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Bakhshwin A, Duckworth LA, Toro Castano P, El Hag M, Plesec T. Is PAS Stain Necessary to Exclude Whipple Disease in Duodenal Biopsies? Int J Surg Pathol 2024:10668969241260818. [PMID: 38899912 DOI: 10.1177/10668969241260818] [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: 06/21/2024]
Abstract
Objective. Whipple disease, caused by Tropheryma whipplei, is a rare infectious condition primarily presenting with malabsorptive diarrhea. Small bowel biopsies typically reveal foamy macrophages containing periodic acid-Schiff-positive/diastase (PAS/D) resistant T. whipplei bacilli, and PAS(D) staining is occasionally requested by clinicians in duodenal biopsies, which are often histologically unremarkable. The yield of PAS(D) staining in such biopsies has never been reported to our knowledge. Methods. The anatomic pathology database was searched for all specimens of duodenal biopsies stained with PAS(D) from 1993 to 2021. Specimens were categorized by the following histomorphologic features: unremarkable, nonspecific changes, or expansion of the lamina propria by aggregates of foamy histiocytes. Follow-up information was collected, including microbiologic confirmatory testing. Results. There was a total of 193 specimens of duodenal biopsies stained with PAS(D). Biopsies lacking foamy histiocytes on H&E (n = 158) were never PAS-positive. Thirteen biopsies contained PAS-positive histiocytes; 9 out of the 13 PAS-positive specimens were subsequently confirmed to be T. whipplei. Of the 193 specimens, 124 specimens had a clinical request for PAS(D) staining. Only 3 of the 124 (2.4%) specimens showed foamy histiocytes containing PAS-positive granules, all of which were confirmed positive for T. whipplei. Conclusion. PAS(D) staining is unnecessary to exclude Whipple disease in duodenal biopsies without foamy macrophage aggregates, regardless of clinical suspicion. Clinical suspicion-driven biopsies often yield negative results for Whipple disease.
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Affiliation(s)
- Ahmed Bakhshwin
- Department of Pathology, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Lauren Ashley Duckworth
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paula Toro Castano
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mohamed El Hag
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Thomas Plesec
- Department of Pathology, Robert J. Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
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Moos V, von Lampe B, Schneider T. Massive Mesenteric Lymphadenopathy: An Unusual Outcome. Gastroenterology 2024; 166:e5-e9. [PMID: 38029847 DOI: 10.1053/j.gastro.2023.11.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/10/2023] [Accepted: 11/11/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Verena Moos
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, CBF, Medical Department for Gastroenterology, Rheumatology and Infectious Diseases, Berlin, Germany.
| | - Bernd von Lampe
- Vivantes, Humboldt-Klinikum, Department of Gastroenterology and Hepatology, Berlin, Germany
| | - Thomas Schneider
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, CBF, Medical Department for Gastroenterology, Rheumatology and Infectious Diseases, Berlin, Germany
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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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Caillet Portillo D, Puéchal X, Masson M, Kostine M, Michaut A, Ramon A, Wendling D, Costedoat-Chalumeau N, Richette P, Marotte H, Vix-Portet J, Dubost JJ, Ottaviani S, Mouterde G, Grasland A, Frazier A, Germain V, Coury F, Tournadre A, Soubrier M, Cavalie L, Brevet P, Zabraniecki L, Jamard B, Couture G, Arnaud L, Richez C, Degboé Y, Ruyssen-Witrand A, Constantin A. Diagnosis and treatment of Tropheryma whipplei infection in patients with inflammatory rheumatic disease: Data from the French Tw-IRD registry. J Infect 2024; 88:132-138. [PMID: 38141787 DOI: 10.1016/j.jinf.2023.12.010] [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: 10/18/2023] [Revised: 11/23/2023] [Accepted: 12/15/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVES Tropheryma whipplei infection can manifest as inflammatory joint symptoms, which can lead to misdiagnosis of inflammatory rheumatic disease and the use of disease-modifying antirheumatic drugs. We investigated the impact of diagnosis and treatment of Tropheryma whipplei infection in patients with inflammatory rheumatic disease. METHODS We initiated a registry including patients with disease-modifying antirheumatic drugs-treated inflammatory rheumatic disease who were subsequently diagnosed with Tropheryma whipplei infection. We collected clinical, biological, treatment data of the inflammatory rheumatic disease, of Tropheryma whipplei infection, and impact of antibiotics on the evolution of inflammatory rheumatic disease. RESULTS Among 73 inflammatory rheumatic disease patients, disease-modifying antirheumatic drugs initiation triggered extra-articular manifestations in 27% and resulted in stabilisation (51%), worsening (34%), or improvement (15%) of inflammatory rheumatic disease. At the diagnosis of Tropheryma whipplei infection, all patients had rheumatological symptoms (mean age 58 years, median inflammatory rheumatic disease duration 79 months), 84% had extra-rheumatological manifestations, 93% had elevated C-reactive protein, and 86% had hypoalbuminemia. Treatment of Tropheryma whipplei infection consisted mainly of doxycycline plus hydroxychloroquine, leading to remission of Tropheryma whipplei infection in 79% of cases. Antibiotic treatment of Tropheryma whipplei infection was associated with remission of inflammatory rheumatic disease in 93% of cases and enabled disease-modifying antirheumatic drugs and glucocorticoid discontinuation in most cases. CONCLUSIONS Tropheryma whipplei infection should be considered in inflammatory rheumatic disease patients with extra-articular manifestations, elevated C-reactive protein, and/or hypoalbuminemia before disease-modifying antirheumatic drugs initiation or in inflammatory rheumatic disease patients with an inadequate response to one or more disease-modifying antirheumatic drugs. Positive results of screening and diagnostic tests for Tropheryma whipplei infection involve antibiotic treatment, which is associated with complete recovery of Tropheryma whipplei infection and rapid remission of inflammatory rheumatic disease, allowing disease-modifying antirheumatic drugs and glucocorticoid discontinuation.
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Affiliation(s)
- Damien Caillet Portillo
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France.
