Whipple's disease: new aspects of pathogenesis and treatment

Pulmonary sarcomatoid carcinoma: A rare case report, diagnostic dilemma and review of literature

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.

Autoimmune diseases of the spine and spinal cord

Magnetic resonance imaging (MRI) and clinicopathological tools have led to the identification of a wide spectrum of autoimmune entities that involve the spine. A clearer understanding of the unique imaging features of these disorders, along with their clinical presentations, will prove invaluable to clinicians and potentially limit the need for more invasive procedures such as tissue biopsies. Here, we review various autoimmune diseases affecting the spine and highlight salient imaging features that distinguish them radiologically from other disease entities.

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

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.

Whipple's disease - A typical endoscopic finding of a rare disease

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.

Whipple's disease: A rare disease that can be spotted by many doctors

Whipple's disease, an extremely rare, chronic infection caused by Tropheryma whipplei, an actinobacterium ubiquitously present in the environment, is a multisystemic condition that can affect several organs. Therefore, Whipple's disease should always be considered by physicians working across various branches of medicine, including internal medicine, rheumatology, infectious diseases, gastroenterology, haematology, and neurology. Initially, Whipple's disease is challenging to diagnose due to both its rarity and non-specific clinical features, almost indistinguishable from rheumatological conditions. A few years later, the onset of gastrointestinal symptoms increases the specificity of its clinical picture and helps in reaching the correct diagnosis. Diagnosis is typically made by finding PAS-positive macrophages in the lamina propria at duodenal biopsy. PCR for Tropheryma whipplei is nowadays also increasingly available, and represents an undeniable help in diagnosing this condition. However, it may also be misleading as false positives can occur. If not promptly recognized and treated, central nervous system involvement may develop, which can be fatal. The therapeutic gold standard has not yet been fully established, particularly in cases of recurrent disease, neurological involvement, and an immune reconstitution inflammatory syndrome that may arise following the initiation of antibiotic therapy.

A serological assay using Tropheryma whipplei antigens for the presumptive exclusion of Whipple disease

Whipple disease (WD) is a rare infection in genetically susceptible people caused by the bacterium Tropheryma whipplei. An indirect immunofluorescence serological assay (IFA), detecting patient antibodies to the bacterium, was developed using T. whipplei as antigen. We hypothesised that this assay could be used to rule out WD in patients in whom the diagnosis was being considered, based on high immunoglobulin (Ig) G titres to T. whipplei. In this study, 16 confirmed WD patients and 156 age-matched controls from across Australia were compared serologically. WD patients mostly underproduced IgG antibody to T. whipplei, with titres of ≤1:32 being common. While at an antibody titre of <1:64 the assay sensitivity for WD was only 69% [95% confidence interval (CI) 41-89%], its specificity for excluding WD was 91% (95% CI 85-95%). This specificity increased to 95% (95% CI 90-98%) at an antibody titre of <1:16. Patients with antibody titres of >1:64 were unlikely to have WD. At this titre, the seroprevalence of T. whipplei IgG antibody was 92% (223/242) in Australian blood donors. Unlike other serological assays, which are used to confirm a specific infection, this novel assay is designed to rule out WD infection with a specificity in Australia of 91%. Further validation of this assay, by trialling in other countries, should now be undertaken, as its usefulness is dependent on there being a high background seropositivity to T. whipplei in the general population at the location in which the assay is being used.

Whipple's Disease Presenting With a Chief Complaint of Dyspnea and Cough From Pulmonary Invasion Without Evidence of Gastrointestinal Involvement

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.

Current knowledge of the immune reconstitution inflammatory syndrome in Whipple disease: a review

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.

[Co-occurrence of Whipple's disease and hyperparathyroidism - coincidence or causal relationship?]

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.

