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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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Shen Y, Cui SS, Teng XB, Han MF, Zhang YB. Clinical, Laboratory, and Imaging Characteristics of Tropheryma Whipplei Detection in Bronchoalveolar Lavage Fluid Using Next-Generation Sequencing: A Case-Control Study. Infect Drug Resist 2024; 17:3101-3112. [PMID: 39050831 PMCID: PMC11268753 DOI: 10.2147/idr.s470084] [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: 03/21/2024] [Accepted: 07/05/2024] [Indexed: 07/27/2024] Open
Abstract
Objective The aim of this study was to assess the prevalence of Tropheryma whipplei (TW) infection in the population and to investigate the clinical symptoms, as well as the laboratory and imaging characteristics of patients testing positive for TW using next-generation sequencing (NGS). Methods A retrospective review was conducted on 1346 bronchoalveolar lavage fluid (BALF) samples collected between January 2021 and September 2023. The case group comprised patients with TW detected using NGS while the control group included 65 randomly chosen Gram-positive bacterial infection patients without TW. Comparative analyses were carried out on the basic demographics, laboratory parameters, and imaging findings between the two groups. Additionally, the case group underwent an in-depth examination of underlying diseases, pathogens, final diagnoses, treatment strategies. Results The case group comprised of 51 patients with TW, constituting 3.8% of the total. There was no significant difference in gender and age between the case and control groups (P = 0.84, P = 0.07). Symptoms such as coughing, expectoration, wheezing, fever, and hemoptysis are less commonly detected in the case group with a higher incidence of chest pain when compared to the control group (P >0.05). The case group exhibited decreased albumin levels and increased C-reactive protein and D-dimer levels compared to normal levels. Imaging findings in the case group commonly included nodules, patchy images, and interstitial changes, the most common underlying disease is cardiovascular disease, and the most frequently co-occurring pathogen is the human herpesvirus. Among the case group, 27 patients received a final diagnosis of pneumonia, and 3 patients clinically diagnosed with Whipple's disease demonstrated improvement in both symptoms and imaging after treatment. Conclusion NGS revealed a relatively low overall detection rate of TW-positive patients using BALF. TW was more prevalent in middle-aged and elderly male patients characterized by symptoms such as cough, expectoration, shortness of breath, and fever. Chest imaging in these cases typically showed nodules and interstitial changes.
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Affiliation(s)
- Ya Shen
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, People’s Republic of China
- Department of Respiratory and Critical Care Medicine, Fuyang Infectious Disease Clinical College of Anhui Medical University, Fuyang, 236000, People’s Republic of China
| | - Shun-Shun Cui
- Department of Respiratory and Critical Care Medicine, Fuyang People’s Hospital, Fuyang, 236000, People’s Republic of China
| | - Xiao-Bao Teng
- Department of Respiratory and Critical Care Medicine, Fuyang Infectious Disease Clinical College of Anhui Medical University, Fuyang, 236000, People’s Republic of China
| | - Ming-Feng Han
- Department of Respiratory and Critical Care Medicine, Fuyang Infectious Disease Clinical College of Anhui Medical University, Fuyang, 236000, People’s Republic of China
| | - Yan-Bei Zhang
- Department of Geriatric Respiratory and Critical Care Medicine, The First Affiliated Hospital of Anhui Medical University, Hefei, 230000, People’s Republic of China
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Liu X, Guo L, Ding X, Kang Z. Pulmonary sarcomatoid carcinoma: A rare case report, diagnostic dilemma and review of literature. Medicine (Baltimore) 2024; 103:e38797. [PMID: 38968487 PMCID: PMC11224848 DOI: 10.1097/md.0000000000038797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/12/2024] [Indexed: 07/07/2024] Open
Abstract
RATIONALE Pulmonary sarcomatoid carcinoma (PSC), a rare tumor, comprises 0.1% to 0.4% of all malignant lung tumors. Given the rarity of PSC, its clinical course, therapeutic guidelines, and patient outcomes remain largely unknown. Therefore, it is imperative to alert clinicians to this extremely rare and instructive early-onset cancer. PATIENT CONCERNS This report describes a 28-year-old woman with PSC, who was initially misdiagnosed with Whipple's disease. A conclusive diagnosis of PSC was made following careful clinical examination, imaging, and histopathological evaluation of the patient's biopsy sample. Radiological imaging revealed multiple nodules and mass formations in the left upper lobe of the patient's lung, with the largest measuring of 5.4 × 3.2 cm. DIAGNOSIS Histopathological examination indicated the presence of a malignant neoplasm associated with necrosis suggestive of sarcoma, which was pathologically staged as cT4N1M1. INTERVENTIONS AND OUTCOMES A regimen of doxorubicin and ifosfamide was administered therapeutically, resulting in a stable disease state. LESSONS The rarity and tumor origin challenge the diagnosis, which emphasizes the imperative role of histological examination, immunohistochemistry, and flow cytometry in achieving an accurate diagnosis. This report summarizes the existing publications to provide a comprehensive overview of PSC, including its clinical manifestations, radiographic imaging, pathologic features, diagnostic challenges, treatment strategies, and prognosis, and aims to improve the understanding of PSC.
