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Krüger SR, Norvard ER, Larssen KW, Maierhofer U, Hestmann H, Papathomas T. Generalized lymphadenopathy due to Tropheryma whipplei: Thinking outside the box! Int J Infect Dis 2024; 143:107033. [PMID: 38556042 DOI: 10.1016/j.ijid.2024.107033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Revised: 03/26/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024] Open
Affiliation(s)
- Stig Ree Krüger
- Department of Clinical Pathology, Vestre Viken Hospital Trust, Drammen, Norway.
| | - Espen Rigby Norvard
- Department of Clinical Pathology, Vestre Viken Hospital Trust, Drammen, Norway
| | - Kjersti Wik Larssen
- Department of Medical Microbiology, St. Olav's University Hospital, Trondheim, Norway
| | - Ursa Maierhofer
- Department of Clinical Pathology, Vestre Viken Hospital Trust, Drammen, Norway
| | - Helene Hestmann
- Department of Medicine, Vestre Viken Hospital Trust, Bærum, Norway
| | - Thomas Papathomas
- Department of Clinical Pathology, Vestre Viken Hospital Trust, Drammen, Norway; Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, United Kingdom
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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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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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Weber M, Dancygier H, Blasberg T, Wedi E. [Co-occurrence of Whipple's disease and hyperparathyroidism - coincidence or causal relationship?]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1214-1220. [PMID: 37309099 DOI: 10.1055/a-1984-0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Whipple's disease is a rare infectious disease with multiple clinical manifestations. The disease is named after George Hoyt Whipple, who first recorded the illness in 1907 after conducting the autopsy of a 36-year-old man with weight loss, diarrhea, and arthritis. Under the microscope, Whipple discovered a rod-shaped bacterium in the patient's intestinal wall, which was not confirmed as a new bacterial species until 1992, when it was named Tropheryma whipplei.Recurrence of Whipple's disease can occur years after an initial diagnosis and often manifests with extraintestinal symptoms such as arthritides or skin efflorescences, years before a gastrointestinal complaint. However, the simultaneous occurrence of primary hyperparathyroidism in the present case is a hitherto unknown clinical picture and opens up new questions and perspectives in the context of diagnostics and therapy.
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Affiliation(s)
- Marie Weber
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| | | | - Tobias Blasberg
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| | - Edris Wedi
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
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Diesing TS. Neurologic Manifestations of Gastrointestinal and Nutritional Disorders. Continuum (Minneap Minn) 2023; 29:708-733. [PMID: 37341328 DOI: 10.1212/con.0000000000001235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE A tie between nutritional or gastrointestinal and neurologic disease has been recognized for centuries. Many gastrointestinal disorders are associated with neurologic disease through nutritional, immune-mediated, or degenerative pathophysiologies. This article reviews neurologic disorders in patients with gastrointestinal disease and gastrointestinal manifestations in their own neurologic patients. LATEST DEVELOPMENTS Development of new gastric and bariatric surgical procedures and the widespread use of over-the-counter gastric acid-reducing medications continue to create vitamin and nutritional deficiencies despite modern diet and supplementation. Some supplements, such as vitamin A, vitamin B6, and selenium, themselves are now found to cause disease. Recent work has shown extraintestinal and neurologic manifestations of inflammatory bowel disease. Chronic brain damage in liver disease has been recognized, and the opportunity to intervene may exist in the covert beginning stages. The characterization of gluten-related neurologic symptoms and differentiation from those of celiac disease is an evolving body of work. ESSENTIAL POINTS Gastrointestinal and neurologic diseases related to common immune-mediated, degenerative, or infectious mechanisms are common and can coexist in the same patient. Furthermore, gastrointestinal disease may cause neurologic complications because of nutritional inadequacies, malabsorption, and hepatic dysfunction. In many cases, the complications are treatable but have subtle or protean presentations. Therefore, the consulting neurologist must be current in knowledge of the growing ties between gastrointestinal and neurologic disease.
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Contribution of PCR to Differential Diagnosis between Patients with Whipple Disease and Tropheryma whipplei Carriers. J Clin Microbiol 2023; 61:e0145722. [PMID: 36656022 PMCID: PMC9945495 DOI: 10.1128/jcm.01457-22] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
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 (CT) 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 CT value below 30 were 52.4% and >99.9%, respectively. The high specificity of duodenal PCR with low CT 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 CT value from a duodenal biopsy specimen provides valuable guidance, especially in patients with PAS-negative results.
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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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Shams S, Niloofar Rezaie, Beltrame A, Moro L, Piubelli C, Amiri FB, Esmaeili S. Tropheryma whipplei intestinal colonization in immunocompromised children in Iran: a preliminary study. Future Microbiol 2021; 16:1161-1166. [PMID: 34615382 DOI: 10.2217/fmb-2021-0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Saeed Shams
- Cellular and Molecular Research Center, Qom University of Medical Sciences, Qom, 3736175513, Iran
| | - Niloofar Rezaie
- Department of Microbiology, Pasteur Institute of Iran, Tehran, 1316943551, Iran
| | - Anna Beltrame
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, 37024, Italy
| | - Lucia Moro
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, 37024, Italy
| | - Chiara Piubelli
- Department of Infectious, Tropical Diseases and Microbiology, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, 37024, Italy
| | - Fahimeh Bagheri Amiri
- Department of Epidemiology and Biostatistics, Research Centre for Emerging and Reemerging Infectious Diseases, Pasteur Institute of Iran, Tehran, 1316943551, Iran
| | - Saber Esmaeili
- Department of Epidemiology and Biostatistics, Research Centre for Emerging and Reemerging Infectious Diseases, Pasteur Institute of Iran, Tehran, 1316943551, Iran
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Abstract
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.