Updates in Culture-Negative Endocarditis

Blood culture-negative infective endocarditis (BCNE) is a challenging condition associated with significant morbidity and mortality. This review discusses the epidemiology, microbiology, diagnosis, and treatment of BCNE considering advancements in molecular diagnostics and increased access to cardiac surgery. BCNE can be categorized into bacterial endocarditis with sterilized blood cultures due to previous antibiotic treatment, endocarditis caused by fastidious microorganisms, and true BCNE caused by intracellular organisms that cannot be cultured using traditional techniques. Non-infectious causes such as nonbacterial thrombotic endocarditis should also be considered. Diagnostic approaches involve thorough patient history; blood and serum testing, including appropriate handling of blood cultures; serological testing; and molecular techniques such as targeted and shotgun metagenomic sequencing. Where available, evaluation of explanted cardiac tissue through histopathology and molecular techniques is crucial. The therapy for BCNE depends on the likely causative agent and the presence of prosthetic material, with surgical intervention often required.

Uptake of Tropheryma whipplei by Intestinal Epithelia

Background: Tropheryma whipplei (TW) can cause different pathologies, e.g., Whipple’s disease and transient gastroenteritis. The mechanism by which the bacteria pass the intestinal epithelial barrier, and the mechanism of TW-induced gastroenteritis are currently unknown. Methods: Using ex vivo disease models comprising human duodenal mucosa exposed to TW in Ussing chambers, various intestinal epithelial cell (IEC) cultures exposed to TW and a macrophage/IEC coculture model served to characterize endocytic uptake mechanisms and barrier function. Results: TW exposed ex vivo to human small intestinal mucosae is capable of autonomously entering IECs, thereby invading the mucosa. Using dominant-negative mutants, TW uptake was shown to be dynamin- and caveolin-dependent but independent of clathrin-mediated endocytosis. Complementary inhibitor experiments suggested a role for the activation of the Ras/Rac1 pathway and actin polymerization. TW-invaded IECs underwent apoptosis, thereby causing an epithelial barrier defect, and were subsequently subject to phagocytosis by macrophages. Conclusions: TW enters epithelia via an actin-, dynamin-, caveolin-, and Ras-Rac1-dependent endocytosis mechanism and consecutively causes IEC apoptosis primarily in IECs invaded by multiple TW bacteria. This results in a barrier leak. Moreover, we propose that TW-packed IECs can be subject to phagocytic uptake by macrophages, thereby opening a potential entry point of TW into intestinal macrophages.

Contribution of PCR to Differential Diagnosis between Patients with Whipple Disease and Tropheryma whipplei Carriers

Differentiation between Whipple disease (WD) patients and patients carrying Tropheryma whipplei but suffering from disease other than WD ("carriers") remains complex. We aimed to evaluate T. whipplei PCR among patients with WD and carriers in a large cohort at our referral clinical microbiology laboratory. This is an observational retrospective cohort study, including all patients between 2008 and 2020 with at least one positive result for T. whipplei using the real-time PCR RealCycler TRWH-UX kit. A total of 233 patients were included: 197 were considered carriers, and 36 had WD. Among the WD patients, 32 underwent biopsies, of which 18 (56%) had a positive periodic acid-Schiff (PAS) staining. Among the 27 duodenal biopsy specimens, 13 (48%) were PAS positive. PCR results before antibiotic treatment were positive in both feces and saliva in 16/21 WD (76%) patients and 68/197 (35%) carriers (P < 0.001). Duodenal biopsy specimens yielded positive PCR in 20/22 (91%) WD patients and 27/72 (38%) carriers (P < 0.001). The cycle threshold (C_T) value detected in duodenal biopsy specimens from WD patients was significantly lower than that of carriers (P < 0.001), regardless of the PAS staining results. For a diagnosis of WD, duodenal PCR sensitivity and specificity at a C_T value below 30 were 52.4% and >99.9%, respectively. The high specificity of duodenal PCR with low C_T values may help confirming the diagnosis of WD, especially in patients with negative PAS results in digestive biopsy specimens, who represent half of all patients. A low PCR C_T value from a duodenal biopsy specimen provides valuable guidance, especially in patients with PAS-negative results.