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Affiliation(s)
- Xilin Liu
- Department of Hand and Foot Surgery, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Lixin Guo
- Department of Rehabilitation, The Second Hospital of Jilin University, Changchun, China
| | - Xiangfu Ding
- Department of Thyroid Surgery, The Second Hospital of Jilin University, Changchun, China
| | - Zhichen Kang
- Department of Rehabilitation, The Second Hospital of Jilin University, Changchun, China
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Miller A, Park JC, Penney A, Geraghty JJ, Lui F. An Unusual Case of Limbic Encephalitis Caused by Whipple Disease. Cureus 2024; 16:e65385. [PMID: 39071075 PMCID: PMC11283316 DOI: 10.7759/cureus.65385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 07/30/2024] Open
Abstract
Whipple disease (WD), a multisystemic infectious disorder caused by Tropheryma whipplei (T. whipplei), typically presents with gastrointestinal (GI) symptoms such as abdominal pain, diarrhea, GI bleeding, and weight loss. Uncommonly, it can also involve the central nervous system (CNS) and may present with a range of symptoms, including personality changes, dementia, and rhombencephalitis. Prompt antibiotic treatment and careful follow-up are crucial for favorable patient outcomes and a reduction in morbidity and mortality. In this case, we describe a 46-year-old male with primary CNS-WD and discuss the symptomatic manifestations, diagnostic findings, differential diagnosis, and management. This patient initially presented with arthritic complaints and, over a five-year period, developed progressive neurocognitive symptoms, including anxiety, panic attacks, retrograde amnesia, personality changes, aphasia, anhedonia, dysarthria, and rapidly progressive dementia. Magnetic resonance imaging (MRI) revealed symmetric T2 fluid-attenuated inversion recovery (FLAIR) hyperintensities in the bilateral medial temporal lobes, hippocampi, and hypothalamus. A lumbar puncture (LP) showed mild pleocytosis and elevated protein, with no autoimmune or paraneoplastic causes. Temporal lobe biopsy revealed rod-like structures, and T. whipplei DNA was confirmed by polymerase chain reaction (PCR). This case underscores the importance of maintaining a high index of suspicion for WD in patients presenting with atypical symptoms with rapidly progressive dementia, as early detection and management are key to circumventing irreversible neurological damage and death.
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Affiliation(s)
- Aimee Miller
- College of Medicine, California Northstate University, Elk Grove, USA
| | - Johann C Park
- College of Medicine, California Northstate University, Elk Grove, USA
| | - Angela Penney
- College of Medicine, California Northstate University, Elk Grove, USA
| | - John J Geraghty
- Department of Neurology, Kaiser Permanente Roseville Medical Center, Roseville, USA
| | - Forshing Lui
- College of Medicine, California Northstate University, Elk Grove, USA
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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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Giardini HAM, Neves FS, Pereira IA, Cordeiro RA. Lyme disease and Whipple's disease: a comprehensive review for the rheumatologist. Adv Rheumatol 2024; 64:16. [PMID: 38438928 DOI: 10.1186/s42358-024-00359-x] [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: 01/16/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
Despite their rarity, Lyme disease and Whipple's disease are of significant importance in rheumatology, as both can manifest as chronic arthritis, presenting challenges in the differential diagnosis of inflammatory arthropathies. In Lyme disease, arthritis typically emerges as a late manifestation, usually occurring six months after the onset of erythema migrans. The predominant presentation involves mono- or oligoarthritis of large joints, with a chronic or remitting-recurrent course. Even with appropriate antimicrobial treatment, arthritis may persist due to inadequate immunological control triggered by the disease. In contrast, Whipple's disease may present with a migratory and intermittent seronegative poly- or oligoarthritis of large joints, preceding classic gastrointestinal symptoms by several years. Both disorders, particularly Whipple's disease, can be misdiagnosed as more common autoimmune rheumatic conditions such as rheumatoid arthritis and spondyloarthritis. Epidemiology is crucial in suspecting and diagnosing Lyme disease, as the condition is transmitted by ticks prevalent in specific areas of the United States, Europe, and Asia. On the contrary, the causative agent of Whipple's disease is widespread in the environment, yet invasive disease is rare and likely dependent on host genetic factors. In addition to erythema migrans in Lyme disease and gastrointestinal manifestations in Whipple's disease, neurological and cardiac involvement can further complicate the course of both. This article offers a comprehensive review of the epidemiological, pathophysiological, clinical, and therapeutic aspects of both diseases.
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Affiliation(s)
- Henrique Ayres Mayrink Giardini
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, 455- 3º andar- sala 3192 Cerqueira Cesar, CEP:01246-903, Sao Paulo, SP, Brazil.
| | - Fabricio Souza Neves
- Rheumatology Division, Internal Medicine Department, Health Sciences Center, Universidade Federal de Santa Catarina (UFSC), Florianopolis, SC, Brazil
| | | | - Rafael Alves Cordeiro
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, 455- 3º andar- sala 3192 Cerqueira Cesar, CEP:01246-903, Sao Paulo, SP, Brazil
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Canhão BT, Trigo A, Madeira JI, Simão A, Madaleno J. Prolonged arthralgias in Whipple's disease - A common but often overlooked symptom of a rare disease. J R Coll Physicians Edinb 2024; 54:41-43. [PMID: 38606805 DOI: 10.1177/14782715241237283] [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] [Indexed: 04/13/2024] Open
Abstract
Whipple's disease is a multisystemic chronic infectious condition caused by Tropheryma whipplei (T. whipplei). Though characterised often by insidious weight loss, diarrhoea, and arthralgia, three other distinct manifestations can be observed, namely localised disease, acute infection and asymptomatic carriage. The diagnosis relies on histopathological examination of duodenal biopsies and polymerase chain reaction analysis of the 16S rRNA gene for T. whipplei. We report the case of a middle-aged man admitted for etiologic investigation of prolonged, migrating, and inflammatory arthralgias and subsequent development of gastrointestinal symptoms. Despite its reputation as a great mimicker of many different illnesses, the difficulty in diagnosis probably lies with its rarity rather than its masking.
