-01685-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/12/2024] [Indexed: 07/25/2024]
Abstract
A 60-year-old male patient presented with ischemic-embolic stroke. Transesophageal echocardiography revealed the cause to be aortic valve endocarditis with highly eccentric aortic valve regurgitation. The blood cultures taken several times remained sterile. The indication for surgical aortic valve replacement was made. Conventional microbiological work-up of the heart valve did not reveal any pathogens. The additional molecular genetic testing using eubacterial PCR ("polymerase chain reaction" [PCR]) finally demonstrated the presence of Tropheryma whipplei. A number of therapeutic options were available. The authors decided on intravenous antibiotic therapy with ceftriaxone for 14 days and follow-up therapy with oral trimethoprim/sulfamethoxazole for 1 year. The case illustrates the importance of additional molecular diagnostics beyond the conventional methods in blood culture-negative endocarditis to identify the pathogen and initiate appropriate therapy.
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Affiliation(s)
- L Schönfeld
- Klinik für Innere Medizin IA, Bundeswehrzentralkrankenhaus, Rübenacherstraße 170, 56072, Koblenz, Deutschland
| | - G Scheumann
- Klinik für Innere Medizin IA, Bundeswehrzentralkrankenhaus, Rübenacherstraße 170, 56072, Koblenz, Deutschland.
| | - J Jöckel
- Klinik für Innere Medizin IA, Bundeswehrzentralkrankenhaus, Rübenacherstraße 170, 56072, Koblenz, Deutschland
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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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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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McGee M, Brienesse S, Chong B, Levendel A, Lai K. Tropheryma whipplei Endocarditis: Case Presentation and Review of the Literature. Open Forum Infect Dis 2019; 6:ofy330. [PMID: 30648125 PMCID: PMC6329903 DOI: 10.1093/ofid/ofy330] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 12/03/2018] [Indexed: 12/17/2022] Open
Abstract
Whipple’s disease is a rare infective condition, classically presenting with gastrointestinal manifestations. It is increasingly recognized as an important cause of culture-negative endocarditis. We present a case of Whipple’s endocarditis presenting with heart failure. A literature review identified 44 publications documenting 169 patients with Whipple’s endocarditis. The average age was 57.1 years. There is a clear sex predominance, with 85% of cases being male. Presenting symptoms were primarily articular involvement (52%) and heart failure (41%). In the majority of cases, the diagnosis was made on examination of valvular tissue. Preexisting valvular abnormalities were reported in 21%. The aortic valve was most commonly involved, and multiple valves were involved in 64% and 23% of cases, respectively. Antibiotic therapy was widely varied and included a ceftriaxone, trimethoprim, and sulfamethoxazole combination. The average follow-up was 20 months, and mortality was approximately 24%. Physician awareness is paramount in the diagnosis and management of this rare condition.
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Affiliation(s)
- Michael McGee
- John Hunter Hospital, New Lambton, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
| | - Stephen Brienesse
- John Hunter Hospital, New Lambton, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
| | - Brian Chong
- John Hunter Hospital, New Lambton, NSW, Australia
| | | | - Katy Lai
- John Hunter Hospital, New Lambton, NSW, Australia.,University of Newcastle, Newcastle, NSW, Australia
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Wartique L, Lagier JC, Raoult D, Jamilloux Y, Sève P. Mesenteric lymphadenitis as a presenting feature of Whipple's disease: Value of PCR analysis. Int J Infect Dis 2018; 75:15-17. [PMID: 30096359 DOI: 10.1016/j.ijid.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease (WD) is a rare chronic and systemic infection caused by the ubiquitous actinomycete Tropheryma whipplei. A case of localized infection with mesenteric adenopathy associated with a prolonged unexplained fever is reported herein. Screening by PCR on saliva and stool was positive, and T. whipplei was formally identified by specific PCR on duodenal and mesenteric adenopathy biopsies. Histological analysis did not demonstrate periodic acid-Schiff-positive macrophages or positive T. whipplei immunochemistry in either the duodenal mucosa or mesenteric nodes. Treatment with hydroxychloroquine and doxycycline allowed a rapid resolution of symptoms, and subsequent saliva and stool PCR results were negative.
