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Lai LM, Zhu XY, Zhao R, Chen Q, Liu JJ, Liu Y, Yuan L. Tropheryma whipplei detected by metagenomic next-generation sequencing in bronchoalveolar lavage fluid. Diagn Microbiol Infect Dis 2024; 109:116374. [PMID: 38805857 DOI: 10.1016/j.diagmicrobio.2024.116374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024]
Abstract
Whipple's disease is a chronic systemic infectious disease that mainly affects the gastrointestinal tract. In some cases, Tropheryma whipplei can cause infection at the implant site or even throughout the body. In this study, we collected alveolar lavage fluid samples from patients with Tropheryma whipplei from 2020 to 2022, and retrospectively analyzed the clinical data of Tropheryma whipplei positive patients. Patient's past history, clinical manifestations, laboratory examinations, chest CT findings, treatment, and prognosis were recorded. 16 BALFs (70/1725, 4.0 %) from 16 patients were positive for Tropheryma whipplei. 8 patients were male with an average age of 50 years. The main clinical symptoms of patients included fever (9/16), cough (7/16), dyspnea (7/16), and expectoration (5/16), but neurological symptoms and arthralgia were rare. Cardiovascular and cerebrovascular diseases were the most common comorbidity (n=8). The main laboratory characteristics of the patient are red blood cell count, hemoglobin, total protein and albumin below normal levels (11/16), and/or creatinine above normal levels(14/16). Most chest computed tomography mainly show focal or patchy heterogeneous infection (n=5) and pleural effusion (n=8). Among the 6 samples, Tropheryma whipplei was the sole agent, and Klebsiella pneumoniae was the most common detected other pathogens. Metagenomic next-generation sequencing technology has improved the detection rate and attention of Tropheryma whipplei. Further research is needed to distinguish whether Tropheryma whipplei present in respiratory samples is a pathogen or an innocent bystander.
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Affiliation(s)
- Lan Min Lai
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Xin Yu Zhu
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Rui Zhao
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Qiang Chen
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Jiao Jiao Liu
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Yang Liu
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Lei Yuan
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China.
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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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3
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Liu F, Yang X, He Z, OuYang C, Yang X, Yang C. Using Targeted Next-Generation Sequencing to Diagnose Severe Pneumonia Due to Tropheryma Whipplei and Human Metapneumovirus: A Case Report and Literature Review. Infect Drug Resist 2024; 17:1863-1868. [PMID: 38745678 PMCID: PMC11092972 DOI: 10.2147/idr.s451477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 04/17/2024] [Indexed: 05/16/2024] Open
Abstract
Background In addition to the well-known Whipple's disease (WD), Tropheryma Whipplei (TW) can also lead to acute pneumonia. There is no unified consensus on the susceptible population, pathogenesis, clinical manifestations, diagnostic criteria, and treatment options for TW pneumonia. Clinical Presentation and Intervention This is an elderly patient with multiple injuries caused by falling from a building, and was transferred to intensive care unit (ICU) for mechanical ventilation and empirical anti-infection treatment due to severe pneumonia, and then the results of targeted next-generation sequencing (tNGS) in patient's bronchoalveolar lavage fluid (BALF) suggested TW and human metapneumovirus (HMPV) infection, and after switching to anti-infective therapy for TW, the patient was successfully extubated and transferred out of the ICU. Conclusion This is the first case of using tNGS to diagnose severe pneumonia caused by TW and HMPV. We hope that our study can serve as a reference for the diagnosis and treatment of related cases in the future.
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Affiliation(s)
- Fang Liu
- Department of Intensive Care Unit, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, People’s Republic of China
| | - XuYong Yang
- Department of Pediatrics, Gaoxin Hospital of The First Affiliated Hospital of Nanchang University, Nanchang, People’s Republic of China
| | - Zhaohui He
- Department of Intensive Care Unit, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, People’s Republic of China
| | - Chenghong OuYang
- Department of Intensive Care Unit, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, People’s Republic of China
| | - Xiaogang Yang
- Department of Intensive Care Unit, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, People’s Republic of China
| | - Chunli Yang
- Department of Intensive Care Unit, Jiangxi Provincial People’s Hospital, The First Affiliated Hospital of Nanchang Medical College, Nanchang, People’s Republic of China
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Deng Y, Zhang H, Lu J, Zhou Z, Zhang T, Cui X. Whipple's disease of the respiratory system: A case report. Exp Ther Med 2024; 27:133. [PMID: 38414785 PMCID: PMC10895612 DOI: 10.3892/etm.2024.12421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 01/25/2024] [Indexed: 02/29/2024] Open
Abstract
Whipple's disease (WD) is a multiple-system chronic disease caused by Tropheryma whipplei (T. whipplei) infection. The present study describes 3 cases of WD with clinical manifestations of cough, chest pain, headache, dyspnea, sputum, joint pain, abdominal pain, diarrhea and weight loss. Chest computed tomography (CT) showed signs of plaques, nodules and pleural thickening; and bronchoscopic alveolar lavage fluid metagenomic-sequencing indicated that it was T. whipplei. One patient was treated with meropenem as the starting regimen and two patients were treated with ceftriaxone as the starting regimen. Furthermore, two patients were provided with a maintenance regimen of cotrimoxazole and one was given a maintenance regimen of minocycline, which was combined with meropenem and ceftriaxone in order to improve their cough, chest pain, headache and dyspnea symptoms. To the best of our knowledge, there are few reports on WD of the respiratory system caused by T. whipplei, and differential diagnosis is the key to clinical diagnosis. When WD of the respiratory system is difficult to diagnose, metagenomic second-generation sequencing (mNGS) may be a better choice, which can achieve early diagnosis and early treatment. However, its clinical value is still limited; therefore, more research needs to be conducted in the future.
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Affiliation(s)
- Yue Deng
- Department of Respiratory and Critical Care Medicine, The Fifth People's Hospital of Chongqing, Chongqing 400062, P.R. China
| | - Hongmei Zhang
- Department of Respiratory and Critical Care Medicine, The Fifth People's Hospital of Chongqing, Chongqing 400062, P.R. China
| | - Junyu Lu
- Department of Respiratory and Critical Care Medicine, The Fifth People's Hospital of Chongqing, Chongqing 400062, P.R. China
| | - Zhiyu Zhou
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Ting Zhang
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital of Chongqing Medical University, Chongqing 400010, P.R. China
| | - Xuerong Cui
- Department of Respiratory Medicine, People's Hospital of Shizhu Tujia Autonomous County, Chongqing 409199, P.R. China
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Saffioti C, Nebiolo M, Caorsi R, Mesini A, Severino M, Brisca G, Castagnola E, Gattorno M. Whipple Disease Presenting as Isolated Transverse Myelitis with Permanent Neurological Damage in a Patient with Systemic Lupus Erythematosus: A Case Report of a Difficult Diagnosis with a Literature Review. Infect Dis Rep 2024; 16:269-280. [PMID: 38525769 PMCID: PMC10961757 DOI: 10.3390/idr16020022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/03/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
We describe an atypical case of Whipple disease exclusively involving the spinal cord in an adolescent receiving immunosuppressive therapy for systemic lupus erythematosus. The diagnosis was particularly difficult since lupus and Whipple disease can present similar clinical features and the patient's prolonged contact with sewage was initially not mentioned. A literature review of the clinical, imaging, diagnostic, and therapeutic challenges of Whipple disease is also performed.