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Affiliation(s)
- Bernardo Tourais Canhão
- Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - André Trigo
- Gastroenterology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Joana Inês Madeira
- Pathology Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Adélia Simão
- Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - João Madaleno
- Internal Medicine Department, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Ladna M, George J, Forsmark CE. Whipple's Disease Presenting With a Chief Complaint of Dyspnea and Cough From Pulmonary Invasion Without Evidence of Gastrointestinal Involvement. Cureus 2024; 16:e54554. [PMID: 38516502 PMCID: PMC10956915 DOI: 10.7759/cureus.54554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2024] [Indexed: 03/23/2024] Open
Abstract
A patient with immune thrombocytopenia, systemic lupus erythematosus on chronic corticosteroids, and interstitial lung disease was referred to the pulmonology clinic due to progressively worsening dyspnea. A bronchoscopy was done and a thorough workup was negative for any infectious pathology or malignancy. A lung biopsy with MicroGenDX test (MicroGen Diagnostics, Lubbock, TX) revealed Tropheryma whipplei, consistent with a Whipple disease diagnosis. Histopathology of biopsy specimens from an esophagogastroduodenoscopy showed moderate chronic active Helicobacter gastritis and unremarkable duodenal specimens without evidence of Tropheryma whipplei. For Helicobacter pylori gastritis, she was prescribed quadruple therapy with omeprazole, bismuth, metronidazole, and tetracycline. For pulmonary Whipple's disease, she completed two weeks of IV ceftriaxone, which led to improvement in dyspnea, and then was transitioned to 12 months of oral sulfamethoxazole-trimethoprim. In rare cases, Whipple's disease can present as isolated pulmonary disease without gastrointestinal involvement, especially in immunosuppressed patients with compromised lungs.
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Affiliation(s)
- Michael Ladna
- Internal Medicine, University of Florida College of Medicine, Gainesville, USA
| | - John George
- Gastroenterology, University of Florida College of Medicine, Gainesville, USA
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Ruffer N, Holzer MT, Gkanatsas Y, Schinglerová I, Boro D, Krusche M, Kötter I. [Chronic Tropheryma whipplei infection: an important differential diagnosis of refractory polyarthritis]. Z Rheumatol 2023; 82:885-891. [PMID: 35384513 PMCID: PMC10695860 DOI: 10.1007/s00393-022-01194-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Refractory arthritis is a common problem in routine rheumatology practice, and can be a diagnostic challenge. In these cases, chronic Tropheryma whipplei (T. whipplei) infection is an important differential diagnosis that should be considered. OBJECTIVE Based on five clinical cases, this case-based review describes the diagnostic and therapeutic principles in the management of chronic T. whipplei infection. RESULTS Whipple's disease is a multisystemic infectious disease caused by the bacterium T. whipplei. The disease typically manifests with arthralgia, weight loss and diarrhoea. Joint involvement often develops years before gastrointestinal symptoms occur. In addition to systemic manifestations ("classic Whipple's disease"), T. whipplei can also lead to localized joint infections without gastrointestinal involvement. Articular manifestations of systemic and localized T. whipplei infections are commonly misdiagnosed as a sign of various forms of autoimmmune arthritis. DISCUSSION Whipple's disease and localized T. whipplei joint infection should be considered in the diagnostic work-up of refractory arthritis. Synovial fluid analysis by means of specific polymerase chain reaction-based testing for T. whipplei is diagnostically ground-breaking.
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Affiliation(s)
- Nikolas Ruffer
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Marie-Therese Holzer
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland.
- III. Medizinische Klinik, Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Yannik Gkanatsas
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Izabela Schinglerová
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Damir Boro
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik, Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Ina Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
- III. Medizinische Klinik, Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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Mecklenburg J, Moos V, Moter A, Siebert E, Nave AH, Schneider T, Ruprecht K, Euskirchen P. The spectrum of central nervous system involvement in Whipple's disease. Eur J Neurol 2023; 30:3417-3429. [PMID: 35852414 DOI: 10.1111/ene.15511] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE To assess the clinical spectrum of central nervous system (CNS) involvement as well as cerebrospinal fluid (CSF) and neuroimaging findings in patients with Whipple's disease (WD) and to analyze the association of neurological symptoms with CSF and imaging findings. METHODS Neurological involvement was retrospectively analyzed in a series of 36 patients diagnosed with WD at a single center between 1992 and 2019. Findings of 81 comprehensive CSF examinations from 36 patients, including polymerase chain reaction (PCR) tests for Tropheryma whipplei (TW) in CSF from 35 patients, were systematically evaluated. The prevalence of ischemic stroke in patients with WD was compared to a matched control cohort. RESULTS Neurological symptoms occurred in 23 of 36 (63.9%) patients, with cognitive, motor, and oculomotor dysfunction being most frequent. TW was detected by PCR in CSF of 13 of 22 (59.1%) patients with and four of 13 (30.8%, p = 0.0496) patients without neurological symptoms. Total CSF protein (p = 0.044) and lactate (p = 0.035) were moderately elevated in WD with neurologic symptoms compared with WD without. No intrathecal immunoglobulin synthesis was observed. Three of 36 (8.3%) patients had hydrocephalus due to aqueductal stenosis. Patients with WD had an unexpectedly high prevalence of ischemic stroke (10/36, 27.7%) compared to matched controls (10/360, 3.2%). CONCLUSIONS Neurological involvement in patients with WD is common. Detection of TW DNA in CSF is only partly associated with neurological symptoms. Elevated CSF parameters suggest CNS parenchymal infection. Stroke is a hitherto underrecognized manifestation of WD. These findings suggest that mechanisms beyond CNS infection contribute to the spectrum of CNS involvement in WD.