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Affiliation(s)
- Lucie Wartique
- Department of Internal Medicine, Grand Hôpital de Charleroi, Charleroi, Belgium
| | | | - Didier Raoult
- Aix Marseille Université, IRD, MEPHI, IHU - Méditerranée Infection, Marseille, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
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6
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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: 88] [Impact Index Per Article: 12.6] [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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Derrick C, Love BL, Sanasi-Bhola K. Successful treatment with ceftriaxone induction and minocycline maintenance for gastrointestinal Whipple's disease. J Antimicrob Chemother 2015; 71:1123-5. [PMID: 26679252 DOI: 10.1093/jac/dkv422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Caroline Derrick
- University of South Carolina-School of Medicine, 1 Richland Medical Park, Suite 420, Columbia, SC 29203, USA
| | - Bryan L Love
- WJB Dorn Veterans Affairs Medical Center, 6349 Garners Ferry Road, Columbia, SC 29209, USA
| | - Kamla Sanasi-Bhola
- University of South Carolina-School of Medicine, 1 Richland Medical Park, Suite 420, Columbia, SC 29203, USA
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Gruber JR, Sarro R, Delaloye J, Surmely JF, Siniscalchi G, Tozzi P, Jaques C, Jaton K, Delabays A, Greub G, Rutz T. Tropheryma whipplei bivalvular endocarditis and polyarthralgia: a case report. J Med Case Rep 2015; 9:259. [PMID: 26577283 PMCID: PMC4650277 DOI: 10.1186/s13256-015-0746-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 10/23/2015] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Tropheryma whipplei infection should be considered in patients with suspected infective endocarditis with negative blood cultures. The case (i) shows how previous symptoms can contribute to the diagnosis of this illness, and (ii) elucidates current recommended diagnostic and therapeutic approaches to Whipple's disease. CASE PRESENTATION A 71-year-old Swiss man with a past history of 2 years of diffuse arthralgia was admitted for a possible endocarditis with severe aortic and mitral regurgitation. Serial blood cultures were negative. Our patient underwent replacement of his aortic and mitral valve by biological prostheses. T. whipplei was documented by polymerase chain reactions on both removed valves and on stools, as well as by valve histology. A combination of hydroxychloroquine and doxycycline was initiated as lifetime treatment followed by the complete disappearance of his arthralgia. CONCLUSIONS This case report underlines the importance of considering T. whipplei as a possible causal etiology of blood culture-negative endocarditis. Lifelong antibiotic treatment should be considered for this pathogen (i) due to the significant rate of relapses, and (ii) to the risk of reinfection with another strain since these patients likely have some genetic predisposition.
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Affiliation(s)
- Janina Rivas Gruber
- Department of Internal Medicine, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 11, 1011, Lausanne, Switzerland.
| | - Rossella Sarro
- Institute of Pathology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 25, 1011, Lausanne, Switzerland.
| | - Julie Delaloye
- Infectious Disease Service, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 48, 1011, Lausanne, Switzerland.
| | | | - Giuseppe Siniscalchi
- Service of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 46, 1011, Lausanne, Switzerland.
| | - Piergiorgio Tozzi
- Service of Cardiac Surgery, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 46, 1011, Lausanne, Switzerland. .,Service of Cardiology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Cyril Jaques
- Cabinet Medical, Avenue de Florimont 8, 1006, Morges, Switzerland.
| | - Katia Jaton
- Institute of Microbiology, University of Lausanne, Rue de Bugnon 48, 1011, Lausanne, Switzerland.
| | - Alain Delabays
- Service of Cardiology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
| | - Gilbert Greub
- Infectious Disease Service, Centre Hospitalier Universitaire Vaudois (CHUV), Rue de Bugnon 48, 1011, Lausanne, Switzerland.
| | - Tobias Rutz
- Service of Cardiology, Centre Hospitalier Universitaire Vaudois (CHUV), Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Lagier JC, Fenollar F, Raoult D. Maladie de Whipple et infections à Tropheryma whipplei. Quand l’interniste doit y penser ? Comment les traiter ? Rev Med Interne 2014; 35:801-7. [DOI: 10.1016/j.revmed.2014.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/03/2014] [Accepted: 04/22/2014] [Indexed: 12/17/2022]
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Emonet S, Wuillemin T, Harbarth S, Wassilew N, Cikirikcioglu M, Schrenzel J, Lagier JC, Raoult D, van Delden C. Relapse of Tropheryma whipplei endocarditis treated by trimethoprim/sulfamethoxazole, cured by hydroxychloroquine plus doxycycline. Int J Infect Dis 2014; 30:17-9. [PMID: 25461667 DOI: 10.1016/j.ijid.2014.11.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Accepted: 11/03/2014] [Indexed: 12/17/2022] Open
Abstract
The best treatment for Tropheryma whipplei infections is controversial. We report a patient who suffered from T. whipplei aortic native valve endocarditis that relapsed despite surgery and four weeks of intravenous ceftriaxone followed by several months of oral trimethoprim/sulfamethoxazole. Cure was achieved after replacement of the prosthesis with a homograft and 18 months of oral doxycycline-hydroxychloroquine. We discuss the need for a change in treatment guidelines for T. whipplei infections.