| | - Xavier Puéchal
- National Referral Centre for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, AP-HP Centre, Paris, France; Université Paris Cité, Paris, France
| | - Maëva Masson
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France
| | - Marie Kostine
- Department of Rheumatology, National Reference Center for Systemic Autoimmune Rare Diseases RESO, Bordeaux University Hospital, Bordeaux, France
| | - Alexia Michaut
- Hospital Centre, Loire Vendée Ocean, Rheumatology, La Roche-sur-Yon, France
| | - André Ramon
- Le Bocage Hospital, University Hospital of Dijon, Rheumatology, Dijon, France
| | - Daniel Wendling
- CHU de Besançon, Service de Rhumatologie, Université de Franche-Comté, Besançon, France
| | - Nathalie Costedoat-Chalumeau
- National Referral Centre for Rare Systemic Autoimmune Diseases, Department of Internal Medicine, Hôpital Cochin, AP-HP Centre, Paris, France; Université Paris Cité, Paris, France
| | - Pascal Richette
- Hôpital Lariboisière Hospital, AP-HP, Paris, Rheumatology, Paris, France
| | - Hubert Marotte
- Université Jean Monnet Saint-Étienne, CHU Saint-Étienne, Service de Rhumatologie, Mines Saint-Etienne, INSERM, SAINBIOSE U1059, F-42023 Saint-Etienne, France
| | | | - Jean-Jacques Dubost
- CHU Clermont-Ferrand, Université Clermont Auvergne, INRAe, Department of Rheumatology, Clermont Ferrand, France
| | | | - Gaël Mouterde
- Rheumatology Department, CHU Montpellier & IDESP, Montpellier University, Montpellier, France
| | - Anne Grasland
- Louis-Mourier Hospital, AP-HP, Université Paris Cité, Rheumatology, Colombes, France
| | - Aline Frazier
- Hôpital Lariboisière Hospital, AP-HP, Paris, Rheumatology, Paris, France
| | | | - Fabienne Coury
- University of Lyon, University Lyon 1, Department of Rheumatology, Lyon Sud Hospital, Hospices Civils de Lyon, Lyon Immunopathology Federation (LIFe), INSERM UMR 1033, Lyon, France
| | - Anne Tournadre
- CHU Clermont-Ferrand, Université Clermont Auvergne, INRAe, Department of Rheumatology, Clermont Ferrand, France
| | - Martin Soubrier
- CHU Clermont-Ferrand, Université Clermont Auvergne, INRAe, Department of Rheumatology, Clermont Ferrand, France
| | - Laurent Cavalie
- Bacteriology and Hygiene Laboratory, Federal Institute of Biology (IFB), Purpan Hospital, Toulouse & IRSD, INSERM, INRAE, ENVT Toulouse III University - Paul Sabatier, Toulouse, France
| | - Pauline Brevet
- Department of Rheumatology and CIC-CRB 1404, Inserm 1234, Rouen University, Rouen, France
| | - Laurent Zabraniecki
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France
| | - Bénédicte Jamard
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France
| | - Guillaume Couture
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France
| | - Laurent Arnaud
- Hautepierre Hospital, University Hospital of Strasbourg, Rheumatology, Strasbourg, France
| | - Christophe Richez
- Department of Rheumatology, National Reference Center for Systemic Autoimmune Rare Diseases RESO, Bordeaux University Hospital, Bordeaux, France
| | - Yannick Degboé
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France
| | - Adeline Ruyssen-Witrand
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France; Centre d'Investigation Clinique de Toulouse CIC1436, Inserm, Team PEPSS "Pharmacologie En Population Cohortes et Biobanques", Toulouse, France
| | - Arnaud Constantin
- Pierre-Paul Riquet University Hospital, Toulouse & Toulouse III University - Paul Sabatier, Rheumatology, Toulouse, France.
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Liew KC, Nguyen C, Waidyatillake NT, Nguyen T, Walton A, Harris O, Athan E, Stenos J, Graves SR. A serological assay using Tropheryma whipplei antigens for the presumptive exclusion of Whipple disease. Pathology 2024; 56:98-103. [PMID: 38061960 DOI: 10.1016/j.pathol.2023.09.010] [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: 03/08/2023] [Revised: 09/08/2023] [Accepted: 09/19/2023] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
- Kwee Chin Liew
- Department of Microbiology, Australian Clinical Labs, Geelong, Vic, Australia; Australian Rickettsial Reference Laboratory, University Hospital Geelong, Geelong, Vic, Australia; Deakin University, School of Medicine, Geelong, Vic, Australia.
| | - Chelsea Nguyen
- Australian Rickettsial Reference Laboratory, University Hospital Geelong, Geelong, Vic, Australia
| | - Nilakshi T Waidyatillake
- Barwon Health, University Hospital Geelong, Geelong, Vic, Australia; Allergy and Lung Health Unit, Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Vic, Australia
| | - Trang Nguyen
- Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR-Pathology West, Sydney, NSW, Australia
| | - Aaron Walton
- Australian Rickettsial Reference Laboratory, University Hospital Geelong, Geelong, Vic, Australia; Deakin University, School of Medicine, Geelong, Vic, Australia
| | - Owen Harris
- Department of Microbiology, Australian Clinical Labs, Geelong, Vic, Australia; Deakin University, School of Medicine, Geelong, Vic, Australia; Barwon Health, University Hospital Geelong, Geelong, Vic, Australia
| | - Eugene Athan
- Australian Rickettsial Reference Laboratory, University Hospital Geelong, Geelong, Vic, Australia; Deakin University, School of Medicine, Geelong, Vic, Australia; Barwon Health, University Hospital Geelong, Geelong, Vic, Australia
| | - John Stenos
- Australian Rickettsial Reference Laboratory, University Hospital Geelong, Geelong, Vic, Australia
| | - Stephen R Graves
- Australian Rickettsial Reference Laboratory, University Hospital Geelong, Geelong, Vic, Australia
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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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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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Biesen R, Alexander T, Burmester GR, Albach FN. Recovery of hearing loss, depression and erosive polyarthritis after diagnosis of Whipple's disease. Rheumatol Adv Pract 2023; 7:rkad060. [PMID: 37457656 PMCID: PMC10348829 DOI: 10.1093/rap/rkad060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/18/2023] Open
Affiliation(s)
- Robert Biesen
- Correspondence to: Robert Biesen, Department of Rheumatology and Clinical Immunology, Charité University Hospital, Charitéplatz 1, D-10117 Berlin, Germany. E-mail:
| | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Gerd-Rüdiger Burmester
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Fredrik N Albach
- Department of Rheumatology and Clinical Immunology, Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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[Massive pancarditis-autopsy report]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:132-138. [PMID: 36592174 PMCID: PMC9807089 DOI: 10.1007/s00292-022-01170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 01/03/2023]
Abstract
We report on a 69-year-old man suffering from chronic progressive oligoarthritis (localized in metacarpal and knee joints), which clinically was interpreted as steroid-sensitive seronegative chronic arthritis. The patient died from sudden death at the emergency department after a 4-week history of increasing cough and dyspnea (meanwhile obtaining negative testing results for SARS-CoV-2). During the autopsy, we found massive pancarditis affecting all cardiac compartments, in particular exhibiting constrictive pericarditis, myocarditis, and multivalvular endocarditis. Microscopically, interstitial myocarditis could be observed. Performing extensive molecular analyses, we detected Tropheryma whipplei in the tissue specimens of the heart, but not in various duodenal tissue probes or in the synovial membrane. Taken together, in the present case the cause of death was acute cardiac failure due to multivalvular pancarditis due to T. whipplei. Besides from classical symptoms and morphological signs, Whipple's disease may present with various features. Regarding the differential diagnosis of a chronic multisystem disorder with aspects of hitherto unknown arthralgia, Whipple's disease should be considered.