Culture-Negative Endocarditis and Cerebral Demyelination: A Challenging Case of Whipple's Disease

Whipple's disease is a rare condition that, when not recognized and properly treated, can be fatal. A 49-year-old female presented with a five-month history of diarrhoea with watery stools seven times per day, nocturnal abdominal pain, asthenia, and a weight loss of 30% of her body mass in three months. The patient had a four-year medical history of bilateral mechanic gonalgia, arthralgia of the metacarpophalangeal and interphalangeal joints, and anaemia. The examination was remarkable for hyperpigmentation, along with a body mass index (BMI) of 15.8 kg/m². The diagnosis of Whipple's disease was made with upper gastrointestinal endoscopy, with typical histologic findings and a positive PCR for Tropheryma whipplei. Investigations also revealed cerebral demyelination and endocarditis in three valves. Treatment with intravenous ceftriaxone for four weeks and oral cotrimoxazole for one year resulted in complete resolution of the symptoms and endocarditis. This case report shows uncommon features of the disease and debates the challenging decisions toward diagnosis and effective treatment.

Whipple's disease with normal duodenal histology diagnosed by ileal biopsy using balloon endoscopy

A 34 year-old previously healthy Japanese woman presented with a 4 year history of migratory arthralgia, chronic diarrhea, mild fever, and 10 kg weight loss. She was initially misdiagnosed with seronegative arthritis, followed by eosinophilic gastroenteritis. Oral prednisolone was found to be ineffective. Upper endoscopy revealed normal duodenal mucosa. Duodenal biopsy specimen indicated no abnormalities. However, balloon endoscopy revealed white shaggy villi in the ileum, and a biopsy specimen from which revealed diffuse infiltration of foamy macrophages in the lamina propria. These macrophages contained diastase-periodic acid-Schiff positive granules, consistent with Whipple's disease. Polymerase chain reaction analysis of DNA extracted from the ileum was compatible with Whipple's disease. In most previously reported cases of Whipple's disease, the duodenum was affected and duodenal biopsy specimens led to a diagnosis of Whipple's disease. Whipple's disease with normal duodenal histology is extremely rare and balloon endoscopy might be a useful diagnostic tool in such a case. The patient was treated with intravenous ceftriaxone and oral trimethoprim-sulfamethoxazole, and her symptoms improved one month after treatment. Balloon endoscopy performed 32 months later revealed complete improvement in lesions of the ileum.

Intestinal barrier dysfunction mediates Whipple's disease immune reconstitution inflammatory syndrome (IRIS)

Background & Aims

Classical Whipple's disease (CWD) affects the gastrointestinal tract and causes chronic diarrhea, malabsorption, and barrier dysfunction with microbial translocation (MT). Immune reconstitution inflammatory syndrome (IRIS) is a serious complication during antimicrobial treatment of CWD. The pathomechanisms of IRIS have not been identified and mucosal barrier integrity has not been studied in patients with IRIS CWD.

Methods

In 96 CWD patients (n = 23 IRIS, n = 73 non‐IRIS) and 30 control subjects, we analysed duodenal morphology by histology, measured serum markers of MT, and proinflammatory cytokines in biopsy supernatants, and correlated microbial translocation with T cell reconstitution and activation.

Results

Before treatment, duodenal specimens from patients who later developed IRIS exhibited a more pronounced morphological transformation that suggested a disturbed barrier integrity when compared with the non‐IRIS group. Villous atrophy was mediated by increased apoptosis of epithelial cells, which was insufficiently counterbalanced by regenerative proliferation of crypt cells. Pretreatment deficiencies in the mucosal secretion of proinflammatory cytokines and chemokines (e.g., IL‐6, CCL2) in these patients markedly resolved after therapy induction. High serum levels of lipopolysaccharides (LPS), soluble CD14 (sCD14), and LPS‐binding protein (LBP) combined with low endotoxin core antibody (EndoCAb) titres suggested systemic MT in CWD patients developing IRIS. CD4⁺ T cell count and activation in IRIS CWD patients correlated positively with sCD14 levels and negatively with EndoCAb titres. Furthermore, the degree of intestinal barrier dysfunction and MT was predictive for the onset of IRIS.