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Affiliation(s)
- Jasper Mecklenburg
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Verena Moos
- Medical Department of Gastroenterology, Rheumatology and Infectious Diseases, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annette Moter
- Institute for Microbiology, Infectious Diseases and Immunology, Biofilmcenter, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- MoKi Analytics and Moter Diagnostics, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Heinrich Nave
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauferkrankungen (DZHK), Partner Site Berlin, Berlin, Germany
| | - Thomas Schneider
- Medical Department of Gastroenterology, Rheumatology and Infectious Diseases, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Euskirchen
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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12
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Song X, Duan R, Duan L, Wei L. Current knowledge of the immune reconstitution inflammatory syndrome in Whipple disease: a review. Front Immunol 2023; 14:1265414. [PMID: 37901208 PMCID: PMC10611461 DOI: 10.3389/fimmu.2023.1265414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by exaggerated and dysregulated inflammatory responses that occur as a result of reconstitution of adaptive or innate immunity. A wide range of microorganisms have been found to be associated with IRIS, such as human immunodeficiency virus (HIV), Mycobacterium and actinobacteria. Whipple disease (WD) is an infectious disorder caused by the Gram-positive bacterium Tropheryma whipplei (T. whipplei) and IRIS also serves as a complication during its treament. Although many of these pathological mechanisms are shared with related inflammatory disorders, IRIS in WD exhibits distinct features and is poorly described in the medical literature. Novel investigations of the intestinal mucosal immune system have provided new insights into the pathogenesis of IRIS, elucidating the interplay between systemic and local immune responses. These insights may be used to identify monitoring tools for disease prevention and to develop treatment strategies. Therefore, this review synthesizes these new concepts in WD IRIS to approach the feasibility of manipulating host immunity and immune reconstitution of inflammatory syndromes from a newer, more comprehensive perspective and study hypothetical options for the management of WD IRIS.
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Affiliation(s)
| | | | | | - Lijuan Wei
- Department of Gastroenterology and Digestive Endoscopy Center, The Second Hospital of Jilin University, Chang Chun, Jilin, China
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13
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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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14
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Muacevic A, Adler JR, Ramasamy D, Kumar S. Whipple's Disease (WD) Without Arthropathy in an Immunocompromised Patient. Cureus 2022; 14:e31659. [PMID: 36545168 PMCID: PMC9761016 DOI: 10.7759/cureus.31659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 11/21/2022] Open
Abstract
Whipple's disease (WD) is a rare disorder caused by the pathogen Tropheryma whipplei (T. whipplei). We report a unique presentation of WD in which the patient did not exhibit arthralgia which is characteristic of this disease. A 67-year-old man with a history of chronic hepatitis B infection and human immunodeficiency virus (HIV) infection presented with weight loss, nausea, vomiting, and myalgia. Endoscopy demonstrated erythema in the gastric body, lymphangiectasia of the duodenum, and increased granularity of the terminal ileum. Mucosal biopsies revealed macrophages in the lamina propria with focal histiocytic aggregates throughout the small bowel and cecum, consistent with WD. Confirmatory T. whipplei polymerase chain reaction(PCR) testing was positive. WD is a rare diagnosis that must be considered in the differential diagnoses of patients presenting with unexplained nausea, vomiting, diarrhea, and anemia. Furthermore, in patients with HIV, the possibilities would also include opportunistic gastrointestinal pathogens. Classic WD is characterized by diarrhea, weight loss, abdominal pain, and extra-intestinal involvement manifesting as joint pain. We describe a case of WD occurring in a patient with HIV, without the disease's characteristic joint involvement.