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He YT, Peterson K, Crothers J, Dejace J, Hale AJ. Endocarditis and systemic embolization from Whipple's disease. IDCases 2021; 24:e01105. [PMID: 33868927 PMCID: PMC8047165 DOI: 10.1016/j.idcr.2021.e01105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Yu Ting He
- University of Vermont Medical Center, Burlington, VT, United States
| | | | - Jessica Crothers
- University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Jean Dejace
- University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Andrew J. Hale
- University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
- Corresponding author at: University of Vermont Medical Center, Infectious Disease Unit, 111 Colchester Avenue, Mailstop 115 SM2, Burlington, VT 05401, United States.
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Yetmar Z, Cano Cevallos E, Mahmood M. Abdominal Pain, Fevers, and Intestinal Lymphangiectasia. Clin Infect Dis 2020; 69:2035-2036. [PMID: 31724060 DOI: 10.1093/cid/ciz041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zachary Yetmar
- Department of Internal Medicine, and, Rochester, Minnesota
| | | | - Maryam Mahmood
- Division of Infectious Diseases, Mayo Clinic, Rochester, Minnesota
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Dubost JJ, Couderc M, Mathieu S, Tournadre A, Soubrier M. Chronic bursitis and tenosynovitis revealing Whipple's disease. Joint Bone Spine 2020; 87:481-482. [PMID: 32007648 DOI: 10.1016/j.jbspin.2020.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 01/23/2020] [Indexed: 10/25/2022]
Abstract
Joint complaints, most commonly intermittent arthritis, are the initial manifestation in about three-fourths of Whipple's disease cases. We herein report on two cases wherein Whipple's disease manifested itself as chronic bursitis and tenosynovitis at several sites. A 42 year-old man had bilateral olecranon bursitis, a right patellar bursitis and an extensor tenosynovitis on the left wrist and a 54 year-old man had extensor tenosynovitis at both wrists and a bilateral tenosynovitis of the extensors at both ankle. Methotrexate in both patients and etanercept in one of them were not effective. Polymerase chain reaction testing revealed Tropheryma whipplei on feces, bursitis and articular fluid samples. Duodenal biopsy proved to be normal. Doxycycline and hydroxychloroquine were rapidly effective. Chronic bursitis and tenosynovitis must be added to the list of rheumatologic manifestations that may evoke the diagnosis of Whipple disease.
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Affiliation(s)
- Jean-Jacques Dubost
- Department of Rheumatology, CHU Clermont ferrand, 58 rue Montalembert, 63003 Clermont Ferrand Cedex 1, France.
| | - Marion Couderc
- Department of Rheumatology, CHU Clermont ferrand, 58 rue Montalembert, 63003 Clermont Ferrand Cedex 1, France
| | - Sylvain Mathieu
- Department of Rheumatology, CHU Clermont ferrand, 58 rue Montalembert, 63003 Clermont Ferrand Cedex 1, France
| | - Anne Tournadre
- Department of Rheumatology, CHU Clermont ferrand, 58 rue Montalembert, 63003 Clermont Ferrand Cedex 1, France
| | - Martin Soubrier
- Department of Rheumatology, CHU Clermont ferrand, 58 rue Montalembert, 63003 Clermont Ferrand Cedex 1, France
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Whipple's Disease Affecting Ileal Peyer's Patches: The First Case Report. Case Rep Pathol 2019; 2019:1509745. [PMID: 31341692 PMCID: PMC6612373 DOI: 10.1155/2019/1509745] [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: 02/25/2019] [Revised: 05/14/2019] [Accepted: 05/23/2019] [Indexed: 11/17/2022] Open
Abstract
Whipple's disease is a rare chronic systemic bacterial infectious disease which can affect multiple organs, with a wide clinical spectrum encompassing many symptoms presenting in various forms and combinations. In the cases where the gastrointestinal tract is implicated, the more frequent localizations involve the small bowel, especially the duodenum. A case of a 67-year-old man who underwent clinical investigation after presenting with a progressive weight loss and showing a hypercapting right paracoeliac adenopathy at PET-CT scan is reported herein. A gastroscopy and a colonoscopy were done. The biopsies of the endoscopically normal ileal mucosa encompassed some submucosal Peyer's patches. Histological examination of this lymphoid tissue revealed several foamy macrophages which turned out positive on periodic acid-Schiff special staining. Polymerase chain reaction of the microdissected lymph follicles allowed for confirming Whipple's disease diagnosis. A targeted antibiotic treatment administrated to the patient led to a rapid clinical improvement. This finding of a previously unreported localization of infected macrophages in Whipple's disease suggests that sampling the organized mucosal-submucosal lymphoid tissue may increase the diagnostic yield in endoscopic biopsies.
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