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Affiliation(s)
- Stephane Emonet
- Service of Infectious Diseases, Department of Medical Specialties, University Hospitals Geneva, Switzerland; Bacteriology laboratory, Department of Laboratories and Genetic Medicine, University Hospitals Geneva, Switzerland.
| | | | - Stephan Harbarth
- Service of Infectious Diseases, Department of Medical Specialties, University Hospitals Geneva, Switzerland
| | - Nasstasja Wassilew
- Service of Infectious Diseases, Department of Medical Specialties, University Hospitals Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, Department of Surgery, University Hospitals Geneva, Switzerland
| | - Jacques Schrenzel
- Service of Infectious Diseases, Department of Medical Specialties, University Hospitals Geneva, Switzerland; Bacteriology laboratory, Department of Laboratories and Genetic Medicine, University Hospitals Geneva, Switzerland
| | - Jean-Christophe Lagier
- Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, 13005 Marseille, France
| | - Didier Raoult
- Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, 13005 Marseille, France
| | - Christian van Delden
- Service of Infectious Diseases, Department of Medical Specialties, University Hospitals Geneva, Switzerland
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Fenollar F, Lagier JC, Raoult D. Tropheryma whipplei and Whipple's disease. J Infect 2014; 69:103-12. [DOI: 10.1016/j.jinf.2014.05.008] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 05/15/2014] [Accepted: 05/19/2014] [Indexed: 11/26/2022]
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12
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Lochouarn M, Lagier JC, Raoult D, Pulcini C. A case of Whipple's disease evolving over 30 years. Med Mal Infect 2014; 44:331-3. [PMID: 25015310 DOI: 10.1016/j.medmal.2014.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2013] [Revised: 04/27/2014] [Accepted: 06/02/2014] [Indexed: 11/29/2022]
Affiliation(s)
- M Lochouarn
- Service d'infectiologie, hôpital l'Archet 1, CHU de Nice, 151, route Saint-Antoine-de-Ginestière, BP 3079, 06202 Nice cedex 3, France.
| | - J-C Lagier
- URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, faculté de médecine, université d'Aix-Marseille, 27, boulevard Jean-Moulin, 13385 Marseille cedex 5, France
| | - D Raoult
- URMITE, UM63, CNRS 7278, IRD 198, Inserm 1095, faculté de médecine, université d'Aix-Marseille, 27, boulevard Jean-Moulin, 13385 Marseille cedex 5, France
| | - C Pulcini
- Service d'infectiologie, hôpital l'Archet 1, CHU de Nice, 151, route Saint-Antoine-de-Ginestière, BP 3079, 06202 Nice cedex 3, France; Faculté de médecine, université de Nice-Sophia Antipolis, 28, avenue Valombrose, 06100 Nice, France
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Lagier JC, Fenollar F, Lepidi H, Giorgi R, Million M, Raoult D. Treatment of classic Whipple's disease: from in vitro results to clinical outcome. J Antimicrob Chemother 2013; 69:219-27. [PMID: 23946319 DOI: 10.1093/jac/dkt310] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Patients with classic Whipple's disease have a lifetime defect in immunity to Tropheryma whipplei and frequently develop treatment failures, relapses or reinfections. Empirical treatments were tested before culture was possible, but the only in vitro bactericidal treatment consists of a combination of doxycycline and hydroxychloroquine. METHODS Our laboratory has been a reference centre since the first culturing of Tropheryma whipplei, and we have tested 27,000 samples by PCR and diagnosed 250 cases of classic Whipple's disease. We report here the clinical course of patients who were followed by one of our group. RESULTS Of 29 patients, 22 (76%) were previously treated with immunosuppressive drugs, 26 (90%) suffered from arthralgias and 22 (76%) exhibited weight loss. Intravenous initial treatment was paradoxically associated with an increased risk of failure (P = 0.0282). Treatment with doxycycline and hydroxychloroquine (± sulfadiazine or trimethoprim/sulfamethoxazole) was associated with a better outcome (0/13 failures), whereas all 14 patients who were first treated with trimethoprim/sulfamethoxazole and referred to us (P < 0.0001) experienced failure. Among the patients treated with doxycycline and hydroxychloroquine after previous antibiotic treatments, two presented with a reinfection caused by different T. whipplei strains. Finally, serum therapeutic drug monitoring allowed us to detect a lack of compliance in the only patient with failure among the 22 patients treated with lifetime doxycycline. CONCLUSIONS In vitro results were confirmed by clinical outcomes and trimethoprim/sulfamethoxazole was associated with failures. The recommended management is a combination of doxycycline and hydroxychloroquine for 1 year, followed by doxycycline for the patient's lifetime along with stringent therapeutic drug monitoring.
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Affiliation(s)
- Jean-Christophe Lagier
- Aix Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, 13005 Marseille, France
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