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15
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The Brief Case: Tropheryma whipplei Infection Resulting in Neurological Symptoms. J Clin Microbiol 2022; 60:e0147821. [PMID: 35975990 PMCID: PMC9383192 DOI: 10.1128/jcm.01478-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Rapidly progressive dementia and intractable diarrhea: a teaching case report and a systematic review of cognitive impairment in Whipple’s disease. Neurol Sci 2022; 43:907-926. [PMID: 34981284 PMCID: PMC8722651 DOI: 10.1007/s10072-021-05844-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/22/2021] [Indexed: 11/02/2022]
Abstract
Objective Methods Results Conclusions Supplementary Information
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17
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Kunogi T, Ando K, Fujiya M. Balloon endoscopy and capsule endoscopy are useful in the diagnosis of small bowel lesions in Whipple's disease. Dig Endosc 2022; 34:248. [PMID: 34716947 DOI: 10.1111/den.14180] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Takehito Kunogi
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Hokkaido, Japan
| | - Katsuyoshi Ando
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Hokkaido, Japan
| | - Mikihiro Fujiya
- Gastroenterology and Endoscopy, Division of Metabolism and Biosystemic Science, Gastroenterology and Hematology/Oncology, Department of Medicine, Asahikawa Medical University, Hokkaido, Japan
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18
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Layer P, Andresen V, Allescher H, Bischoff SC, Claßen M, Elsenbruch S, Freitag M, Frieling T, Gebhard M, Goebel-Stengel M, Häuser W, Holtmann G, Keller J, Kreis ME, Kruis W, Langhorst J, Jansen PL, Madisch A, Mönnikes H, Müller-Lissner S, Niesler B, Pehl C, Pohl D, Raithel M, Röhrig-Herzog G, Schemann M, Schmiedel S, Schwille-Kiuntke J, Storr M, Preiß JC, Andus T, Buderus S, Ehlert U, Engel M, Enninger A, Fischbach W, Gillessen A, Gschossmann J, Gundling F, Haag S, Helwig U, Hollerbach S, Karaus M, Katschinski M, Krammer H, Kuhlbusch-Zicklam R, Matthes H, Menge D, Miehlke S, Posovszky MC, Schaefert R, Schmidt-Choudhury A, Schwandner O, Schweinlin A, Seidl H, Stengel A, Tesarz J, van der Voort I, Voderholzer W, von Boyen G, von Schönfeld J, Wedel T. Update S3-Leitlinie Reizdarmsyndrom: Definition, Pathophysiologie, Diagnostik und Therapie. Gemeinsame Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Neurogastroenterologie und Motilität (DGNM) – Juni 2021 – AWMF-Registriernummer: 021/016. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:1323-1415. [PMID: 34891206 DOI: 10.1055/a-1591-4794] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- P Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - V Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - H Allescher
- Zentrum für Innere Medizin, Gastroent., Hepatologie u. Stoffwechsel, Klinikum Garmisch-Partenkirchen, Garmisch-Partenkirchen, Deutschland
| | - S C Bischoff
- Institut für Ernährungsmedizin, Universität Hohenheim, Stuttgart, Deutschland
| | - M Claßen
- Klinik für Kinder- und Jugendmedizin, Klinikum Links der Weser, Bremen, Deutschland
| | - S Elsenbruch
- Klinik für Neurologie, Translational Pain Research Unit, Universitätsklinikum Essen, Essen, Deutschland.,Abteilung für Medizinische Psychologie und Medizinische Soziologie, Ruhr-Universität Bochum, Bochum, Deutschland
| | - M Freitag
- Abteilung Allgemeinmedizin Department für Versorgungsforschung, Universität Oldenburg, Oldenburg, Deutschland
| | - T Frieling
- Medizinische Klinik II, Helios Klinikum Krefeld, Krefeld, Deutschland
| | - M Gebhard
- Gemeinschaftspraxis Pathologie-Hamburg, Hamburg, Deutschland
| | - M Goebel-Stengel
- Innere Medizin II, Helios Klinik Rottweil, Rottweil, und Innere Medizin VI, Psychosomat. Medizin u. Psychotherapie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - W Häuser
- Innere Medizin I mit Schwerpunkt Gastroenterologie, Klinikum Saarbrücken, Saarbrücken, Deutschland
| | - G Holtmann
- Faculty of Medicine & Faculty of Health & Behavioural Sciences, Princess Alexandra Hospital, Brisbane, Australien
| | - J Keller
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - M E Kreis
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland
| | | | - J Langhorst
- Klinik für Integrative Medizin und Naturheilkunde, Sozialstiftung Bamberg, Klinikum am Bruderwald, Bamberg, Deutschland
| | - P Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten, Berlin, Deutschland
| | - A Madisch
- Klinik für Gastroenterologie, interventionelle Endoskopie und Diabetologie, Klinikum Siloah, Klinikum Region Hannover, Hannover, Deutschland
| | - H Mönnikes
- Klinik für Innere Medizin, Martin-Luther-Krankenhaus, Berlin, Deutschland
| | | | - B Niesler
- Abteilung Molekulare Humangenetik Institut für Humangenetik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Pehl
- Medizinische Klinik, Krankenhaus Vilsbiburg, Vilsbiburg, Deutschland
| | - D Pohl
- Klinik für Gastroenterologie und Hepatologie, Universitätsspital Zürich, Zürich, Schweiz
| | - M Raithel
- Medizinische Klinik II m.S. Gastroenterologie und Onkologie, Waldkrankenhaus St. Marien, Erlangen, Deutschland
| | | | - M Schemann
- Lehrstuhl für Humanbiologie, TU München, Deutschland
| | - S Schmiedel
- I. Medizinische Klinik und Poliklinik Gastroenterologie, Universitätsklinikum Hamburg-Eppendorf, Deutschland
| | - J Schwille-Kiuntke
- Abteilung für Psychosomatische Medizin und Psychotherapie, Medizinische Universitätsklinik Tübingen, Tübingen, Deutschland.,Institut für Arbeitsmedizin, Sozialmedizin und Versorgungsforschung, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - M Storr
- Zentrum für Endoskopie, Gesundheitszentrum Starnberger See, Starnberg, Deutschland
| | - J C Preiß
- Klinik für Innere Medizin - Gastroenterologie, Diabetologie und Hepatologie, Vivantes Klinikum Neukölln, Berlin, Deutschland
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19
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Méneret A, Garcin B, Frismand S, Lannuzel A, Mariani LL, Roze E. Treatable Hyperkinetic Movement Disorders Not to Be Missed. Front Neurol 2021; 12:659805. [PMID: 34925200 PMCID: PMC8671871 DOI: 10.3389/fneur.2021.659805] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 10/27/2021] [Indexed: 12/13/2022] Open
Abstract
Hyperkinetic movement disorders are characterized by the presence of abnormal involuntary movements, comprising most notably dystonia, chorea, myoclonus, and tremor. Possible causes are numerous, including autoimmune disorders, infections of the central nervous system, metabolic disturbances, genetic diseases, drug-related causes and functional disorders, making the diagnostic process difficult for clinicians. Some diagnoses may be delayed without serious consequences, but diagnosis delays may prove detrimental in treatable disorders, ranging from functional disabilities, as in dopa-responsive dystonia, to death, as in Whipple's disease. In this review, we focus on treatable disorders that may present with prominent hyperkinetic movement disorders.