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Affiliation(s)
- Carolina Saffioti
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (C.S.); (A.M.); (E.C.)
| | - Marta Nebiolo
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genoa, Italy;
| | - Roberta Caorsi
- Rheumatolgy and Autoinflammatory Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (R.C.); (M.G.)
| | - Alessio Mesini
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (C.S.); (A.M.); (E.C.)
| | | | - Giacomo Brisca
- Paediatric and Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Elio Castagnola
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (C.S.); (A.M.); (E.C.)
| | - Marco Gattorno
- Rheumatolgy and Autoinflammatory Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (R.C.); (M.G.)
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Valadas A, Fatela N, Sepúlveda Santos T, Carvalho ML. Whipple's disease - A typical endoscopic finding of a rare disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024; 116:157-158. [PMID: 36454089 DOI: 10.17235/reed.2022.9338/2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
A 49-year-old female presented with a 5-month course of diarrhoea, nocturn abdominal pain, asthenia, and weight loss of 30% of her body mass in three months. The patient had also a four-year medical history of bilateral mechanic gonalgy and arthralgias of the metacarpophalangeal and interphalangeal joints, despite treatment with prednisolone. On examination the patient had hyperpigmentation of the face and thorax, low-grade fever, and a BMI of 15,8 Kg/m2. Diarrhoea was documented with watery stools seven times per day despite loperamide, brownish, with no visible blood or mucous. Since the upper GI endoscopy and colonoscopy had no macroscopic abnormalities, the patient underwent a capsule endoscopy, which revealed continuous mucosal lesion with lymphangiectasia, oedema, villous atrophy and areas of denudation with hematinic punctate from the duodenum to the ileum. Diagnosis of Whipple's Disease was made with typical histology findings in duodenum material and a positive PCR for Tropheryma whipplei.
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Affiliation(s)
- Ana Valadas
- Internal Medicine, Hospital de Santa Maria. Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - Narcisa Fatela
- Gastrenterology and Hepathology, Hospital de Santa Maria. Centro Hospitalar Universitário Lisboa Norte, Portugal
| | - Tiago Sepúlveda Santos
- Internal Medicine, Hospital de Santa Maria. Centro Hospitalar Universitário Lisboa Norte
| | - Maria Leonor Carvalho
- Gastroenterology and Hepathology, Hospital de Santa Maria. Centro Hospitalar Universitário Lisboa Norte
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Chen Q, Niu YL, Zhang T. Diagnosis and treatment of Whipple disease after kidney transplantation: A case report. World J Clin Cases 2023; 11:6019-6024. [PMID: 37727483 PMCID: PMC10506035 DOI: 10.12998/wjcc.v11.i25.6019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 07/20/2023] [Accepted: 08/01/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Kidney transplantation is the standard treatment for end-stage renal disease. Particularly, rare and specific pathogenic infections which are asymptomatic are often difficult to diagnose, causing delayed and ineffective treatment and thus seriously affecting prognosis. Tropheryma whipplei (T. whipplei) is a Gram-positive actinomycete widely found in soil, sewage, and other external environments and is present in the population as an asymptomatic pathogen. There is relatively little documented research on T. whipplei in renal transplant patients, and there are no uniform criteria for treating this group of post-transplant patients. This article describes the treatment of a 42-year-old individual with post-transplant T. whipplei infection following kidney transplantation. CASE SUMMARY To analyze clinical features of Whipple's disease and summarize its diagnosis and treatment effects after renal transplantation. Clinical data of a Whipple's disease patient treated in the affiliated hospital of Guizhou Medical University were collected and assessed retrospectively. The treatment outcomes and clinical experience were then summarized via literature review. The patient was admitted to the hospital due to recurrent diarrhea for 1 mo, shortness of breath, and 1 wk of fever, after 3 years of renal transplantation. The symptoms of the digestive and respiratory systems were not significantly improved after adjusting immunosuppressive regimen and anti-diarrheal, empirical antibiotic treatments. Bronchoscopic alveolar fluid was collected for meta-genomic next-generation sequencing (mNGS). The deoxyribonucleic acid sequence of Tropheryma whipplei was detected, and Whipple's disease was diagnosed. Meropenem, ceftriaxone, and other symptomatic treatments were given, and water-electrolyte balance was maintained. Symptoms resolved quickly, and the patient was discharged after 20 d of hospitalization. The compound sulfamethoxazole tablet was continued for 3 mo after discharge. No diarrhea, fever, and other symptoms occurred during the 6-month follow-up. CONCLUSION Whipple's disease is rare, with no specific symptoms, which makes diagnosis difficult. Polymerase chain reaction or mNGS should be immediately performed when the disease is suspected to confirm the diagnosis.
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Affiliation(s)
- Qian Chen
- Department of Organ Transplantation, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Yu-Lin Niu
- Department of Organ Transplantation, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
| | - Tao Zhang
- Department of Organ Transplantation, Affiliated Hospital of Guizhou Medical University, Guiyang 550000, Guizhou Province, China
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Weber M, Dancygier H, Blasberg T, Wedi E. [Co-occurrence of Whipple's disease and hyperparathyroidism - coincidence or causal relationship?]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1214-1220. [PMID: 37309099 DOI: 10.1055/a-1984-0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Whipple's disease is a rare infectious disease with multiple clinical manifestations. The disease is named after George Hoyt Whipple, who first recorded the illness in 1907 after conducting the autopsy of a 36-year-old man with weight loss, diarrhea, and arthritis. Under the microscope, Whipple discovered a rod-shaped bacterium in the patient's intestinal wall, which was not confirmed as a new bacterial species until 1992, when it was named Tropheryma whipplei.Recurrence of Whipple's disease can occur years after an initial diagnosis and often manifests with extraintestinal symptoms such as arthritides or skin efflorescences, years before a gastrointestinal complaint. However, the simultaneous occurrence of primary hyperparathyroidism in the present case is a hitherto unknown clinical picture and opens up new questions and perspectives in the context of diagnostics and therapy.
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Affiliation(s)
- Marie Weber
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| | | | - Tobias Blasberg
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| | - Edris Wedi
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
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Fang Z, Liu Q, Tang W, Yu H, Zou M, Zhang H, Xue H, Lin S, Pei Y, Ai J, Chen J. Experience in the diagnosis and treatment of pneumonia caused by infection with Tropheryma whipplei: A case series. Heliyon 2023; 9:e17132. [PMID: 37484369 PMCID: PMC10361318 DOI: 10.1016/j.heliyon.2023.e17132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 07/25/2023] Open
Abstract
Tropheryma whipplei (TW) is the root cause of Whipple's disease (WD), a rare infectious illness leading to multi-organ impairment. A prominent feature of WD is acute pneumonia, which can be exceedingly challenging to diagnose clinically due to the pathogen's surreptitious nature. However and significantly, with the advent of metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF), it offers clinicians a potent tool at their disposal to detect TW infections. The present study conducted a retrospective analysis of clinical data gleaned from five patients in Hunan Province in China. Findings in this study demonstrated the potential of BALF-mNGS in diagnosing pneumonia caused by TW infection.
