An atypical case of neuro-Whipple: Clinical presentation, magnetic resonance spectroscopy and follow-up

Treatment of classic Whipple's disease: from in vitro results to clinical outcome

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.

Tropheryma whipplei as a commensal bacterium

Tropheryma whipplei is the bacterial agent of the well-known and rare Whipple's disease, mainly observed among Caucasians. This bacterium has recently been involved in other chronic and acute infections. For a long time, the only known source of the bacterium was patients with Whipple's disease; however, thanks to the advent of molecular biology, T. whipplei has now been detected in specimens from healthy individuals, mainly in stool and saliva samples. The prevalence of carriage depends on several factors, such as age, exposure and geographical area, reaching 75% in stool specimens from children less than 4 years old in rural Africa. T. whipplei is a commensal bacterium that only causes Whipple's disease in a subset of individuals, probably those with a still-uncharacterized specific immunological defect.