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Affiliation(s)
- Aurélie Méneret
- Département de Neurologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
| | - Béatrice Garcin
- Service de Neurologie, Hôpital Avicenne, APHP, Bobigny, France
| | - Solène Frismand
- Département de Neurologie, Hôpital universitaire de Nancy, Nancy, France
| | - Annie Lannuzel
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
- Département de Neurologie, Centre Hospitalier Universitaire de la Guadeloupe, Pointe-à-Pitre, France
- Faculté de Médecine, Université Des Antilles, Pointe-à-Pitre, France
- Centre D'investigation Clinique Antilles Guyane, Pointe-à-Pitre, France
| | - Louise-Laure Mariani
- Département de Neurologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
| | - Emmanuel Roze
- Département de Neurologie, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France
- Sorbonne Université, Institut du Cerveau - Paris Brain Institute - ICM, Inserm, CNRS, Paris, France
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20
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DeBoer R, Jayatilaka S, Donato A. Seronegative Arthritis as a Complication of Whipple's Disease. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211017717. [PMID: 34045913 PMCID: PMC8135203 DOI: 10.1177/11795476211017717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/22/2021] [Indexed: 12/18/2022]
Abstract
Whipple's disease (WD) is an uncommon cause of seronegative arthritis. WD is known for its gastrointestinal symptoms of diarrhea, weight loss, and abdominal pain. However, arthritis may precede gastrointestinal symptoms by 6 to 7 years. We describe a case of an 85-year-old Caucasian male with multiple joint complaints, not responsive to traditional treatments for conditions such as rheumatoid arthritis and osteoarthritis. We suggest that WD be considered for seronegative arthritis especially affecting large joints.
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Affiliation(s)
- Rebecca DeBoer
- Department of Medicine, Reading Hospital, Reading, PA, USA
| | | | - Anthony Donato
- Department of Medicine, Reading Hospital, Reading, PA, USA
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21
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Clinical manifestations of Whipple's disease mimicking rheumatic disorders. Reumatologia 2021; 59:104-110. [PMID: 33976464 PMCID: PMC8103404 DOI: 10.5114/reum.2021.105418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022] Open
Abstract
Whipple’s disease is a rare, chronic, systemic disorder caused by Tropheryma whipplei infection. The most common symptoms are weight loss, arthralgia, diarrhea and abdominal pain. Other organ involvement can also occur in the patients. Joint manifestations may mimic rheumatoid arthritis or spondyloarthritis. Arthalgia, arthritis, spondylodiscitis, bursitis and/or tenosynovitis are seen in the majority of the patients. This explains why some of the symptoms are misdiagnosed as those of rheumatic diseases. Understanding of Whipple’s disease is important for differential diagnostics of several rheumatic symptoms.
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22
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Bosello F, Casalino G, Neri E, Alfano A, Bonora A, Marchini G. Unique Features of Posterior Ocular Involvement of Whipple's Disease in a Patient with No Gastrointestinal Symptoms. Ocul Immunol Inflamm 2021; 30:1168-1171. [PMID: 33545009 DOI: 10.1080/09273948.2020.1859548] [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: 10/22/2022]
Abstract
Purpose: To describe posterior ocular involvement features of Whipple's disease (WD) in a patient with no gastrointestinal symptoms.Methods: Retrospective case report.Observation: A 53-year-old man with a 2-year history of seronegative arthritis presented with bilateral intraocular inflammation, optic disc edema, and cystoid macular edema (CME) in the left eye. A diagnosis of noninfectious uveitis was made and oral prednisolone was started. Despite initial improvement, after 6 weeks, CME was found in both eyes. Because of the initial response, the anti-tumor necrosis factor agent Adalimumab was started. Twelve weeks after initiation of adalimumab, fundus examination revealed widespread dot-blot retinal hemorrhages and multifocal chorioretinal lesions at the posterior pole and mid-periphery. The chorioretinal lesions appeared as hyperreflective drusen-like deposits located in the sub-retinal pigment epithelium (RPE) space on the tomographic scan. WD was considered and confirmed by polymerase chain reaction test and duodenal biopsy.Conclusion: Posterior ocular involvement in WD may present with a wide clinical spectrum including intraocular inflammation and unique features of sub-RPE deposits, widespread retinal hemorrhages, and optic disc edema.