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Affiliation(s)
- Zhixiong Fang
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Qiong Liu
- Linxiang People’s Hospital, Hunan province, China
| | - Wei Tang
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Hongyin Yu
- Center for Infectious Diseases, The First People's Hospital of Huaihua, Hunan, China
| | - Min Zou
- Department of Respiratory and Critical Care Medicine, The First People’s Hospital of Xiangtan City Affiliated to Nanhua University, Hunan, China
| | - Haiming Zhang
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Haiyan Xue
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Sha Lin
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Yi Pei
- Department of Tuberculosis, Changsha Central Hospital, Changsha, China
| | - Jingwen Ai
- Department of Infectious Disease, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Chen
- Department of Liver Diseases, Third Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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Ye H, Hu X, Tong TRSW, Chen S, Li T, Xing F, Chan JFW, Yuen KY, Chiu KHY. Whipple's disease presenting as weight gain and constipation in a Chinese woman. BMC Infect Dis 2023; 23:302. [PMID: 37158848 PMCID: PMC10165756 DOI: 10.1186/s12879-023-08276-y] [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: 02/09/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Whipple's disease is a chronic infection due to Tropheryma whipplei, commonly reported in the Caucasian but not in the Chinese population. CASE PRESENTATION A 52-year-old female with good past health, was diagnosed with Whipple's disease, presenting with constipation, unintentional weight gain, and fleeting polyarthralgia. Investigations prior to admission showed raised CA125 and computed tomography of the abdomen showed multiple retroperitoneal mesenteric lymphadenopathies. Extensive investigations performed on secondary causes of weight gain were unrevealing. Subsequent PET-CT scan revealed generalized lymphadenopathy involving the left deep cervical, supraclavicular, and retroperitoneal mesenteric area. Excisional biopsy of the left supraclavicular lymph node was performed, with histology showing infiltrations of Periodic acid-Schiff positive foamy macrophages. T. whipplei DNA was detected in her serum, saliva, stool, and lymph node by PCR targeting the 16S ribosomal RNA gene. She was started on intravenous ceftriaxone, and then stepped down to oral antibiotics for a total of 44 months. The recurrence of fever after 12 days of ceftriaxone raised the suspicion of Immune Reconstitution Inflammatory Syndrome (IRIS). Serial imaging showed a gradual reduction in the size of retroperitoneal lymphadenopathies. Literature review on Whipple's disease in the Chinese population identified 13 reports of detectable T. whipplei DNA in clinical specimens. The majority of the cases were pneumonia, followed by culture-negative endocarditis, encephalitis, and skin and soft tissue infection. However, most patients with pneumonia were diagnosed based on next generation sequencing alone, with the resolution of pulmonary infiltrates without adequate duration of antibiotics, suggesting the possibility of colonization instead of infection. The recommendation of long-term doxycycline suppression after treatment may be supported by the slow response of retroperitoneal lymphadenopathies to antibiotics in our patient. CONCLUSIONS Unintentional weight gain and constipation could be atypical presentations of Whipple's disease. It is a rare disease in the Chinese population despite the advancement of molecular techniques in the diagnosis of infections. A prolonged course of antibiotics may be required due to slow clinical response as documented by serial imaging in our case. The possibility of IRIS should be considered in patients with breakthrough fever during treatment of Whipple's disease.
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Affiliation(s)
- Haiyan Ye
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Xiao Hu
- Department of Respiratory Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | | | - Shuang Chen
- Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Tao Li
- Department of Radiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Fanfan Xing
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jasper Fuk-Woo Chan
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Carol Yu Centre for Infection, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kwok-Yung Yuen
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Carol Yu Centre for Infection, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kelvin Hei-Yeung Chiu
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China.
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Clarke MCC, Price RN. Delayed Diagnosis of Whipple’s Disease Complicated by Jarisch–Herxheimer Reaction to Ceftriaxone Treatment: A Case Report and Literature Review. Trop Med Infect Dis 2022; 7:tropicalmed7030040. [PMID: 35324587 PMCID: PMC8954982 DOI: 10.3390/tropicalmed7030040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/25/2023] Open
Abstract
Whipple’s disease is a rare chronic infection caused by the actinomycete Tropheryma whipplei. Patients commonly present with gastrointestinal symptoms. We present a case of classic Whipple’s disease complicated by a probable Jarisch–Herxheimer reaction following the initiation of ceftriaxone treatment.
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Affiliation(s)
- Marcus C C Clarke
- Division of Medicine, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, NT 0810, Australia
| | - Ric N Price
- Division of Medicine, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, NT 0810, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Ellengowan Dr, Casuarina, NT 0810, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX1 2JD, UK
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Leyens J, Bender TTA, Mücke M, Stieber C, Kravchenko D, Dernbach C, Seidel MF. The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis. Orphanet J Rare Dis 2021; 16:326. [PMID: 34294115 PMCID: PMC8296612 DOI: 10.1186/s13023-021-01945-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 07/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences. RESULTS A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000. CONCLUSIONS RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.
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Affiliation(s)
- Judith Leyens
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Neonatology and Pediatric Care, Children's University Hospital, Bonn, Germany
| | - Tim Th A Bender
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Institute of Human Genetics, University Hospital, Bonn, Germany
| | - Martin Mücke
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
| | - Christiane Stieber
- Institute of General Practice and Family Medicine, University Hospital, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Dmitrij Kravchenko
- Center for Rare Diseases Bonn (ZSEB), University Hospital, Bonn, Germany
- Department of Radiology, University Hospital, Bonn, Germany
| | - Christian Dernbach
- Division of Medical Psychology and Department of Psychiatry, University Hospital, Bonn, Germany
| | - Matthias F Seidel
- Department of Rheumatology, Spitalzentrum-Centre hospitalier, Biel-Bienne, Switzerland.
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13
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Knol S, Nijhuis RL, Geeraedts F, Linssen GC. Blood Culture-negative Endocarditis Caused by Tropheryma whipplei: Whipple's endocarditis. Eur J Case Rep Intern Med 2021; 8:002596. [PMID: 34123951 DOI: 10.12890/2021_002596] [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] [Received: 04/28/2021] [Accepted: 05/02/2021] [Indexed: 11/05/2022] Open
Abstract
Case description A 67-year-old man was admitted with progressive heart failure due to blood culture-negative endocarditis of the aortic valve. Urgent aortic valve replacement was needed. Polymerase chain reaction (PCR) testing of samples of the explanted aortic valve revealed Tropheryma whipplei. The patient received ceftriaxone, followed by long-term co-trimoxazole. Recent arthralgia may have been a diagnostic clue. Conclusion Whipple's endocarditis should be considered in patients with arthralgia and blood culture-negative endocarditis (BCNIE). LEARNING POINTS Whipple's endocarditis should be considered in patients with symptoms of arthralgia and blood culture-negative endocarditis (BCNIE).Serum polymerase chain reaction is the main diagnostic test.Both physician awareness and multidisciplinary management by regional endocarditis teams are recommended strategies to provide optimal patient care.