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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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Muacevic A, Adler JR, Venade G, Rodrigues P, Tavares J. Why Is Whipple's Disease Still a Challenging Diagnosis? A Case Report and Brief Review of Literature. Cureus 2023; 15:e34029. [PMID: 36814727 PMCID: PMC9939952 DOI: 10.7759/cureus.34029] [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: 01/20/2023] [Indexed: 01/22/2023] Open
Abstract
Whipple's disease (WD) is a rare multisystemic infectious disease caused by Tropheryma whipplei. The pathogenesis of Whipple's disease remains unknown and clinical experience relies solely on various case reports published in the literature. The disease may occur at any age, with most studies describing patients in their fifth decade. Classic WD mainly affects the gastrointestinal tract, but extraintestinal commitment can occur, with the most common manifestations being arthralgias, lymphadenopathy, fever, and neurological symptoms. We present a case of a 69-year-old woman who presented with fever, macular rash, abdominal pain, lymphadenopathy, pleural and pericardial effusion, weight loss, and severely altered mental status over seven days. Initial workup tests only revealed leucopenia, thrombocytopenia, and hyperferritinemia. Since the fever persisted despite antibiotic treatment, an extensive workup was required until the final diagnosis of classic WD through histological examination of duodenal biopsies. Treatment with ceftriaxone was implemented for two weeks, followed by trimethoprim-sulfamethoxazole 160/800mg bid for 12 months. The patient presented full recovery and no recurrence after three years of follow-up. Even though WD was first described more than a century ago, WD is an elusive disease with a wide variety of clinical findings, leading to a still significant delay in diagnosis. WD should be considered in the differential diagnosis of rheumatologic disorders, chronic abdominal pain or diarrhea, neurological manifestations not suggestive of any other specific disease, non-caseating granulomatous diseases, and cases of lymphadenopathies. The authors aim to add additional clinical data and raise awareness for a rare condition that can be lethal if not timely treated. More studies and recommendations are needed concerning screening patients and treatment, with an urgent need to improve the delay in diagnosis.
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Chen S, Zhou YC, Si S, Liu HY, Zhang QR, Yin TF, Xie CX, Yao SK, Du SY. Atypical Whipple’s disease with special endoscopic manifestations: A case report. World J Clin Cases 2022; 10:13044-13051. [PMID: 36568994 PMCID: PMC9782934 DOI: 10.12998/wjcc.v10.i35.13044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 10/30/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Whipple’s disease is a rare systemic infection caused by Tropheryma whipplei. Most patients present with nonspecific symptoms, and routine laboratory and imaging examination results also lack specificity. The diagnosis often relies on invasive manipulation, pathological examination, and molecular techniques. These difficulties in diagnosing Whipple’s disease often result in misdiagnosis and inappropriate treatments.
CASE SUMMARY This paper reports on the case of a 58-year-old male patient who complained of fatigue and decreased exercise capacity. The results of routine blood tests indicated hypochromic microcytic anemia. Results of gastroscopy and capsule endoscopy showed multiple polypoid bulges distributed in the duodenal and proximal jejunum. A diagnosis of small intestinal adenomatosis was initially considered; hence, the Whipple procedure, a pylorus-preserving pancreaticoduodenectomy, was performed. Pathological manifestations showed many periodic acid-Schiff-positive macrophages aggregated in the intestinal mucosa of the duodenum, upper jejunum, and surrounding lymph nodes. Based on comprehensive analysis of symptoms, laboratory findings, and pathological manifestations, the patient was finally diagnosed with Whipple’s disease. After receiving 1 mo of antibiotic treatment, the fatigue and anemia were significantly improved.
CONCLUSION This case presented with atypical gastrointestinal manifestations and small intestinal polypoid bulges, which provided new insight on the diagnosis of Whipple’s disease.
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Affiliation(s)
- Shuo Chen
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Yuan-Chen Zhou
- Peking University China-Japan Friendship School of Clinical Medicine, Peking University, Beijing 100029, China
| | - Shuang Si
- Department of General Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Hong-Yan Liu
- Department of Pathology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qing-Rui Zhang
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Teng-Fei Yin
- Peking University China-Japan Friendship School of Clinical Medicine, Peking University, Beijing 100029, China
| | - Chu-Xi Xie
- Graduate School, Beijing University of Chinese Medicine, Beijing 100029, China
| | - Shu-Kun Yao
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing 100029, China
| | - Shi-Yu Du
- Department of Gastroenterology, China-Japan Friendship Hospital, Beijing 100029, China
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Capsule Endoscopy in the Diagnosis, Disease Mapping, and Monitoring of Treatment Response in Gastrointestinal Whipple's Disease. ACG Case Rep J 2022; 9:e00842. [PMID: 36128577 PMCID: PMC9481437 DOI: 10.14309/crj.0000000000000842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 07/04/2022] [Accepted: 07/14/2022] [Indexed: 11/05/2022] Open
Abstract
Whipple's disease is a rare systemic infection causing malabsorption. Affected patients often undergo extensive investigation until final diagnosis with periodic acid-Schiff-positive histology. We present the case of a 73-year-old man diagnosed with Whipple's disease after a prolonged history, with a focus on capsule endoscopy (CE) in both mapping the extent of the pathology and follow-up. We demonstrate pre-treatment and post-treatment CE images, allowing visualization of resolved small bowel pathology, and demonstrate histological resolution. The early use of CE in the investigation of Whipple's disease may expedite diagnosis in patients with more distal bowel pathology and help assess disease severity.
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Whipple's disease with normal duodenal histology diagnosed by ileal biopsy using balloon endoscopy. Clin J Gastroenterol 2022; 15:702-707. [PMID: 35522379 DOI: 10.1007/s12328-022-01638-0] [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: 01/26/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
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.
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Stroher CK, Santos ALM, Ceron L, Fabrin LL. Whipple's disease: a case report in Santa Catarina, Brazil. LE INFEZIONI IN MEDICINA 2022; 30:139-142. [PMID: 35350250 PMCID: PMC8929735 DOI: 10.53854/liim-3001-18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 01/09/2022] [Indexed: 06/14/2023]
Abstract
Whipple's disease is a rare systemic infection caused by a diastase-resistant and Gram-positive bacillus called Tropheryma whipplei. The diagnosis of the disease is difficult and often late due to the variety of the symptoms. The objective of this study was to report a rare case of Whipple's disease treated at the Internal Medicine service of a hospital in the Midwest of Santa Catarina, Brazil. The patient was invited for an interview to describe the history of symptoms and previous treatments. Additionally, test results and treatments performed during hospitalization were assessed through the medical records. The case report describes a 39-year-old white male who presented, at the time of diagnosis, severe diarrhea, hematochezia, weight loss, fever, and inguinal adenomegaly, in addition to preceding migratory polyarthritis. After investigation, the diagnosis of Whipple's disease was achieved in conjunction with antibiotic treatment, with improvement of clinical and laboratory symptoms after 15 days. This case highlights the broad array of symptoms and the non-specific features of the Whipple's disease. Establishing an early diagnosis is essential for the success of the treatment, avoiding a long-lasting escalation of symptoms, which lead to cachexia and a devastating loss of the patient's quality of life.