Conclusion

Prolonged MT across a dysfunctional intestinal mucosal barrier due to severe tissue damage favors dysbalanced immune reconstitution and systemic immune activation in IRIS CWD. Therefore, the monitoring of inflammatory and MT markers in CWD patients might be helpful in identifying patients who are at risk of developing IRIS. Therapeutic strategies to reconstitute the mucosal barrier and control inflammation could assist in the prevention of IRIS.

Endoscopic diagnosis of Whipple disease in a patient without gastrointestinal symptoms: A case report

Whipple's disease is a systemic chronic bacterial infection caused by Tropheryma whipplei, a gram‐positive bacillus. T. whipplei infection in the small intestine often causes malabsorption and is often accompanied by gastrointestinal symptoms such as diarrhea and abdominal pain. In this report, we describe our experience with a case of Whipple's disease in which the affected patient did not have the typical gastrointestinal symptoms. The patient was an 80‐year‐old male who presented with complaints of weight loss and lower leg edema due to malabsorption and shortness of breath during exertion. A blood test revealed a decreased albumin level and an elevated C‐reactive protein level. Endoscopic images revealed diffuse white villi, the presence of which extended from the duodenum to the upper jejunum. We made a diagnosis of Whipple's disease based on pathological findings associated with the duodenum, electron microscopic findings, and findings of polymerase chain reaction (PCR) tests (performed using mucosal tissue). Clinical symptoms and endoscopic findings improved with antibiotics. Real‐time PCR tests were performed for a quantitative evaluation of the effect of treatment. Endoscopy is useful for diagnosing Whipple's disease when there is an absence of gastrointestinal symptoms, and hypoalbuminemia of unknown etiology is observed.

Delayed Diagnosis of Whipple’s Disease Complicated by Jarisch–Herxheimer Reaction to Ceftriaxone Treatment: A Case Report and Literature Review

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.

Tropheryma whipplei in the stool samples of children with acute diarrhea: a study from Tehran, Iran

Background

Recently, Tropheryma whipplei has been suggested as one of the causative agents of diarrhea among children worldwide. Limited data is available on the prevalence of T. whipplei among children with diarrhea in most countries such as Iran. This study was conducted to evaluate the prevalence of T. whipplei in children with acute diarrhea in Iran.

Methods

In this study, the stool samples were collected from 130 children under 10 years old with acute diarrhea from children's hospitals in Tehran city. Genomic DNA was extracted from stool samples and was tested for the presence of DNA of T. whipplei using the SYBR Green Real-time PCR method. Positive T. whipplei samples were finally confirmed by PCR Product sequencing.

Results

The mean age of participants was 32.5 months, and 54.6% of children were female. Using the SYBR Green Real-time PCR, 9.23% (12/130) of samples were positive for T. whipplei, which were confirmed by sequencing. 66.67% of positive cases were males. The duration of diarrhea in infected children with T. whipplei (83.3%) was significantly longer (OR: 5.93, 95% CI 1.24–28.22) compared to children with negative results (45.8%). Other demographic factors and clinical signs had not a statistically significant relationship with T. whipplei infection.

Conclusions

In this study, T. whipplei was detected in stool samples of children with acute diarrhea. The results indicated that T. whipplei could be associated with childhood diarrhea in Iran. The health care system and physicians should be aware of the presence of T. whipplei infection in Iran, especially in childhood diarrhea.

Whipple's disease - a rare and challenging complication in a patient with Crohn's disease

INTRODUCTION

Whipple's disease (WD) is a rare and infectious condition leading to multi-organ impairment caused by Tropheryma whipplei (TW), a ubiquitously occurring bacterium. TW can be detected in tissues by histological detection of PAS ("periodic acid-ship reaction")-positive macrophages and by polymerase-chain-reaction (PCR). Clinically, WD is often characterized by diarrhea, abdominal pain, and weight loss. These symptoms are also typical for a flare in Crohn's disease (CD) and, therefore, can lead to fatal misdiagnosis and wrong treatment by using biologics (e.g., anti-TNF-α).