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Affiliation(s)
- Silke Knol
- Department of Cardiology, Hospital Group Twente (ZGT), Almelo and Hengelo, The Netherlands
| | - Rogier L Nijhuis
- Department of Cardiology, Hospital Group Twente (ZGT), Almelo and Hengelo, The Netherlands
| | - Felix Geeraedts
- Laboratory Microbiology Twente Achterhoek (LabMicTA), Hengelo, The Netherlands
| | - Gerard Cm Linssen
- Department of Cardiology, Hospital Group Twente (ZGT), Almelo and Hengelo, The Netherlands
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14
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Feurle GE, Moos V, Stroux A, Gehrmann-Sommer N, Poddubnyy D, Fiehn C, Schneider T. Differential diagnostic value of rheumatic symptoms in patients with Whipple's disease. Sci Rep 2021; 11:5980. [PMID: 33727566 PMCID: PMC7966399 DOI: 10.1038/s41598-021-85217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
Most patients with Whipple’s disease have rheumatic symptoms. The aim of our prospective, questionnaire-based, non-interventional clinical study was to assess whether these symptoms are useful in guiding the differential diagnosis to the rheumatic disorders. Forty patients with Whipple’s disease, followed by 20 patients for validation and 30 patients with rheumatoid-, 21 with psoriatic-, 15 with palindromic- and 25 with axial spondyloarthritis were recruited for the present investigation. Patients with Whipple’s disease and patients with rheumatic disorders were asked to record rheumatic symptoms on pseudonymized questionnaires. The data obtained were subjected to multiple logistic regression analysis. Episodic pain with rapid onset, springing from joint to joint was most common in patients with palindromic arthritis and second most common and somewhat less conspicuous in Whipple’s disease. Continuous pain in the same joints predominated in patients with rheumatoid-, psoriatic-, and axial spondyloarthritis. Multiple logistic equations resulted in a predicted probability for the diagnosis of Whipple’s disease of 43.4 ± 0.19% (M ± SD) versus a significantly lower probability of 23.8 ± 0.19% (M ± SD) in the aggregate of patients with rheumatic disorders. Mean area under the curve (AUC) ± SD was 0.781 ± 0.044, 95% CI 0.695–0.867, asymptotic significance p < 0.001. The logistic equations predicted probability for the diagnosis of Whipple’s disease in the initial series of 40 patients of 43.4 ± 0.19% was not significantly different in the subsequent 20 patients of 38.2 ± 0.28% (M ± SD) (p = 0.376). The data may be useful in a predictive algorithm for diagnosing Whipple’s disease. The project is registered as clinical study DRK S0001566.
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Affiliation(s)
- Gerhard E Feurle
- DRK Krankenhaus Neuwied, Eduard Moerikestrasse 12, 56567, Neuwied, Germany.
| | - Verena Moos
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Stroux
- Institut für Biometrie und Klinische Epidemiologie, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Nadine Gehrmann-Sommer
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Fiehn
- Praxis für Rheumatologie, Klinische Immunologie, Medical Center, Baden-Baden, Germany
| | - Thomas Schneider
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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15
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[A 3-week history of intestinal symptoms in a 67-year-old male patient with chronic arthralgia]. Internist (Berl) 2020; 62:433-440. [PMID: 33296012 DOI: 10.1007/s00108-020-00916-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
Whipple disease is an infection caused by the bacterium Tropheryma whipplei. Due to its unspecific clinical symptoms, it is difficult to diagnose and often remains undetected for a long time. The case of a patient who presented with acute intestinal symptoms to the authors' department is reported. The diagnosis of classic Whipple disease was established. The symptoms subsided under antibiotic therapy. Complications in the form of immune reconstitution inflammatory syndrome (IRIS) occurred, requiring immunosuppressive treatment.
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16
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Luque Paz D, Lakbar I, Tattevin P. A review of current treatment strategies for infective endocarditis. Expert Rev Anti Infect Ther 2020; 19:297-307. [PMID: 32901532 DOI: 10.1080/14787210.2020.1822165] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
INTRODUCTION Infective endocarditis is one of the most difficult-to-treat infectious diseases. AREAS COVERED We restricted this review to the anti-infective treatment of the main bacteria responsible for infective endocarditis, i.e. staphylococci, streptococci, enterococci, and Gram-negative bacilli, including HACEK. Specific topics of major interest in treatment strategy are covered as well, including empirical treatment, oral switch, and treatment duration. We searched in the MEDLINE database to identify relevant studies, trials, reviews, or meta-analyses until May 2020. EXPERT OPINION The use of aminoglycosides for the treatment of endocarditis has been dramatically reduced over the last 20 years. It should be administered once daily, and no longer than 2 weeks. For staphylococcal endocarditis, recent data reinforced the role of anti-staphylococcal penicillins, for methicillin-susceptible isolates (alternative, cefazolin), and vancomycin for methicillin-resistant isolates (alternative, daptomycin). For staphylococcal prosthetic-valve endocarditis, these treatments will be reinforced by the addition of gentamicin during the first 2 weeks, and rifampin throughout the whole treatment duration, i.e. 6 weeks. The optimal duration of antibacterial treatment is 4 weeks for most native valve endocarditis, and 6 weeks for prosthetic-valve endocarditis. The oral switch is safe in patients stabilized after the initial intravenous course.
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Affiliation(s)
- David Luque Paz
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Ines Lakbar
- Anaesthesiology and Critical Care Department, University Hospital of Toulouse, Toulouse, France
| | - Pierre Tattevin
- Infectious Diseases and Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
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17
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Schiepatti A, Nicolardi ML, Marone P, Biagi F. Long-term morbidity and mortality in Whipple's disease: a single-center experience over 20 years. Future Microbiol 2020; 15:847-854. [PMID: 32662657 DOI: 10.2217/fmb-2019-0315] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background: Little is known about long-term morbidity and mortality in Whipple's disease (WD). Aim: To describe morbidity and mortality in patients with WD on a long-term follow-up. Materials & methods: Comorbidities, mortality and causes of death were retrospectively registered. Results: A total of 35 patients with WD (9F, 54 ± 11 years) were followed-up for a median of 104 months. Nine patients developed ten complications; three patients died. A total of 31 severe comorbidities apparently unrelated to WD were found in 20 patients: preneoplastic/neoplastic disorders in seven, thromboembolic and cardiovascular events in seven, pneumonia in four, candidiasis in ten patients. Conclusion: WD is frequently complicated by potentially life-threatening infectious, neoplastic and thromboembolic disorders, thus highlighting the need for a life-long multidisciplinary follow-up.