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Affiliation(s)
- Camila Kleber Stroher
- Hospital Universitário Santa Terezinha (HUST) da Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, Brazil
| | - Arthur Lichs Marçal Santos
- Hospital Universitário Santa Terezinha (HUST) da Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, Brazil
| | - Leandra Ceron
- Hospital Universitário Santa Terezinha (HUST) da Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, Brazil
| | - Liandra Luisa Fabrin
- Hospital Universitário Santa Terezinha (HUST) da Universidade do Oeste de Santa Catarina (UNOESC), Joaçaba, Brazil
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16
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Challenging case of Whipple's disease: The contribution of radiology. Radiol Case Rep 2022; 17:1008-1012. [PMID: 35111275 PMCID: PMC8790621 DOI: 10.1016/j.radcr.2021.12.063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 12/27/2021] [Accepted: 12/30/2021] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease is a rare chronic infectious disease, caused by Tropheryma whipplei. The disease can be challenging to diagnose due to the variable clinical manifestations and the nonspecific laboratory and imaging findings. We report the case of a 75-year-old man, complaining of weight loss and arthralgias with an insidious onset. A thoracic, abdominal and pelvic CT was performed, demonstrating features suggestive of Whipple's disease. Although not specific, the imaging findings of fatty attenuation mesenteric and retroperitoneal enlarged lymph nodes are a common finding in Whipple's disease. Esophagogastroduodenoscopy with duodenal biopsy confirmed the diagnosis through PCR analysis.
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17
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Bulut K, Markova A, Canbay AE, Schmidt WE, Kahraman A. Whipple's disease - a rare and challenging complication in a patient with Crohn's disease. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:598-601. [PMID: 35176806 DOI: 10.1055/a-1747-3666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Kerem Bulut
- Clinic for Internal Medicine and Gastroenterology, St. Clemens-Hospital Geldern, Germany
| | - Antoaneta Markova
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Germany
| | - Ali E Canbay
- Department of Internal Medicine, Knappschaftskrankenhaus, Ruhr-University Bochum, Germany
| | - Wolfgang E Schmidt
- Department of Internal Medicine, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Alisan Kahraman
- Gastroenterology and Hepatology, Max Grundig Clinic, Bühl/Baden, Bühl, Germany.,Department of Gastroenterology and Hepatology, University Clinic of Essen, Germany
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Terrones-Peinador M, Eremiev-Eremiev S, Pigrau-Serrallach C, Solans-Laque R. Recurrent thrombosis as a clinical presentation of Whipple disease. BMJ Case Rep 2022; 15:e247020. [PMID: 35144962 PMCID: PMC8845191 DOI: 10.1136/bcr-2021-247020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2022] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease (WD) is a rare infectious disease with a wide clinical spectrum. Associated thrombotic manifestations are not well described in WD, only related to 'stroke-like syndrome'. We present a case of a 39-year-old man with a 1-year history of self-limited episodes of fever, associated with generalised adenopathies and recurrent superficial and deep venous thrombosis events, which have resorted four times despite the anticoagulant treatment. Finally, the patient is diagnosed with WD. Following treatment the patient improved in his general condition, and no more episodes of fever neither thrombosis appeared during a follow-up of more than 3 years.
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Affiliation(s)
- María Terrones-Peinador
- Internal Medicine Department, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | - Simeón Eremiev-Eremiev
- Infectious Diseases Department, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
| | | | - Roser Solans-Laque
- Internal Medicine Department, Vall d'Hebron University Hospital, Barcelona, Catalunya, Spain
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Zanger K, Nimkin K, Israel EJ, Shih AR. Case 3-2022: A 14-Year-Old Boy with Fever, Joint Pain, and Abdominal Cramping. N Engl J Med 2022; 386:375-383. [PMID: 35081284 DOI: 10.1056/nejmcpc2115850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kerstin Zanger
- From the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Katherine Nimkin
- From the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Esther J Israel
- From the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
| | - Angela R Shih
- From the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Massachusetts General Hospital, and the Departments of Pediatrics (K.Z., E.J.I.), Radiology (K.N.), and Pathology (A.R.S.), Harvard Medical School - both in Boston
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Nasim A, Dodani SK, Badlani S, Babar ZU, Shakil S, Mubarak M, Luck N, Aziz T. Whipple's disease in renal transplant recipients: Management experience of seven cases from Pakistan. Transpl Infect Dis 2021; 24:e13769. [PMID: 34837443 DOI: 10.1111/tid.13769] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 10/23/2021] [Accepted: 11/10/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Whipple's disease (WD) is a rare multi-systemic disorder caused by actinomycetes, Tropheryma whipplei. It presents with weight loss, arthralgia, and diarrhea and may involve the heart, lung, or central nervous system. The use of immunosuppressive medications or underlying immunodeficiency states are associated risk factors. Six cases in transplant recipients have so far been reported worldwide. We describe our experience of WD in renal transplant recipients. METHODS All renal transplant recipients who presented with diarrhea and were diagnosed with WD on duodenal biopsy from 2016 till 2019 were included. Their data regarding duration since transplantation, immunosuppressive therapy, symptoms, treatment response, and outcome were analyzed. RESULTS Seven cases were diagnosed as WD based on duodenal biopsy, with histological findings of periodic acid Schiff-positive granules in macrophages. All were males. The most common symptoms were chronic diarrhea and weight loss. Average time since transplantation was 4.8 years. All patients were on azathioprine and everolimus. Clinical relapse or adverse effects was seen in five of seven patients treated with doxycycline and hydroxychloroquine which was discontinued. Trimethoprim/sulfamethoxazole for 1 year, with initial intravenous ceftriaxone in two patients, resulted in complete remission in all patients at a follow-up period averaging 1.5 years. CONCLUSION WDs in renal transplant recipients most commonly presents as an intestinal disorder. Treatment of 1 year with trimethoprim/sulfamethoxazole has good response with complete remission at 1.5 years of follow up.
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Affiliation(s)
- Asma Nasim
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Sunil Kumar Dodani
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Sanjay Badlani
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Zaheer Udin Babar
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Shaheera Shakil
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Mohammad Mubarak
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Nasir Luck
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
| | - Tahir Aziz
- Sindh Institute of Urology and Transplantation, Chand Bibi Road, Karachi, Pakistan
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21
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Cutaneous Granulomatosis Revealing Whipple's Disease: Value of Tropheryma whipplei Polymerase Chain Reaction Assay for the Diagnosis. Pathogens 2021; 10:pathogens10111438. [PMID: 34832593 PMCID: PMC8622981 DOI: 10.3390/pathogens10111438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 11/03/2021] [Accepted: 11/04/2021] [Indexed: 12/19/2022] Open
Abstract
Whipple's Disease is a rare systemic infectious disease caused by the ubiquitous actinomycetes Tropheryma whipplei (T. whipplei). We report herein a rare case of a cutaneous granulo matosis with hypercalcemia as an unusual presenting feature of Whipple's disease. The diagnosis of the bacteria was obtained from skin and inguinal lymph node biopsy (16 rDNA PCR screening and histological examination using PAS staining). T. whipplei was also identified on saliva and stool specimens, using specific PCR and colonic biopsies. Treatment with hydroxychloroquine and doxycycline allowed a rapid resolution of symptoms with a complete recovery.