CASE REPORT

We here report a young male patient with pre-existing CD. The patient's symptoms were misinterpreted as a flare of CD and illustrate the multifaceted nature of WD. After intensifying immunosuppressive therapy, the patient developed therapy-refractory diarrhea with several opportunistic infections with a final, fatal outcome.

CONCLUSION

Patients with inflammatory bowel disease (IBD) are not only at risk from infectious complications known with clostridium difficile or cytomegalovirus (CMV); infection with WD should also be ruled out by endoscopy and biopsy before the escalation of the immunosuppressive regime.

Rapidly progressive dementia and intractable diarrhea: a teaching case report and a systematic review of cognitive impairment in Whipple’s disease

Objective

Methods

Results

Conclusions

Supplementary Information

Clinical Manifestations and Diagnosis of Axial Spondyloarthritis

BACKGROUND

Axial spondyloarthritis (axSpA) is a chronic, rheumatic disease characterized by inflammation of the sacroiliac joint, spine, and entheses. Axial spondyloarthritis affects up to 1.4% of adults in the United States and is associated with decreased quality of life, increased mortality, and substantial health care-related costs, imposing a high burden on patients, their caregivers, and society.

SUMMARY OF WORK

Diagnosing axSpA can be difficult. In this review, we seek to help rheumatologists in recognizing and diagnosing axSpA.

MAJOR CONCLUSIONS

A discussion of challenges associated with diagnosis is presented, including use and interpretation of imaging, reasons for diagnostic delays, differences in disease presentation by sex, and differential diagnoses of axSpA.

FUTURE RESEARCH DIRECTIONS

The early diagnosis of axSpA and advances in available therapeutic options have improved patient care and disease management, but delays in diagnosis and treatment remain common. Additional research and education are critical for recognizing diverse axSpA presentations and optimizing management early in the course of disease.

Tropheryma whipplei intestinal colonization in immunocompromised children in Iran: a preliminary study

Aim & method: Tropheryma whipplei causes Whipple's disease. Children are reservoirs of this bacterium. The aim of this study was to investigate the presence of T. whipplei in children with immunodeficiency in central Iran from July 2018 to February 2019. Stool samples were tested by SYBR Green and Taq-Man real-time PCR assays. For confirmation, the isolated DNA was sequenced. Results: One hundred and thirty children were enrolled. Acute lymphocytic leukemia was the most reported immunodeficient disease (77%), followed by non-Hodgkin lymphoma and retinoblastoma. Thirteen (10%) children had T. whipplei DNA in the stool; 11.4% of the children under 5 years old were positive. Conclusion: This is the first study showing the circulation of T. whipplei in Iran.

Intestinal Colonization with Tropheryma whipplei-Clinical and Immunological Implications for HIV Positive Adults in Ghana

BACKGROUND

Recent studies demonstrated higher prevalence rates of Tropheryma whipplei (T. whipplei) in HIV positive than in HIV negative subjects. However, associations with the immune status in HIV positive participants were conflicting.

METHODS

For this cross-sectional study, stool samples of 906 HIV positive and 98 HIV negative individuals in Ghana were tested for T. whipplei. Additionally, sociodemographic parameters, clinical symptoms, medical drug intake, and laboratory parameters were assessed.

RESULTS

The prevalence of T. whipplei was 5.85% in HIV positive and 2.04% in HIV negative participants. Within the group of HIV positive participants, the prevalence reached 7.18% in patients without co-trimoxazole prophylaxis, 10.26% in subjects with ART intake, and 12.31% in obese participants. Frequencies of clinical symptoms were not found to be higher in HIV positive T. whipplei carriers compared to T. whipplei negative participants. Markers of immune activation were lower in patients colonized with T. whipplei. Multivariate regression models demonstrated an independent relationship of a high CD4+ T cell count, a low HIV-1 viral load, and an obese body weight with the presence of T. whipplei.