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Affiliation(s)
- Francesca Bosello
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
| | | | - Enrico Neri
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
| | - Alessandro Alfano
- Ophthalmology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Adriana Bonora
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
| | - Giorgio Marchini
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
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23
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Lessard L, Gallay L, Compain C, Robinson P, Lepidi H, Streichenberger N. Myalgia, Headaches, and Ineffective Immunosuppressive Drugs in a 65-Year-Old Female With Rheumatoid Arthritis. Clin Infect Dis 2020; 70:2231-2234. [PMID: 32373940 DOI: 10.1093/cid/ciz793] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lola Lessard
- Service d'Anatomo-Pathologie, Hospices Civils de Lyon, Institut NeuroMyoGène CNRS UMR 5310 - INSERM U1217- Université de Lyon - Université Claude Bernard Lyon 1, France
| | - Laure Gallay
- Département de médecine interne et immunologie clinique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Institut NeuroMyoGène CNRS UMR 5310 - INSERM U1217, France
| | - Caroline Compain
- Service de Médecine interne, Centre Hospitalier Métropole Savoie, Chambéry, France
| | - Philip Robinson
- Direction de la Recherche Clinique et de l'Innovation, Hospices Civils de Lyon, France
| | - Hubert Lepidi
- Institut Hospitalo-Universitaire Méditerranée-Infection, MEPHI, IRD 198, Aix-Marseille-Université, AP-HM, France
| | - Nathalie Streichenberger
- Service d'Anatomo-Pathologie, Hospices Civils de Lyon, Institut NeuroMyoGène CNRS UMR 5310 - INSERM U1217- Université de Lyon - Université Claude Bernard Lyon 1, France
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24
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Kloek AT, Piet JR, Adriani KS. Pearls & Oy-sters: A rare presentation of Whipple disease: Still waters run deep. Neurology 2020; 94:e758-e761. [PMID: 32015179 DOI: 10.1212/wnl.0000000000008976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Anne T Kloek
- From the Department of Neurology (A.T.K.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; Department of Neurology (J.R.P., K.S.A.), OLVG Hospital, Amsterdam; Department of Neurology (J.R.P., K.S.A.), Zaans Medisch Centrum, Zaandam; and Department of Viroscience (K.S.A.), Erasmus MC, Rotterdam, the Netherlands.
| | - Jurgen R Piet
- From the Department of Neurology (A.T.K.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; Department of Neurology (J.R.P., K.S.A.), OLVG Hospital, Amsterdam; Department of Neurology (J.R.P., K.S.A.), Zaans Medisch Centrum, Zaandam; and Department of Viroscience (K.S.A.), Erasmus MC, Rotterdam, the Netherlands
| | - Kirsten S Adriani
- From the Department of Neurology (A.T.K.), Amsterdam Neuroscience, Amsterdam UMC, University of Amsterdam; Department of Neurology (J.R.P., K.S.A.), OLVG Hospital, Amsterdam; Department of Neurology (J.R.P., K.S.A.), Zaans Medisch Centrum, Zaandam; and Department of Viroscience (K.S.A.), Erasmus MC, Rotterdam, the Netherlands
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25
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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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26
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Beltrame A, Ragusa A, Perandin F, Formenti F, Fenollar F, Edouard S, Laroche M, Zavarise G, Doro F, Giorli G, Raoult D, Bisoffi Z. Tropheryma whipplei intestinal colonization in Italian and migrant population: a retrospective observational study. Future Microbiol 2019; 14:283-292. [PMID: 30855186 DOI: 10.2217/fmb-2018-0347] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To obtain the first molecular epidemiological survey of Tropheryma whipplei intestinal colonization in Italy. Materials & methods: Retrospective, observational study to assess the prevalence of T. whipplei, the causative agent of Whipple's disease, in stool samples (real-time PCR) of patients attending the Center for Tropical Diseases (Italy) and risk factors associated. RESULTS Overall prevalence was 6.9% (85/1240). The younger age group showed a significantly higher rate than older age group (12.7 vs 5.9%, p = 0.002). The prevalence was 4.9% for Italians and 9.3% for migrants (p = 0.003). Among the latter, children less than 10 years had higher prevalence than older ones (17.3 vs 7.3%, p = 0.003). The young age, male gender and Giardia duodenalis and Entamoeba histolytica coinfection were risk factors. CONCLUSION Our study confirms an increased risk of acquiring T. whipplei infection during childhood, under poor sanitary conditions.