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22
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Role of enteroscopy in the diagnosis of whipple's disease. Acta Gastroenterol Belg 2021; 84:669-671. [PMID: 34965051 DOI: 10.51821/84.4.020] [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] [Indexed: 11/21/2022]
Abstract
Whipple's disease is a rare chronic systemic infection caused by Tropheryma whipplei. The widespread infection by this rod is responsible for the protean clinical manifestations of the disease, although its classical form is notable for the prevalence of abdominal symptoms such as chronic diarrhea and abdominal pain. Whitish-yellow patches, suggestive of lymphangiectasia, are typically observed in the duodenum during upper endoscopy. The diagnosis of this condition is supported by the identification in duodenal biopsies of Periodic acid-Schiff staining within lamina propria macrophages. Nevertheless, a significant portion of patients do not have lesions within the range of conventional upper endoscopy. Therefore, other endoscopic procedures such as video capsule endoscopy and enteroscopy may be useful to detect more distal lesions. The authors describe a case where the combined used of both techniques allowed the unmasking of this disease.
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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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Totschnig D, Seitz T, Zoufaly A, Hagenauer-Drektraan S, Wenisch C. Whipple's disease diagnosed in a patient with suspected sarcoidosis. Int J Infect Dis 2021; 106:41-42. [PMID: 33766689 DOI: 10.1016/j.ijid.2021.03.053] [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] [Received: 01/11/2021] [Revised: 03/17/2021] [Accepted: 03/18/2021] [Indexed: 11/29/2022] Open
Abstract
This paper presents a case of a 51-year-old patient with chronic diarrhea, weight loss, polyarthralgia, and diffuse lymphadenopathy. Laboratory work-up showed anemia, leukocytosis and thrombocytosis, and increased C-reactive protein (CRP). Due to an inconspicuous differential leukocyte count and lymph node biopsy findings showing granulomatous lymphadenopathy, sarcoidosis was initially suspected. Colonoscopy found no abnormalities and duodenal biopsies showed negative Periodic acid-Schiff stains. However, PCR testing on these biopsies revealed Tropheryma whipplei DNA. Further PCR testing of urine and cerebrospinal fluid also revealed T. whipplei DNA. The patient was treated with ceftriaxone for 2 weeks followed by trimethoprim for a year. A rapid improvement of his symptoms was seen.
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Affiliation(s)
- David Totschnig
- Department of Medicine IV, Kaiser Franz Josef Hospital, Vienna, Austria.
| | - Tamara Seitz
- Department of Medicine IV, Kaiser Franz Josef Hospital, Vienna, Austria
| | - Alexander Zoufaly
- Department of Medicine IV, Kaiser Franz Josef Hospital, Vienna, Austria
| | | | - Christoph Wenisch
- Department of Medicine IV, Kaiser Franz Josef Hospital, Vienna, Austria
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25
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Melas N, Amin R, Gyllemark P, Younes AH, Almer S. Whipple's disease: the great masquerader-a high level of suspicion is the key to diagnosis. BMC Gastroenterol 2021; 21:128. [PMID: 33743602 PMCID: PMC7980341 DOI: 10.1186/s12876-021-01664-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 02/12/2021] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Nikolaos Melas
- Department of Gastroenterology and Emergency Care, Gävle Hospital, Gävle, Sweden
| | - Rasjan Amin
- Department of Anesthesiology and Intensive Care Unit, S:T Göran Hospital, Stockholm, Sweden
| | - Paula Gyllemark
- Department of Infectious Diseases, Region Jönköping County, Jönköping, Sweden.,Division of Inflammation and Infection, Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Amil Haji Younes
- Department of Gastroenterology and Emergency Care, Gävle Hospital, Gävle, Sweden
| | - Sven Almer
- Department of Medicine, Karolinska Institutet, Solna, Sweden. .,Division of Gastroenterology, Karolinska University Hospital, Stockholm, Sweden.
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Feurle GE, Moos V, Stroux A, Gehrmann-Sommer N, Poddubnyy D, Fiehn C, Schneider T. Differential diagnostic value of rheumatic symptoms in patients with Whipple's disease. Sci Rep 2021; 11:5980. [PMID: 33727566 PMCID: PMC7966399 DOI: 10.1038/s41598-021-85217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Gerhard E Feurle
- DRK Krankenhaus Neuwied, Eduard Moerikestrasse 12, 56567, Neuwied, Germany.
| | - Verena Moos
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Stroux
- Institut für Biometrie und Klinische Epidemiologie, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Nadine Gehrmann-Sommer
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Fiehn
- Praxis für Rheumatologie, Klinische Immunologie, Medical Center, Baden-Baden, Germany
| | - Thomas Schneider
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
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Foteinogiannopoulou K, Mouzas I, Tzardi M, Orfanoudaki E, Theodoraki E, Kofteridis D. First case of Whipple's disease successfully treated with tigecycline. Germs 2021; 11:105-110. [PMID: 33898347 DOI: 10.18683/germs.2021.1246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/09/2020] [Accepted: 06/13/2020] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Kalliopi Foteinogiannopoulou
- MD, Gastroenterology Department, University General Hospital of Heraklion, Voutes, Heraklion, Crete, zip code 71110, Greece
| | - Ioannis Mouzas
- MD, PhD, Gastroenterology Department, University General Hospital of Heraklion, Voutes, Heraklion, Crete, zip code 71110, Greece
| | - Maria Tzardi
- MD, PhD, Pathology Department, University General Hospital of Heraklion, Voutes, Heraklion, Crete, zip code 71110, Greece
| | - Eleni Orfanoudaki
- MD, Gastroenterology Department, University General Hospital of Heraklion, Voutes, Heraklion, Crete, zip code 71110, Greece
| | - Eirini Theodoraki
- MD, Gastroenterology Department, University General Hospital of Heraklion, Voutes, Heraklion, Crete, zip code 71110, Greece
| | - Diamantis Kofteridis
- Internal Medicine Department, University General Hospital of Heraklion, Crete, zip code 71110, Greece
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Panarelli NC. Infectious diseases of the upper gastrointestinal tract. Histopathology 2020; 78:70-87. [PMID: 33382485 DOI: 10.1111/his.14243] [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: 06/29/2020] [Revised: 08/10/2020] [Accepted: 08/19/2020] [Indexed: 12/18/2022]
Abstract
A broad spectrum of pathogens produce gastrointestinal disease. The ongoing spread of human immunodeficiency virus/acquired immune deficiency syndrome, the increased use of immunosuppressive therapy and the persistence of overcrowding and suboptimal sanitation in underdeveloped areas facilitate both disease transmission from environmental and foodborne sources and person-to-person transmission. Clinicians increasingly rely on endoscopic biopsy sample interpretation to diagnose gastrointestinal infections. Thus, pathologists must be aware of diagnostic features of a variety of microbial pathogens. Detection with molecular techniques also allows for correlation between infectious agents and their histopathological features, which has expanded our knowledge of the inflammatory changes produced by infectious agents. This review covers infectious disorders of the upper gastrointestinal tract encountered in surgical pathology. Clinical, endoscopic and pathological features are presented. The review emphasises morphological features of viruses, bacteria, fungi and parasites that may be found in tissue samples, and the inflammatory patterns that they produce. Differential diagnoses and useful ancillary techniques are discussed.