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Affiliation(s)
- Annalisa Schiepatti
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, University of Pavia, Pavia 27100, Italy
| | - Maria Luisa Nicolardi
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, University of Pavia, Pavia 27100, Italy
| | - Piero Marone
- Department of Microbiology & Virology, Fondazione IRCCS Policlinico San Matteo, Pavia 27100, Italy
| | - Federico Biagi
- Istituti Clinici Scientifici Maugeri IRCCS, Gastroenterology Unit of Pavia Institute, University of Pavia, Pavia 27100, Italy
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18
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Affiliation(s)
- Camila D Odio
- From the Department of Medicine (C.D.O., C.R.O., J.J.), Section of Hematology (A.I.L.), and the Department of Pathology, Section of Digestive Diseases (D.J.), Yale School of Medicine, New Haven, CT
| | - Corey R O'Brien
- From the Department of Medicine (C.D.O., C.R.O., J.J.), Section of Hematology (A.I.L.), and the Department of Pathology, Section of Digestive Diseases (D.J.), Yale School of Medicine, New Haven, CT
| | - Jeremy Jacox
- From the Department of Medicine (C.D.O., C.R.O., J.J.), Section of Hematology (A.I.L.), and the Department of Pathology, Section of Digestive Diseases (D.J.), Yale School of Medicine, New Haven, CT
| | - Dhanpat Jain
- From the Department of Medicine (C.D.O., C.R.O., J.J.), Section of Hematology (A.I.L.), and the Department of Pathology, Section of Digestive Diseases (D.J.), Yale School of Medicine, New Haven, CT
| | - Alfred I Lee
- From the Department of Medicine (C.D.O., C.R.O., J.J.), Section of Hematology (A.I.L.), and the Department of Pathology, Section of Digestive Diseases (D.J.), Yale School of Medicine, New Haven, CT
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19
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Joshi A, Kaushik V. In-Silico Proteomic Exploratory Quest: Crafting T-Cell Epitope Vaccine Against Whipple's Disease. Int J Pept Res Ther 2020; 27:169-179. [PMID: 32427224 PMCID: PMC7233679 DOI: 10.1007/s10989-020-10077-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2020] [Indexed: 12/11/2022]
Abstract
Whipple’s disease is one of the rare maladies in terms of spread but very fatal one as it is linked with many disorders (like Gastroenteritis, Endocarditis etc.). Also, current regimens include less effective drugs which require long duration follows up. This exploratory study was conducted to commence the investigation for crafting multi target epitope vaccine against its bacterial pathogen Tropheryma whipplei. The modern bioinformatics tools like VaxiJen, NETMHCII PAN 3.2, ALLERGEN-FP, PATCH-DOCK, TOXIC-PRED, MHCPRED and IEDB were deployed, which makes the study more intensive in analyzing proteome of T. whipplei as these methods are based on robust result generating statistical algorithms ANN, HMM, and ML. This Immuno-Informatics approach leads us in the prediction of two epitopes: VLMVSAFPL and IRYLAALHL interacting with 4 and 6 HLA DRB1 alleles of MHC Class II respectively. VLMVSAFPL epitope is a part of DNA-directed RNA polymerase subunit beta, and IRYLAALHL epitope is a part of membranous protein insertase YidC of this bacterium. Molecular-Docking and Molecular-Simulation analysis yields the perfect interaction based on Atomic contact energy, binding scores along with RMSD values (0 to 1.5 Ǻ) in selection zone. The IEDB (Immune epitope database) population coverage analysis exhibits satisfactory relevance with respect to world population.
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Affiliation(s)
- Amit Joshi
- Domain of Bioinformatics, School of Bio-Engineering and Bio-Sciences, Lovely Professional University, Punjab, India
| | - Vikas Kaushik
- Domain of Bioinformatics, School of Bio-Engineering and Bio-Sciences, Lovely Professional University, Punjab, India
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20
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Moter A, Janneck M, Wolters M, Iking-Konert C, Wiessner A, Loddenkemper C, Hartleben B, Lütgehetmann M, Schmidt J, Langbehn U, Janssen S, Geelhaar-Karsch A, Schneider T, Moos V, Rohde H, Kikhney J, Wiech T. Potential Role for Urine Polymerase Chain Reaction in the Diagnosis of Whipple's Disease. Clin Infect Dis 2020; 68:1089-1097. [PMID: 30351371 PMCID: PMC6424077 DOI: 10.1093/cid/ciy664] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Whipple's disease (WD) is a rare infection with Tropheryma whipplei that is fatal if untreated. Diagnosis is challenging and currently based on invasive sampling. In a case of WD diagnosed from a kidney biopsy, we observed morphologically-intact bacteria within the glomerular capsular space and tubular lumens. This raised the questions of whether renal filtration of bacteria is common in WD and whether polymerase chain reaction (PCR) testing of urine might serve as a diagnostic test for WD. METHODS We prospectively investigated urine samples of 12 newly-diagnosed and 31 treated WD patients by PCR. As controls, we investigated samples from 110 healthy volunteers and patients with excluded WD or acute gastroenteritis. RESULTS Out of 12 urine samples from independent, therapy-naive WD patients, 9 were positive for T. whipplei PCR. In 3 patients, fluorescence in situ hybridization visualized T. whipplei in urine. All control samples were negative, including those of 11 healthy carriers with T. whipplei-positive stool samples. In our study, the detection of T. whipplei in the urine of untreated patients correlated in all cases with WD. CONCLUSIONS T. whipplei is detectable by PCR in the urine of the majority of therapy-naive WD patients. With a low prevalence but far-reaching consequences upon diagnosis, invasive sampling for WD is mandatory and must be based on a strong suspicion. Urine testing could prevent patients from being undiagnosed for years. Urine may serve as a novel, easy-to-obtain specimen for guiding the initial diagnosis of WD, in particular in patients with extra-intestinal WD.
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Affiliation(s)
- Annette Moter
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Matthias Janneck
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Manuel Wolters
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | | | - Alexandra Wiessner
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | | | - Björn Hartleben
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | - Julia Schmidt
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Ulrike Langbehn
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| | - Sabrina Janssen
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Anika Geelhaar-Karsch
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Thomas Schneider
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | - Judith Kikhney
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Thorsten Wiech
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
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21
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Whipple's disease: diagnosis and predictive factors of relapse. Eur J Gastroenterol Hepatol 2020; 32:325-328. [PMID: 31764405 DOI: 10.1097/meg.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Whipple's disease is a very rare disease needing a long-term treatment. The most frequent symptoms are recurrent arthralgia or arthritis, chronic diarrhea, abdominal pain, and weight loss. OBJECTIVES In this article, we have highlighted the main clinical features and diagnostic procedures that lead to the diagnosis and comment on the clinical response, treatment, and the factors of relapse. METHODS Subjects were recruited from the Internal Medicine and Rheumatologic Departments of an University Hospital from November 1997 to January 2016. Overall, 12 subjects were finally diagnosed. RESULTS Mean age was 54.3 years (age range: 30-81), with more male patients (58.3%). Almost all patients had articular symptoms and impaired general condition (91.7%); and a majority had digestive symptoms (75%). Regardless of the symptoms, the most efficient diagnostic tools were the PCR screening on the gastrointestinal biopsies and saliva (83.3 and 72.7% positive results, respectively). More than half of the patients relapsed (55.6%). The relapsing patients were older [63.2 (44-81)] and mostly male with a majority (60%) of digestive symptoms and a delayed diagnosis. CONCLUSIONS In current practice, it is highly difficult to diagnose Whipple's disease. In order to decrease the delay between the first symptoms and the diagnosis, effective tools such as saliva and stools PCR should be used because higher delays of diagnosis lead to a higher number of relapses.