CONCLUSIONS

Among HIV positive individuals, T. whipplei colonization was associated with a better immune status but not with clinical consequences. Our data suggest that the withdrawal of co-trimoxazole chemoprophylaxis among people living with HIV on stable cART regimen may inadvertently increase the propensity towards colonization with T. whipplei.

Tropheryma whipplei in Feces of Patients with Diarrhea in 3 Locations on Different Continents

We examined fecal specimens of patients with diarrhea from 3 continents for Tropheryma whipplei and enteropathogens. T. whipplei was most common in South Africa, followed by Singapore and Germany. Its presence was associated with the presence of other pathogens. An independent causative role in diarrhea appears unlikely.

Granulomatous lung disease and immune reconstitution inflammatory syndrome in Whipple's disease

We present the case of a 70-year-old woman with a history of seronegative arthritis, recurrent pleural effusion and weight loss. A prior lung biopsy had revealed non-caseating epithelioid cell granulomas without evidence for microbial organisms on special stains. Intestinal biopsy findings where suspicious for Whipple's disease, which was confirmed by PCR testing, both on the intestinal and retrospectively on the lung tissue. Treatment with ceftriaxone resulted in clinical deterioration with fever, arthritis and recurrent pleuritis consistent with immune reconstitution inflammatory syndrome. Dose increase of glucocorticoids and therapy rotation to doxycycline and hydroxychloroquine resulted in rapid clinical improvement.

Rheumatological features of Whipple disease

Whipple disease (WD) is a rare infectious systemic disease. Rheumatologists are at the frontline of WD diagnosis due to the early rheumatological manifestations. An early diagnosis is crucial, as usual anti-rheumatic drugs, especially TNF inhibitors, may worsen the disease course. We conducted a retrospective multicentre national study from January 2010 to April 2020 to better characterize the rheumatological features of WD. Classic WD (CWD) was defined by positive periodic acid-Schiff (PAS) staining of a small-bowel biopsy sample, and non-CWD (NCWD) was defined by negative PAS staining of a small-bowel biopsy sample but at least one positive Tropheryma whipplei (TW) polymerase chain reaction (PCR) for a digestive or extradigestive specimen. Sixty-eight patients were enrolled, including 11 CWD patients. Twenty patients (30%) received TNF inhibitors during the WD course, with inefficacy or symptom worsening. More digestive symptoms and systemic biological features were observed in CWD patients than in NCWD patients, but both patient groups had similar outcomes, especially concerning the response to antibiotics and relapse rate. Stool and saliva TW PCR sensitivity were both 100% for CWD and 75% for NCWD and 89% and 60% for small-bowel biopsy sample PCR, respectively. WD encountered in rheumatology units has many presentations, which might result from different pathophysiologies that are dependent on host immunity. Given the heterogeneous presentations and the presence of chronic carriage, multiple TW PCR tests on samples from specific rheumatological sites when possible should be performed, but samples from nonspecific digestive and extradigestive sites also have great value.

Clinical manifestations of Whipple's disease mimicking rheumatic disorders

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.

Endocarditis and systemic embolization from Whipple's disease

Whipple’s disease (WD), caused by infection with the organism Tropheryma whipplei, is a rare disease that classically presents with diarrhea, weight loss, and polyarthralgia. Less commonly, Whipple’s Disease can presentation with endocarditis or neurologic infections. The authors report a patient with Whipple’s Disease endocarditis whose initial presentation was acute lower extremity arterial occlusion, and review current literature regarding the epidemiology, diagnosis, treatment, and prognosis of Whipple’s Disease endocarditis.

Whipple's disease: the great masquerader-a high level of suspicion is the key to diagnosis

BACKGROUND

Whipple's disease is a chronic infectious disease that primarily affects the small intestine, but several organs can simultaneously be involved. The disease is caused by a gram-positive bacterium called Tropheryma whipplei. The disease is difficult to suspect because it is rare with unspecific and long-term symptoms; it can be lethal if not properly treated.

