On the wide spectrum of abnormalities in the coronary arteries of Whipple's disease

Cardiovascular pathology in vasculitis

Vasculitides are diseases that can affect any vessel. When cardiac or aortic involvement is present, the prognosis can worsen significantly. Pathological assessment often plays a key role in reaching a definite diagnosis of cardiac or aortic vasculitis, particularly when the clinical evidence of a systemic inflammatory disease is missing. The following review will focus on the main histopathological findings of cardiac and aortic vasculitides.

High-risk and low prevalence disease: Cardiac sarcoidosis and some of its mimics

In this narrative review of cardiac sarcoidosis, based on a literature search using the terms "cardiac sarcoidosis", "tuberculous myocarditis", "Whipple's disease and myocarditis", and"idiopathic giant cell myocarditis", I have defined cardiac sarcoidosis as a disorder which can be diagnosed either by documentation of the presence of sarcoid-related granulomas in myocardial tissue or by documentation of the association of the presence of sarcoid-related granulomas in extracardiac tissue and symptoms such as complete heart block, ventricular tachyarrhythmia, sudden death or dilated cardiomyopathy which are typical of cardiac sarcoidosis. The differential diagnosis of cardiac sarcoidosis includes granulomatous myocarditis attributable to underlying causes such as such as tuberculosis, Whipple's disease, and idiopathic giant cell myocarditis. Diagnostic pathways for cardiac sarcoidosis include biopsy of cardiac and extracardiac tissue, nuclear magnetic resonance imaging, positron emission tomography, and a diagnostic trial of empiric therapy. Problem areas include differentiation between noncaseating granulomatosis attributable to sarcoidosis versus noncaseating granulomatosis attributable to tuberculosis and whether or not the workup of suspected cardiac sarcoidosis should always include evaluation of biopsy tissue by molecular methods for M tuberculosis DNA as well as by mycobacterium tuberculosis culture. The diagnostic significance of necrotising granulomatosis is also unclear. Evaluation of patients on long term immunotherapy should also take due account of the risk of tuberculosis attributable to the use of tumor necrosis factor-alpha antagonists.

Rare but not so rare: The evolving spectrum of Whipple's disease

Knowledge about Whipple's disease began to emerge in 1907, when George Hoyt Whipple recognized the first case of the disease that now bears his name. He reported the case of a 36-year-old physician with "a gradual loss of weight and strength, stools consisting chiefly of neutral fat and fatty acids, indefinite abdominal signs, and a peculiar multiple arthritis" (1). Findings at autopsy consisted of poly-serositis, aortic valve vegetations and deposition of fat in the intestinal mucosa and regional lymph nodes with marked infiltration by foamy macrophages (1). It was originally thought to be a disorder of fat metabolism, and the term 'intestinal lipodystrophy' was proposed. Whipple's disease has since been recognized as a rare, multivisceral, chronic disease with a clinical presentation dominated by a symptom triad of diarrhea, weight loss and malabsorption. However, digestive symptoms are often preceded for months or years by other symptoms, the most common being arthralgia, although cardiovascular, neurological or pulmonary involvement may be more prominent at times. Once considered the ideal case report, recent characterization ofTropheryma whippeliiby means of broad range bacterial ribosomal DNA polymerase chain reaction (PCR) analysis (2,3) and its subsequent cultivation (4) has led to a veritable explosion of individual case reports, case series and hitherto unrecognized manifestations of the disease, such that it is now considered an underdiagnosed infectious disease (5). It is timely to provide an update on new developments in Whipple's disease.