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22
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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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23
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Lagier JC, Raoult D. Whipple's disease and Tropheryma whipplei infections: when to suspect them and how to diagnose and treat them. Curr Opin Infect Dis 2019; 31:463-470. [PMID: 30299363 DOI: 10.1097/qco.0000000000000489] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The delay between first clinical signs and diagnosis of Whipple's disease and Tropheryma whipplei infections is more than 6 years, and relapses are frequently observed, resulting in a need for clinicians to be aware of this infection. RECENT FINDINGS 18 FDG-PET is useful in the diagnosis and the follow-up of patients (particularly in case of neurological involvement). Histological involvement remains the goldstandard for classic Whipple's disease diagnosis. PCR performed on biopsies of fluid is the main tool for the diagnosis of localized chronic infections. PCR performed on urine samples should become an important role of noninvasive diagnostic strategies, while T. whipplei PCR performed on saliva and stool lack specificity. Because of lifetime susceptibility to T. whipplei and in-vitro susceptibility data, a 1-year course of doxycycline and hydroxychloroquine followed by a lifelong treatment by doxycycline is recommended for Whipple's disease, localized endocarditis and encephalitis. SUMMARY Clinical involvement of the different T. whipplei infections is well described, as well as the treatment of Whipple's disease, endocarditis and encephalitis. The place of PCR performed on urine remains to be clarified for diagnosis of localized T. whipplei infections and acute infections as well as the optimal treatment for arthritis and acute infections.
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24
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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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Sluszniak M, Tarner IH, Thiele A, Schmeiser T. [The rich diversity of Whipple's disease]. Z Rheumatol 2018; 78:55-65. [PMID: 30552512 DOI: 10.1007/s00393-018-0573-8] [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: 10/27/2022]
Abstract
Whipple's disease (WD) is a rare, chronic multiorgan disease which can caused by Tropheryma whipplei, a ubiquitous gram positive bacterium. Detection of T. whipplei is mostly performed histologically using periodic acid-Schiff (PAS) staining in affected tissues to visualize characteristic PAS-positive macrophages and by the polymerase chain reaction (PCR). Clinically, WD is often characterized by gastrointestinal symptoms (diarrhea, colic-like abdominal pain and weight loss). Arthritis is a common presentation of WS, often leading to a misdiagnosis of seronegative rheumatoid arthritis and as a consequence to immunosuppressive therapy. The clinical presentation of WD is highly polymorphic affecting different organ systems (e. g. cardiac or neurological manifestation) and making an appropriate clinical diagnosis and even the diagnostic process itself difficult. This article reports on three cases presenting with completely different leading symptoms (initially misdiagnosed as seronegative rheumatoid arthritis, spondyloarthritis and adult onset of Still's disease, respectively) that illustrate the rich diversity of WD. The cases were chosen to draw attention to the fact that although WD is mainly associated with the field of gastroenterology and gastrointestinal (GI) involvement is common, it may appear without GI symptoms. In cases of a clinical suspicion of WD, diagnostic efforts should be made to detect the bacterium in the affected organ. The German S2k guidelines on GI infections and WD published in January 2015 summarized the current state of the art for WD. The currently recommended primary treatment is antibiotics that can infiltrate the cerebrospinal fluid, e. g. ceftriaxone, followed by cotrimoxazole, which should be maintained over several months.
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Affiliation(s)
- M Sluszniak
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland.
| | - I H Tarner
- Abt. für Rheumatologie, Klinische Immunologie, Osteologie und Physikalische Medizin, Kerckhoff-Klinik GmbH Bad Nauheim, Bad Nauheim, Deutschland.,Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - A Thiele
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
| | - T Schmeiser
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
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Diot E, Brugirard S, Hascar T, Vallet P, Vallet AE, Badet F, Bouaziz A, Adelaide L, Régent A. [Movement disorders in a 32-year-old woman]. Rev Med Interne 2018; 39:597-599. [PMID: 29728281 DOI: 10.1016/j.revmed.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 04/10/2018] [Indexed: 11/24/2022]
Affiliation(s)
- E Diot
- Service de neurologie, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - S Brugirard
- Service de neurologie, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - T Hascar
- Service de neurologie, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - P Vallet
- Service de neurologie, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - A-E Vallet
- Service de neurologie, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - F Badet
- Service de médecine interne, maladies infectieuses et tropicales, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - A Bouaziz
- Service de médecine interne, maladies infectieuses et tropicales, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France
| | - L Adelaide
- Service de médecine interne, maladies infectieuses et tropicales, hôpital Lucien-Hussel, montée du Dr-Chapuis, 38209 Vienne cedex 9, France.
| | - A Régent
- Service de médecine interne, hôpital Cochin, 27, rue du Faubourg-Saint-Jacques 75014 Paris, France
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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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Chizinga M, Schiliro D, Mullin B, Barrie RL. Mesenteric lymphadenitis as a presenting feature of Whipple's disease. IDCases 2017; 9:50-52. [PMID: 28660130 PMCID: PMC5479967 DOI: 10.1016/j.idcr.2017.06.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 06/10/2017] [Accepted: 06/10/2017] [Indexed: 11/25/2022] Open
Abstract
Detecting Whipple’s disease, a “great imitator”, requires a high index of suspicion so that antimicrobial treatment can be initiated in a timely manner; a missed diagnosis can be fatal. Although an uncommon cause, Whipple’s disease must be considered in adults with mesenteric lymphadenitis. We report the case of a 39-year-old African American man who presented with chronic joint pain, chronic weight loss, and acute onset epigastric pain. Contrast-enhanced computed tomography of the abdomen and pelvis showed extensive mesenteric lymphadenopathy. A diagnosis of Whipple’s disease was made based upon demonstration of PAS-positive macrophages in the mesenteric lymph node and duodenal biopsies. Antimicrobial therapy resulted in weight gain and resolution of abdominal pain and arthralgia at six months follow-up. Whipple’s disease can be fatal without antibacterial therapy and it always needs to be considered in individuals presenting with any combination of abdominal pain, weight loss, and diarrhea in the background of nonspecific arthritis or arthralgia. Whipple’s disease must also be considered in adults presenting with mesenteric lymphadenitis. Review of CT scans may be helpful, as Whipple’s disease characteristically causes low attenuation mesenteric lymphadenopathy.