CASE PRESENTATION

We here present three patients who presented with a plethora of symptoms, mainly long-standing seronegative arthritis and gastrointestinal symptoms in the form of diarrhea with blood, weight loss, fever, and lymphadenopathy. They were after extensive investigations diagnosed with Whipple's disease, in two of them as long as 8 years after the first occurrence of joint manifestations. The diagnosis was made by PCR targeting the T. whipplei 16S rRNA gene from small bowel specimen in all three patients, and, besides from histopathologic findings from the duodenum and distal ileum in one and mesenteric lymph nodes in another patient.

CONCLUSIONS

This report aims to raise awareness of a very rare disease that presents with a combination of symptoms mimicking other and significantly more common diseases.

Differential diagnostic value of rheumatic symptoms in patients with Whipple's disease

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.

First case of Whipple's disease successfully treated with tigecycline

Introduction

Whipple's disease is a rare chronic infectious disease caused by Tropheryma whipplei. The infection mainly affects the small intestine of middle-aged patients, approximately three times more often in males than in females causing malabsorption and excessive weight loss but other organs may be affected as well.

Case report

We describe a case of a 42-year-old woman with a history of chronic diarrhea and weight loss evolving for at least the last 6 years. The diagnosis of Whipple's disease was confirmed by histopathological examination of duodenal biopsy samples with Periodic acid-Schiff positive macrophages and by polymerase chain reaction technique detecting the DNA of Tropheryma whipplei. The patient was commenced on several antimicrobials including beta-lactams and co-trimoxazole but she did not improve. Finally, after-long lasting i.v. tigecycline 100 mg BID she was commenced on p.o. doxycycline along with hydroxychloroquine 200 mg TID for one year and after by p.o. doxycycline alone.

Discussion

The intriguing thing with this case was not only the natural resistance to co-trimoxazole but that the infection was controlled empirically with long-lasting i.v. tigecycline since several failed attempts to discontinue i.v. treatment followed. This might be due to erratic absorption of oral drugs due to gut inflammation.

Conclusions

To our knowledge, this is the first case of Whipple's disease successfully treated with long-lasting induction parenteral tigecycline followed by p.o. doxycycline along with hydroxychloroquine for one year and after by p.o. doxycycline alone.

A Case of Whipple Disease With Cutaneous Manifestations

ABSTRACT

Whipple disease (WD) is a rare bacterial infectious disease that is classically characterized by years of arthralgia, followed by malabsorption, diarrhea, and weight loss. However, WD may manifest in virtually any organ system, and patients with WD rarely develop subcutaneous erythema nodosum-like lesions. We report a case of a 51-year-old man diagnosed with WD who subsequently developed widely distributed erythematous subcutaneous nodules after 5 months of antibiotic therapy.

Bowel ultrasonography in acute abdomen: beyond acute appendicitis

Acute abdomen is a common reason for consultation in the emergency department. A broad spectrum of entities, including diverse diseases of the gastrointestinal tract, can cause acute abdomen. Although computed tomography is the technique most widely used to evaluate acute abdomen in the emergency department, abdominal ultrasound is often performed first and allows bowel disease to be suspected. This article describes the ultrasound features of diverse bowel diseases that can cause acute abdomen, such as acute diverticulitis, bowel obstruction, gastrointestinal perforation, bowel ischemia, intraabdominal fat necrosis, and miscellaneous processes such as endometriosis, foreign bodies, or vasculitis. Radiologists must be familiar with the different features of abnormal bowel that can be detected incidentally in patients without clinical suspicion of bowel disease. This article focuses on ultrasonographic signs of bowel disease; other articles in this series cover the ultrasonographic signs of acute appendicitis, inflammatory bowel disease, and infectious diseases.