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[A 3-week history of intestinal symptoms in a 67-year-old male patient with chronic arthralgia]. Internist (Berl) 2020; 62:433-440. [PMID: 33296012 DOI: 10.1007/s00108-020-00916-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
Whipple disease is an infection caused by the bacterium Tropheryma whipplei. Due to its unspecific clinical symptoms, it is difficult to diagnose and often remains undetected for a long time. The case of a patient who presented with acute intestinal symptoms to the authors' department is reported. The diagnosis of classic Whipple disease was established. The symptoms subsided under antibiotic therapy. Complications in the form of immune reconstitution inflammatory syndrome (IRIS) occurred, requiring immunosuppressive treatment.
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Tatsuki M, Ishige T, Igarashi Y, Hatori R, Hokama A, Hirato J, Muise A, Takizawa T, Arakawa H. Whipple disease mimicking inflammatory bowel disease. Intest Res 2020; 19:119-125. [PMID: 32610889 PMCID: PMC7873397 DOI: 10.5217/ir.2019.09177] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 04/15/2020] [Indexed: 12/19/2022] Open
Abstract
Whipple disease is a systemic chronic infection caused by Tropheryma whipplei. Although chronic diarrhea is a common gastrointestinal symptom, diagnosis is often difficult because there are no specific endoscopic findings, and the pathogen is not detectable by stool culture. We present a female patient with Whipple disease who developed chronic bloody diarrhea and growth retardation at the age of 4 years. Colonoscopy showed a mildly edematous terminal ileum and marked erythema without vascular patterns throughout the sigmoid colon and rectum. Subsequently, a primary diagnosis of ulcerative colitis was made. Histopathological analysis of the terminal ileum showed the presence of foamy macrophages filled with periodic acid-Schiff-positive particles. Polymerase chain reaction using DNA from a terminal ileum biopsy sample amplified a fragment of 16S rRNA from T. whipplei. Antibiotic treatment relieved the patient’s symptoms. There was no evidence of immunodeficiency in the present case. Since Whipple disease worsens after anti-tumor necrosis factor inhibitor therapy, considering this infection in the differential diagnosis may be important in patients with inflammatory bowel disease, especially before initiation of immunotherapy.
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Affiliation(s)
- Maiko Tatsuki
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Takashi Ishige
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Yoshiko Igarashi
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Reiko Hatori
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Akira Hokama
- Department of Endoscopy, University of the Ryukyus, Nishihara, Japan
| | - Junko Hirato
- Clinical Department of Pathology, Gunma University Hospital, Maebashi, Japan
| | - Aleixo Muise
- Cell Biology Program, Inflammatory Bowel Disease Centre, The Hospital for Sick Children, Toronto, ON, Canada
| | - Takumi Takizawa
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
| | - Hirokazu Arakawa
- Department of Pediatrics, Gunma University Graduate School of Medicine, Maebashi, Japan
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Moter A, Janneck M, Wolters M, Iking-Konert C, Wiessner A, Loddenkemper C, Hartleben B, Lütgehetmann M, Schmidt J, Langbehn U, Janssen S, Geelhaar-Karsch A, Schneider T, Moos V, Rohde H, Kikhney J, Wiech T. Potential Role for Urine Polymerase Chain Reaction in the Diagnosis of Whipple's Disease. Clin Infect Dis 2020; 68:1089-1097. [PMID: 30351371 PMCID: PMC6424077 DOI: 10.1093/cid/ciy664] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Annette Moter
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Matthias Janneck
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Manuel Wolters
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | | | - Alexandra Wiessner
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | | | - Björn Hartleben
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | - Julia Schmidt
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Ulrike Langbehn
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| | - Sabrina Janssen
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Anika Geelhaar-Karsch
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Thomas Schneider
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | - Judith Kikhney
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Thorsten Wiech
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
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Whipple's disease: diagnosis and predictive factors of relapse. Eur J Gastroenterol Hepatol 2020; 32:325-328. [PMID: 31764405 DOI: 10.1097/meg.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Whipple's disease is a very rare disease needing a long-term treatment. The most frequent symptoms are recurrent arthralgia or arthritis, chronic diarrhea, abdominal pain, and weight loss. OBJECTIVES In this article, we have highlighted the main clinical features and diagnostic procedures that lead to the diagnosis and comment on the clinical response, treatment, and the factors of relapse. METHODS Subjects were recruited from the Internal Medicine and Rheumatologic Departments of an University Hospital from November 1997 to January 2016. Overall, 12 subjects were finally diagnosed. RESULTS Mean age was 54.3 years (age range: 30-81), with more male patients (58.3%). Almost all patients had articular symptoms and impaired general condition (91.7%); and a majority had digestive symptoms (75%). Regardless of the symptoms, the most efficient diagnostic tools were the PCR screening on the gastrointestinal biopsies and saliva (83.3 and 72.7% positive results, respectively). More than half of the patients relapsed (55.6%). The relapsing patients were older [63.2 (44-81)] and mostly male with a majority (60%) of digestive symptoms and a delayed diagnosis. CONCLUSIONS In current practice, it is highly difficult to diagnose Whipple's disease. In order to decrease the delay between the first symptoms and the diagnosis, effective tools such as saliva and stools PCR should be used because higher delays of diagnosis lead to a higher number of relapses.
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A Man With Chronic Diarrhea and Weight Loss. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Aguiar Ferreira A, Gomes P, Curvo-Semedo L, Donato P. Whipple's disease: imaging contribution for a challenging case. BMJ Case Rep 2020; 13:13/2/e233071. [PMID: 32047086 DOI: 10.1136/bcr-2019-233071] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease is a rare and difficult-to-diagnose infectious disease, related to infection by gram-positive bacillum Tropheryma whipplei Clinical manifestations are very variable, but the classic form usually begins with recurring arthritis, followed several years later by non-specific abdominal symptoms, leading to late diagnosis. We present the case of a 52-year-old man who was admitted in the emergency department with an insidious clinical picture characterised by weight loss, abdominal pain, diarrhoea and arthralgias. An abdominal ultrasound was performed, showing findings suggestive of Whipple's disease, which, in conjunction with the clinical and laboratory findings, allowed the diagnosis to be correctly addressed. Upper endoscopy with duodenal biopsy revealed findings compatible with Whipple's disease, and the diagnosis was also confirmed through PCR techniques of blood. The patient was given antibiotic therapy, with rapid and substantial clinical improvement.