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Affiliation(s)
- Anna Beltrame
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Andrea Ragusa
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesca Perandin
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Fabio Formenti
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Florence Fenollar
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Sophie Edouard
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Maureen Laroche
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Giorgio Zavarise
- Paediatrics Department, IRCSS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Francesco Doro
- Paediatrics Department, IRCSS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Giovanni Giorli
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy
| | - Didier Raoult
- Aix Marseille Univ, AP-HM, MEPHI, IHU-Méditerranée Infection, 19-21 Bd Jean Moulin, 13005, France
| | - Zeno Bisoffi
- Centre for Tropical Diseases, IRCCS Sacro Cuore - Don Calabria Hospital, Via Sempreboni 5, 37024 Negrar, Italy.,Department of Diagnostic & Public Health, University of Verona, P.le L. A. Scuro 10, 37134 Verona, Italy
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Le Goff M, Cornec D, Guellec D, Marhadour T, Devauchelle-Pensec V, Jousse-Joulin S, Herbette M, Cauvin JM, Le Guillou C, Renaudineau Y, Jamin C, Pers JO, Saraux A. Peripheral-blood b-cell subset disturbances in inflammatory joint diseases induced by Tropheryma whipplei. PLoS One 2019; 14:e0211536. [PMID: 30811404 PMCID: PMC6392227 DOI: 10.1371/journal.pone.0211536] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Accepted: 01/16/2019] [Indexed: 12/18/2022] Open
Abstract
Objective To look for abnormalities in circulating B-cell subsets in patients with rheumatic symptoms of Whipple’s disease (WD). Method Consecutive patients seen between 2010 and 2016 for suspected inflammatory joint disease were identified retrospectively. Results of standardized immunological and serological tests and of peripheral-blood B-cell and T-cell subset analysis by flow cytometry were collected. Patients with criteria suggesting WD underwent PCR testing for Tropheryma whipplei, and those with diagnosis of WD (cases) were compared to those without diagnosis (controls). We used ROC curve analysis to evaluate the diagnostic value of flow cytometry findings for WD. Results Among 2917 patients seen for suspected inflammatory joint disease, 121 had suspected WD, including 9 (9/121, 7.4%) confirmed WD. Proportions of T cells and NK cells were similar between suspected and confirmed WD, whereas cases had a lower proportion of circulating memory B cells (IgD-CD38low, 18.0%±9.7% vs. 26.0%±14.2%, P = 0.041) and higher ratio of activated B cells over memory B cells (4.4±2.0 vs. 2.9±2.2, P = 0.023). Among peripheral-blood B-cells, the proportion of IgD+CD27- naive B cells was higher (66.2%±18.2% vs. 54.6%±18.4%, P = 0.047) and that of IgD-CD27+ switched memory B cells lower (13.3%±5.7% vs. 21.4%±11.9%, P = 0.023), in cases vs. controls. The criterion with the best diagnostic performance was a proportion of IgD+CD27- naive B cells above 70.5%, which had 73% sensitivity and 80% specificity. Conclusion Our study provides data on peripheral-blood B-cell disturbances that may have implications for the diagnosis and pathogenetic understanding of WD.
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Affiliation(s)
- Maëlle Le Goff
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | - Divi Cornec
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Dewi Guellec
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | - Thierry Marhadour
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | - Valérie Devauchelle-Pensec
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Sandrine Jousse-Joulin
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Marion Herbette
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
| | | | | | - Yves Renaudineau
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Christophe Jamin
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Jacques Olivier Pers
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
| | - Alain Saraux
- Rheumatology Unit, Centre National de Référence des Maladies Auto-Immunes Rares (CERAINO), Victor Hugo Network, Brest Teaching Hospital, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Brest University, Inserm, Brest Teaching Hospital, LabEx IGO, Brest, France
- * E-mail:
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28
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Crews NR, Cawcutt KA, Pritt BS, Patel R, Virk A. Diagnostic Approach for Classic Compared With Localized Whipple Disease. Open Forum Infect Dis 2018; 5:ofy136. [PMID: 29992176 PMCID: PMC6030902 DOI: 10.1093/ofid/ofy136] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Accepted: 06/08/2018] [Indexed: 12/11/2022] Open
Abstract
Background Whipple disease (WD), a rare systemic infection caused by Tropheryma whipplei, can be a diagnostic challenge due to its variable presentation. The role of T. whipplei polymerase chain reaction (PCR) is unclear as small bowel biopsy with Periodic acid-Schiff (PAS) staining remains the diagnostic gold standard. Individualized diagnostic approaches based on variable clinical manifestations are underutilized. We investigated the methodologies employed at our institution to diagnose WD. Methods We retrospectively collected all cases of WD diagnosed from 1994 to 2016. Microbiology laboratory and anatomic pathology databases were queried. Case characteristics and disease clinical phenotypes (classical, localized WD arthritis, and localized central nervous system [CNS] disease) were described. The diagnostic approach and testing yield were analyzed and reported. Results Thirty-three cases of WD were diagnosed (18 classic WD [CWD], 9 localized WD arthritis [LWD], 6 CNS WD). Misdiagnosis and delay in diagnosis were frequent. Diagnostic approach and test yield differed by classical vs localized WD involvement. Small bowel tissue biopsy PAS stain/PCR was overwhelmingly positive (86%/92%) in CWD, yet seldom positive (12%/42%) in LWD (P < .001). Affected joint synovial fluid PCR was frequently positive in both CWD (100%, 3/3) and LWD (85%, 6/7). Conclusions These results support the role of small bowel biopsy PAS stain/PCR in the diagnosis of CW, though this approach may be of limited utility in LWD or CNS WD without gastrointestinal symptoms. Affected joint synovial fluid or cerebrospinal fluid PCR was frequently positive in both CWD and LWD, supporting its diagnostic usefulness.
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Affiliation(s)
- Nicholas R Crews
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana
| | - Kelly A Cawcutt
- Divisions of Infectious Diseases and Pulmonary and Critical Care, University of Nebraska Medical Center, Omaha, Nebraska
| | - Bobbi S Pritt
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota.,Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
| | - Robin Patel
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota.,Division of Clinical Microbiology, Mayo Clinic, Rochester, Minnesota
| | - Abinash Virk
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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Current and Future Use of Chloroquine and Hydroxychloroquine in Infectious, Immune, Neoplastic, and Neurological Diseases: A Mini-Review. Clin Drug Investig 2018; 38:653-671. [DOI: 10.1007/s40261-018-0656-y] [Citation(s) in RCA: 180] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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