Refractory Effusions, Crumbly Bones, Mystifying Cachexia and an Absent Mind: An Unusual Presentation of Whipple's Disease with Review of Literature

Whipple's disease is a bacterial infection caused by Tropheryma whipplei and is known to cause perplexing clinical presentations, making its diagnosis challenging. The beginning by the involvement of the gastrointestinal tract, Whipple's disease can slowly progress to affect almost any organ system and lead to chronic multi-system inflammatory disease. Hereby, we present a middle age man who initially manifested with shortness of breath and chronic weight loss. He subsequently developed pleuro-pericardial effusion, ascites, mesenteric lymphadenopathy, possible myocarditis, and severe osteopenia with multiple vertebral fractures during his illness. Esophagogastroduodenoscopy with the biopsy and subsequent molecular confirmation of disease led to the confirmation of WD. Therapeutic management included two separate antibiotic regimens in an attempt to address the refractory course of WD in this patient.

Emerging trends in COVID-19 treatment: learning from inflammatory conditions associated with cellular therapies

Coronavirus disease 2019 (SARS-CoV2) is an active global health threat for which treatments are desperately being sought. Even though most people infected experience mild to moderate respiratory symptoms and recover with supportive care, certain vulnerable hosts develop severe clinical deterioration. While several drugs are currently being investigated in clinical trials, there are currently no approved treatments or vaccines for COVID-19 and hence there is an unmet need to explore additional therapeutic options. At least three inflammatory disorders or syndromes associated with immune dysfunction have been described in the context of cellular therapy. Specifically, Cytokine Release Syndrome (CRS), Immune Reconstitution Inflammatory Syndrome (IRIS), and Secondary Hemophagocytic Lymphohistiocytosis (sHLH) all have clinical and laboratory characteristics in common with COVID19 and associated therapies that could be worth testing in the context of clinical trials. Here we discuss these diseases, their management, and potential applications of these treatment in the context of COVID-19. We also discuss current cellular therapies that are being evaluated for the treatment of COVID-19 and/or its associated symptoms.

Involvement of small bowel in systemic disease: CT and MR imaging finding

Computerized tomography (CT) and magnetic resonance imaging (MRI), particularly MR Enterography, are the standard cross-sectional imaging modalities used to study small bowel involvement in a context of multiorgan disease. Clinical symptoms are generally nonspecific in such cases. Moreover, imaging findings of the different conditions often overlap. However, analysis of the location, distribution of the lesions on the small bowel wall, as well as of the rest of the bowel and of distant organs, may help narrow the spectrum of diagnoses of multiorgan conditions involving both the small bowel and other organs. The purpose of this presentation is to review and illustrate the CT and MRI features of small bowel involvement in systemic disease. Based on the underlying mechanism, we will categorize them as follows: congenital/hereditary, immunologic, infiltrative, vascular, infectious and miscellaneous.

In-Silico Proteomic Exploratory Quest: Crafting T-Cell Epitope Vaccine Against Whipple's Disease

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.

Potential Role for Urine Polymerase Chain Reaction in the Diagnosis of Whipple's Disease

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.

Apolipoprotein AI-Derived Vitreous Amyloidosis: An Elusive Diagnosis

A 56-year-old female presented with vitreous opacity with gradual visual disturbance in her right eye of 1-year duration. A Non-Hodgkin's lymphoma had been treated 15 years before. Presenting best-corrected visual acuity (BCVA) was 20/200 in her right eye and 20/25 in her left eye. Intraocular pressure was 18 mm Hg bilaterally. Slit-lamp examination revealed no abnormal findings in the anterior segment of both eyes, including the absence of cells and flare. Fundoscopic examination indicated hazy media with the typical glass-wool-like appearance in her right eye. B-scan ultrasound demonstrated that the vitreous was full of middle-echo spots, vitreous opacities, and posterior vitreous detachment occurred. The patient underwent vitreous biopsy and a standard 25-gauge pars plana vitrectomy (diagnostic and therapeutic). Intraoperatively, the eye was noted to have severe diffuse debris and very strong vitreoretinal adhesions. Cytospin smears prepared from the vitreous aspirate indicated amorphous acellular material that stained positively with Congo Red and showed apple green birefringence on polarized microscopy, consistent with the diagnosis of amyloidosis. A genetic evaluation of tongue tissue demonstrated apolipoprotein AI-derived amyloidosis. The BCVA was 20/25 OU at 3 months postoperatively.