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Affiliation(s)
- Mwelwa Chizinga
- Yale University, School of Medicine, Yale-Waterbury Residency Program (Department of Internal Medicine), United States
| | - Danise Schiliro
- Yale University, School of Medicine, Yale-Waterbury Residency Program (Department of Internal Medicine), United States
| | - Brett Mullin
- Yale University, School of Medicine, Yale-Waterbury Residency Program (Department of Internal Medicine), United States
| | - Rashida La Barrie
- Yale University, School of Medicine, Yale-Waterbury Residency Program (Department of Internal Medicine), United States
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31
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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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Krums LM, Bodunova NA, Sabelnikova EA, Khomeriki SG, Mirzoev KM, Sokolova MS, Parfenov AI. Whipple’s disease: A clinical case report. TERAPEVT ARKH 2017; 89:103-104. [DOI: 10.17116/terarkh2017892103-104] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The paper describes a 56-year-old female patient who in December 2015 lost her appetite and 20 kg of weight, had diarrhea, rapidly increasing weakness, dizziness, joint pains, fever, swelling of the feet, and convulsions. Blood tests revealed anemia, elevated erythrocyte sedimentation rate, and hypoproteinemia. Computed tomography showed enlarged mesenteric and retroperitoneal lymph nodes. The doctor suspected lymphoma and referred her to the Moscow Clinical Research Center. The diagnosis of Whipple’s disease was established by carrying out a small intestinal (duodenal) mucosal biopsy with the PAS reaction. A fat-free diet and antibiotic therapy with co-trimoxazole 2.0 g/day and ciprolen 0.3 g/day were prescribed for the patient. Fever and diarrhea disappeared, appetite appeared, weight gained, and blood counts normalized over 1 month of treatment. The patient was discharged with a recommendation to continue antibiotic treatment until the histopathological signs of the disease ceased.
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Abstract
In recent years, it has become apparent that Tropheryma whipplei not only causes a chronic multisystemic infection which is often preceded by arthropathies for many years, well known as 'classical' Whipple's disease, but also clinically becomes manifest with localized organ affections and acute (transient) infections in children. T. whipplei is found ubiquitously in the environment and colonizes in some healthy carriers. In this review, we highlight new aspects of this enigmatic infectious disorder.
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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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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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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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37
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Abstract
Background Whipple's disease (WD) is rarely the cause of a malabsorption syndrome. The disease is a chronic infection of the intestinal mucosa with the bacterium Tropheryma whipplei, which leads to a lymphostasis with an impaired absorption of the nutrition. Due to its low incidence (1:1,000,000) and the non-specific early symptoms, the disease is often diagnosed only after many years. Methods Based on a selective literature review and the clinical experience of the authors, the current knowledge of WD regarding pathogenesis, clinical presentation, diagnosis, and therapy are presented in this paper. Results Recent studies suggest that a host-specific dysfunction of the intestinal macrophages is responsible for the chronic infection with T. whipplei. Prior to patients reporting symptoms of a malabsorption syndrome (chronic diarrhea/steatorhea, weight loss), they often suffer from non-specific symptoms (polyarthralgia, fever, fatigue) for many years. Misdiagnoses such as seronegative polyarthritis are frequent. Furthermore, neurological, cardiac, ocular, or dermatological symptoms may occur. The standard method concerning diagnosis is the detection of PAS(periodic acid-Schiff)-positive macrophages in the affected tissues. Immunohistochemical staining and PCR(polymerase chain reaction)-based genetic analysis increase the sensitivity and specificity of conventional detection methods. Endoscopically, the intestinal mucosa appears edematous with lymphangiectasias, enlarged villi, and white-yellowish ring-like structures. The German treatment recommendations include a two-week intravenous induction therapy with ceftriaxone, which is followed by a three-month oral maintenance therapy with trimethoprim/sulfamethoxazole. Conclusion WD is rarely responsible for a malabsorption syndrome. However, if WD is not recognized, the disease can be lethal. New diagnostic methods and prospectively approved therapeutic concepts allow an adequate treatment of the patient. Due to the host-specific susceptibility to T. whipplei, a lifelong follow-up is necessary.
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Affiliation(s)
- Wilfried Obst
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University of Magdeburg, Germany
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University of Magdeburg, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University of Magdeburg, Germany
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Günther U, Moos V, Offenmüller G, Oelkers G, Heise W, Moter A, Loddenkemper C, Schneider T. Gastrointestinal diagnosis of classical Whipple disease: clinical, endoscopic, and histopathologic features in 191 patients. Medicine (Baltimore) 2015; 94:e714. [PMID: 25881849 PMCID: PMC4602506 DOI: 10.1097/md.0000000000000714] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Classic Whipple disease (CWD) is a systemic infection caused by Tropheryma whipplei. Different diagnostic tools have been developed over the last decades: periodic acid-Schiff (PAS) staining, T whipplei-specific polymerase chain reaction (PCR), and T whipplei-specific immunohistochemistry (IHC). Despite all these advances, CWD is still difficult to diagnose because of a variety of clinical symptoms and possibly a long time span between first unspecific symptoms and the full-blown clinical picture of the disease. Herein, we report an observational cohort study summarizing epidemiologic data, clinical manifestations, and diagnostic parameters of 191 patients with CWD collected at our institution. Gastrointestinal manifestations are the most characteristic symptoms of CWD affecting 76% of the cohort. Although the small bowel was macroscopically conspicuous in only 27% of cases, 173 (91%) patients presented with characteristic histological changes in small bowel biopsies (in 2 patients, these changes were only seen within the ileum). However, 18 patients displayed normal small bowel histology without typical PAS staining. In 9 of these patients, alternative test were positive from their duodenal specimens (ie, T whipplei-specific PCR and/or IHC). Thus, in 182 patients (95%) a diagnostic hint toward CWD was obtained from small bowel biopsies. Only 9 patients (5%) were diagnosed solely based on positive T whipplei-specific PCR and/or IHC of extraintestinal fluids (eg, cerebrospinal fluid, synovial fluid) or extraintestinal tissue (eg, lymph node, synovial tissue), respectively. Thus, despite efforts to diagnose CWD from alternative specimens, gastroscopy with duodenal biopsy and subsequent histological and molecular-biological examination is the most reliable diagnostic tool for CWD.