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Affiliation(s)
| | - Paula Gomes
- Medical Imaging, Coimbra University Hospital Centre, Coimbra, Portugal
| | - Luís Curvo-Semedo
- Medical Imaging, Coimbra University Hospital Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
| | - Paulo Donato
- Medical Imaging, Coimbra University Hospital Centre, Coimbra, Portugal.,Faculty of Medicine, University of Coimbra, Coimbra, Portugal
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Olivier M, Licitra C, Field Z, Ge L, Hill D, Madruga M, Carlan SJ. Thrombocytopenia and endocarditis in a patient with Whipple's disease: case report. BMC Infect Dis 2020; 20:71. [PMID: 31969117 PMCID: PMC6977297 DOI: 10.1186/s12879-020-4799-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 01/15/2020] [Indexed: 12/18/2022] Open
Abstract
Background Whipple’s disease (WD) is a rare multisystem infectious disorder that is caused by the actinomycete Tropheryma whipplei. It presents with joint pain followed by abdominal pain, diarrhea, malabsorption and finally failure to thrive. Diagnosis requires tissue sampling and histology with periodic acid-Schiff [PAS] staining. Thrombocytopenia associated with endocarditis associated with WD has been reported twice. Case presentation A 56 year old Caucasian male presented with years of steroid treated joint pain and recent onset diarrhea, weight loss and abdominal pain. Ultimately he was found to have a platelet count of 4000 with concomitant endocarditis and embolic stroke. Small bowel biopsy confirmed the diagnosis of WD approximately 1 year after his first visit. His platelets improved with antibiotic treatment but he eventually expired 16 months after his initial consult and 5 months after his definitive diagnosis. Conclusion WD can remain undiagnosed and untreated until late in the course of the illness. A high index of suspicion is recognized as necessary for early diagnosis to begin treatment. Critical thrombocytopenia associated with endocarditis is a rare and potentially poor prognostic sign in late stage Whipple’s disease.
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Affiliation(s)
- Maxim Olivier
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Carmelo Licitra
- Division of Infectious Diseases, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Zachary Field
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Li Ge
- Department of Pathology, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Dustin Hill
- Division of Cardiology, Orlando Regional Healthcare, Orlando, Florida, USA
| | - Mario Madruga
- Department of Medicine, Orlando Regional Healthcare, Orlando, Florida, USA
| | - S J Carlan
- Division of Academic Affairs and Research, Orlando Regional Healthcare, 1401 Lucerne Terrace, 2nd floor, Orlando, Fl, 32806, USA.
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Scheurwater MA, Verduin CM, van Dantzig JM. Whipple's endocarditis: a case report of a blood culture-negative endocarditis. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 3:1-6. [PMID: 31912002 PMCID: PMC6939820 DOI: 10.1093/ehjcr/ytz222] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 06/04/2019] [Accepted: 11/21/2019] [Indexed: 12/17/2022]
Abstract
Background Whipple's disease is caused by Tropheryma whipplei and causes a self-limiting gastrointestinal infection. The majority of the population is an asymptomatic carrier, however, in some patients, it causes an invasive infection with for example arthritis, endocarditis, or involvement of the eyes. Case summary This case describes a man with long-lasting complaints of progressive dyspnoea caused by heart failure due to total destruction of the aortic and mitral valve as a result of T. whipplei endocarditis, diagnosed with serum polymerase chain reaction. The patient was treated with ceftriaxone and prolonged co-trimoxazole therapy and surgical replacement of the aortic and mitral valve. He was discharged to a rehabilitation centre. Discussion Tropheryma whipplei is one of the possible microorganisms classified as causing blood culture-negative endocarditis, with predominantly afebrile patients that do not fulfil the Dukes criteria, which makes it difficult to diagnose. Polymerase chain reaction is the cornerstone of the diagnosis. It requires long-term antibiotic treatment up to 12 months. It is recommended by the European Society of Cardiology to discuss treatment in an Endocarditis Team because Whipple's endocarditis has only rarely been described in the literature previously. Whipple's endocarditis has high mortality and relapse rates.
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Affiliation(s)
- Miriam A Scheurwater
- Department of Cardiology, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA Eindhoven, The Netherlands
| | - Cees M Verduin
- Department of Microbiology, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA Eindhoven, The Netherlands
| | - Jan-Melle van Dantzig
- Department of Cardiology, Catharina Hospital Eindhoven, Postbus 1350, 5602 ZA Eindhoven, The Netherlands
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Tison A, Saraux A. Potential Role for Urine Polymerase Chain Reaction in the Diagnosis of Whipple Disease. Clin Infect Dis 2019; 69:904-905. [PMID: 30945731 DOI: 10.1093/cid/ciz094] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/28/2019] [Indexed: 12/17/2022] Open
Affiliation(s)
| | - Alain Saraux
- Rheumatology Unit, CHU Brest, France.,Unité Mixte de Recherche, Lymphocytes B et Autoimmunité, Brest University, Institut national de la santé et de la recherche médicale, Brest Teaching Hospital, LabEx Immunotherapy-Graft-Oncology, 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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Whipple's Disease: Diagnostic Value of rpoB Gene PCR from Peripheral Blood Mononuclear Cells. Mol Diagn Ther 2019; 22:459-469. [PMID: 29882197 DOI: 10.1007/s40291-018-0339-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Chronic infection with Tropheryma whipplei, known as Whipple's disease (WD), classically affects the gastrointestinal tract, but any organ system may be affected, and isolated manifestations occur. Reliable diagnosis based on a combination of periodic acid-Schiff (PAS) staining, T. whipplei-specific immunohistochemistry (IHC), and polymerase chain reaction (PCR) from duodenal biopsies may be challenging in cases without classical gastrointestinal infection, so the need for additional diagnostic materials is urgent. OBJECTIVE Our objective was to evaluate additional diagnostic possibilities for WD. METHODS We analyzed samples from 20 patients with WD and 18 control subjects in a prospective observational pilot study. In addition to WD diagnosis by PAS staining, T. whipplei-specific IHC and PCR of duodenal or extra intestinal tissues, whole EDTA blood, peripheral blood mononuclear cells (PBMCs) and PBMC fractions enriched with or depleted of cluster of differentiation (CD)-14+ cells were examined using T. whipplei rpoB gene PCR. RESULTS Tropheryma whipplei DNA was detected in 35 of 60 (58.3%) preparations from 16 of 20 patients with WD, most of whom lacked gastrointestinal signs and characteristic PAS-positive duodenal macrophages. CONCLUSION This study provides evidence for the potential suitability of blood, particularly PBMCs, as material to assist in the diagnosis of WD via rpoB gene real-time PCR. Thus, PCR from blood preparations can be helpful for diagnostic decision making in atypical cases of WD.
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Santos Seoane SM, Martínez Gutiérrez R, Venta Menéndez VI. Whipple's disease: when diarrhea is absent. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2019; 111:492-493. [PMID: 31140288 DOI: 10.17235/reed.2019.6015/2018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Whipple's disease is a rare bacterial, chronic and multisystemic disease, produced by the gram-positive bacillus Tropheryma whipplei. The clinical manifestations are varied and diagnosis is often delayed. The four cardinal symptoms are arthralgias, weight loss, diarrhea and abdominal pain. The classic symptoms could be preceded up to three quarters by different joint manifestations that evolve intermittently. The average time to diagnosis is 6 years. We present the case of a young patient with recurrent febrile episodes and associated joint disease, in whom the absence of digestive symptoms led to a diagnostic laparoscopy since this entity was not suspected before.