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Affiliation(s)
- Ute Günther
- From the Charité - Campus Benjamin Franklin (UG, VM, GOffenmüller, GOelkers, TS), Medical Clinic I Gastroenterology, Infectious Diseases, Rheumatology; Vivantes Auguste-Viktoria-Klinikum (UG), Klinik für Innere Medizin, Infektiologie und Gastroenterologie; Evangelisches Krankenhaus Königin Elisabeth (WH), Abteilung Innere Medizin/Gastroeneterologie, Infektiologie und Nephrologie; Deutsches Herzzentrum Berlin (AM), Biofilmzentrum; and PathoTres (CL), Berlin, Germany
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Abstract
PURPOSE OF REVIEW Chronic infections of the small intestine cause significant morbidity and mortality globally. This review focuses on the recent advances in the field of our understanding of selected intestinal infections. RECENT FINDINGS Primary and secondary immunodeficiency increase the susceptibility to many chronic intestinal infections. Endoscopy and intestinal biopsies are central to establishing a diagnosis of these conditions. Tuberculosis (TB) remains a major global health challenge. Emerging therapeutic agents to counteract multidrug-resistant strains have shown clinical efficacy, but concerns regarding mortality remain. PCR-based diagnostic TB tests have the potential to reduce diagnostic delays, but remain to be validated for intestinal infections. Adjunctive diagnostic imaging modalities can differentiate infections from Crohn's disease with increasing accuracy. Whipple's disease remains rare, but there have been substantial advances in our understanding of the causative organism Tropheryma whipplei. Extended treatment with broad-spectrum antibiotics is effective in most cases. The narrow therapeutic window and limited armamentarium for treating invasive filamentous fungal infections contribute to their significant morbidity and high rates of mortality. SUMMARY The speed and accuracy of diagnosing chronic intestinal infections have improved with recent imaging and laboratory methodologies. Significant research opportunities remain for clinicians and scientists to improve the diagnostic accuracy and clinical outcomes of chronic intestinal infections.
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Affiliation(s)
- Billy Bourke
- aNational Centre for Paediatric Gastroenterology, Our Lady's Children's Hospital bNational Children's Research Centre, Crumlin, Dublin cUCD School of Medicine and Medical Science dConway Institute, University College Dublin, Belfield, Dublin, Ireland
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Iwata H, Sawada R, Mizutani S, Yamanishi Y. Systematic drug repositioning for a wide range of diseases with integrative analyses of phenotypic and molecular data. J Chem Inf Model 2015; 55:446-59. [PMID: 25602292 DOI: 10.1021/ci500670q] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Drug repositioning, or the application of known drugs to new indications, is a challenging issue in pharmaceutical science. In this study, we developed a new computational method to predict unknown drug indications for systematic drug repositioning in a framework of supervised network inference. We defined a descriptor for each drug-disease pair based on the phenotypic features of drugs (e.g., medicinal effects and side effects) and various molecular features of diseases (e.g., disease-causing genes, diagnostic markers, disease-related pathways, and environmental factors) and constructed a statistical model to predict new drug-disease associations for a wide range of diseases in the International Classification of Diseases. Our results show that the proposed method outperforms previous methods in terms of accuracy and applicability, and its performance does not depend on drug chemical structure similarity. Finally, we performed a comprehensive prediction of a drug-disease association network consisting of 2349 drugs and 858 diseases and described biologically meaningful examples of newly predicted drug indications for several types of cancers and nonhereditary diseases.
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Affiliation(s)
- Hiroaki Iwata
- Division of System Cohort, Multi-Scale Research Center for Medical Science, Medical Institute of Bioregulation, Kyushu University , 3-1-1 Maidashi, Higashi-ku, Fukuoka, Fukuoka 812-8582, Japan
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Puri BK, Hakkarainen-Smith JS, Monro JA. The potential use of cholestyramine to reduce the risk of developing Clostridium difficile-associated diarrhoea in patients receiving long-term intravenous ceftriaxone. Med Hypotheses 2014; 84:78-80. [PMID: 25497389 DOI: 10.1016/j.mehy.2014.11.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 11/11/2014] [Accepted: 11/26/2014] [Indexed: 12/14/2022]
Abstract
Intravenous pharmacotherapy with the third-generation cephalosporin ceftriaxone is unfortunately associated with a relatively high incidence of Clostridium difficile-associated diarrhoea. Cholestyramine (colestyramine) is an anion-binding resin which can bind luminal C.difficile toxin A (TcdA) and toxin B (TcdB) and which may be beneficial in the treatment of recurrent antibiotic-associated pseudomembranous colitis. We therefore hypothesised that concomitant oral cholestyramine might reduce the risk of C.difficile-associated diarrhoea in patients receiving long-term intravenous ceftriaxone. A pilot study was carried out in which it was found that only three out of 46 (6.5%) such patients being treated with 2 g ceftriaxone daily for Lyme borreliosis, who also received 4 g cholestyramine daily, developed C.difficile-associated diarrhoea. This is smaller than a published report of the incidence of this complication in six out of 26 (23.1%) patients following 1-3 days' treatment with 1 g intravenous ceftriaxone, but without oral cholestyramine (p=0.06). We therefore recommend that a larger, double-blind placebo-controlled trial be carried out to test this hypothesis.
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Affiliation(s)
- B K Puri
- Department of Medicine, Hammersmith Hospital, Imperial College London, UK.
| | | | - Jean A Monro
- Breakspear Medical Group, Hemel Hempstead, Hertfordshire, UK
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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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Validation of an rpoB gene PCR assay for detection of Tropheryma whipplei: 10 years' experience in a National Reference Laboratory. J Clin Microbiol 2013; 51:3858-61. [PMID: 23966507 DOI: 10.1128/jcm.01703-13] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The performance of a real-time PCR assay targeting the Tropheryma whipplei rpoB gene was evaluated using test strains and 1,236 clinical specimens in a national reference laboratory. The novel rpoB-PCR assay proved to be specific, revealed improved analytical sensitivity, and substantially accelerated detection of T. whipplei DNA in clinical specimens.
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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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Whipple's Disease: Our Own Experience and Review of the Literature. Gastroenterol Res Pract 2013; 2013:478349. [PMID: 23843784 PMCID: PMC3703430 DOI: 10.1155/2013/478349] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Accepted: 05/22/2013] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease is a chronic infectious systemic disease caused by the bacterium Tropheryma whipplei. Nondeforming arthritis is frequently an initial complaint. Gastrointestinal and general symptoms include marked diarrhoea (with serious malabsorption), abdominal pain, prominent weight loss, and low-grade fever. Possible neurologic symptoms (up to 20%) might be associated with worse prognosis. Diagnosis is based on the clinical picture and small intestinal histology revealing foamy macrophages containing periodic-acid-Schiff- (PAS-) positive material. Long-term (up to one year) antibiotic therapy provides a favourable outcome in the vast majority of cases. This paper provides review of the literature and an analysis of our 5 patients recorded within a 20-year period at a tertiary gastroenterology centre. Patients were treated using i.v. penicillin G or amoxicillin-clavulanic acid + i.v. gentamicin for two weeks, followed by p.o. doxycycline (100 mg per day) plus p.o. salazopyrine (3 g per day) for 1 year. Full remission was achieved in all our patients.
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Fenollar F, Lagier JC, Rolain JM, Célard M, Bouchot O, Eicher JC, Lepidi H, Raoult D. Tropheryma whipplei endocarditis relapses after treatment with trimethoprim/sulfamethoxazole. Int J Antimicrob Agents 2013; 41:592-4. [DOI: 10.1016/j.ijantimicag.2013.02.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 02/11/2013] [Indexed: 11/28/2022]
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