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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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Epidemiology of Whipple's Disease in the USA Between 2012 and 2017: A Population-Based National Study. Dig Dis Sci 2019; 64:1305-1311. [PMID: 30488239 PMCID: PMC6499665 DOI: 10.1007/s10620-018-5393-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 11/22/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prior studies on the epidemiology of Whipple's disease are limited by small sample size and case series design. We sought to characterize the epidemiology of Whipple's disease in the USA utilizing a large population-based database. METHODS We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of electronic health record data from 26 major integrated healthcare systems in the USA. We identified a cohort of patients with a diagnosis of Whipple's disease based on systemized nomenclature of medical terminology (SNOMED CT) codes. We calculated the overall and age-, race-, ethnicity, and gender-based prevalence of Whipple's disease and prevalence of associated diagnoses using univariate analysis. RESULTS A total of 35,838,070 individuals were active in the database between November 2012 and November 2017. Of these, 350 individuals had a SNOMED CT diagnosis of Whipple's disease, with an overall prevalence of 9.8 cases per 1 million. There was no difference in prevalence based on sex. However, prevalence of Whipple's disease was higher in Caucasians, non-Hispanics, and individuals > 65 years old. Individuals with a diagnosis of Whipple's disease were more likely to have associated diagnoses/findings of arthritis, CNS disease, endocarditis, diabetes, malignancy, dementia, vitamin D deficiency, iron deficiency, chemotherapy, weight loss, abdominal pain, and lymphadenopathy. CONCLUSIONS To our knowledge, this is the largest study to date examining the epidemiology of Whipple's disease. In this large population-based study, the overall prevalence of Whipple's disease in the USA is 9.8 cases per 1 million people. It affects men and women at similar rates and is more common in Caucasians, non-Hispanics, and people > 65 years old.
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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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Abstract
BACKGROUND Whipple disease (WD) is an infection caused by the bacterium Tropheryma whipplei (TW). Few cases have been reported in the USA. AIMS To report on the demographics, clinical manifestations, diagnostic findings, treatment, and outcomes of TW infection. METHODS Cases of TW infection diagnosed from 1995 to 2010 were identified in three US referral centers and from 1995 to 2015 in one. Definite classic WD was defined by positive periodic acid-Schiff (PAS) staining and probable WD by specific positive TW polymerase chain reaction (PCR) of intestinal specimens. Localized infections were defined by a positive TW PCR result from samples of other tissues/body fluids. RESULTS Among the 33 cases of TW infections, 27 (82%) were male. Median age at diagnosis was 53 years (range 11-75). Diagnosis was supported by a positive TW PCR in 29 (88%) and/or a positive PAS in 16 (48%) patients. Classic WD was the most frequent presentation (n = 18, 55%), with 14 definite and 4 probable cases. Localized infections (n = 15, 45%) affected the central nervous system (n = 7), joints (n = 4), heart (n = 2), eye (n = 1), and skeletal muscle (n = 1). Blood PCR was negative in 9 of 17 (53%) cases at diagnosis. Ceftriaxone intravenously followed by trimethoprim and sulfamethoxazole orally was the most common regimen (n = 23, 70%). Antibiotic therapy resulted in clinical response in 24 (73%). CONCLUSIONS TW infection can present as intestinal or localized disease. Negative small bowel PAS and PCR do not exclude the diagnosis of TW infection, and blood PCR is insensitive for active infection.
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Sluszniak M, Tarner IH, Thiele A, Schmeiser T. [The rich diversity of Whipple's disease]. Z Rheumatol 2018; 78:55-65. [PMID: 30552512 DOI: 10.1007/s00393-018-0573-8] [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: 10/27/2022]
Abstract
Whipple's disease (WD) is a rare, chronic multiorgan disease which can caused by Tropheryma whipplei, a ubiquitous gram positive bacterium. Detection of T. whipplei is mostly performed histologically using periodic acid-Schiff (PAS) staining in affected tissues to visualize characteristic PAS-positive macrophages and by the polymerase chain reaction (PCR). Clinically, WD is often characterized by gastrointestinal symptoms (diarrhea, colic-like abdominal pain and weight loss). Arthritis is a common presentation of WS, often leading to a misdiagnosis of seronegative rheumatoid arthritis and as a consequence to immunosuppressive therapy. The clinical presentation of WD is highly polymorphic affecting different organ systems (e. g. cardiac or neurological manifestation) and making an appropriate clinical diagnosis and even the diagnostic process itself difficult. This article reports on three cases presenting with completely different leading symptoms (initially misdiagnosed as seronegative rheumatoid arthritis, spondyloarthritis and adult onset of Still's disease, respectively) that illustrate the rich diversity of WD. The cases were chosen to draw attention to the fact that although WD is mainly associated with the field of gastroenterology and gastrointestinal (GI) involvement is common, it may appear without GI symptoms. In cases of a clinical suspicion of WD, diagnostic efforts should be made to detect the bacterium in the affected organ. The German S2k guidelines on GI infections and WD published in January 2015 summarized the current state of the art for WD. The currently recommended primary treatment is antibiotics that can infiltrate the cerebrospinal fluid, e. g. ceftriaxone, followed by cotrimoxazole, which should be maintained over several months.
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Affiliation(s)
- M Sluszniak
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland.
| | - I H Tarner
- Abt. für Rheumatologie, Klinische Immunologie, Osteologie und Physikalische Medizin, Kerckhoff-Klinik GmbH Bad Nauheim, Bad Nauheim, Deutschland.,Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - A Thiele
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
| | - T Schmeiser
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
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Herbette M, Cren JB, Joffres L, Lucas C, Ricard E, Salliot C, Guinard J, Perdriger A, Solau-Gervais E, Bouvard B, Saraux A. Usefulness of polymerase chain reaction for diagnosing Whipple's disease in rheumatology. PLoS One 2018; 13:e0200645. [PMID: 30020975 PMCID: PMC6051605 DOI: 10.1371/journal.pone.0200645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 06/30/2018] [Indexed: 12/17/2022] Open
Abstract
Objectives To determine when Tropheryma whipplei polymerase chain reaction (PCR) is appropriate in patients evaluated for rheumatological symptoms. Methods In a retrospective observational study done in rheumatology units of five hospitals, we assessed the clinical and radiological signs that prompted T. whipplei PCR testing between 2010 and 2014, the proportion of patients diagnosed with Whipple’s disease, the number of tests performed and the number of diagnoses according to the number of tests, the patterns of Whipple’s disease, and the treatments used. Diagnostic ascertainment was based on 1- Presence of at least one suggestive clinical finding; 2- at least one positive PCR test, and 3- a response to antibiotic therapy described by the physician as dramatic, including normalization of C Reactive Protein. Results At least one PCR test was performed in each of 267 patients. Rheumatic signs were peripheral arthralgia (n = 239, 89%), peripheral arthritis (n = 173, 65%), and inflammatory back pain (n = 85, 32%). Whipple’s disease was diagnosed in 13 patients (4.9%). The more frequently positive tests were saliva and stool. In the centres with no diagnoses of Whipple’s disease, arthritis was less common and constitutional symptoms more common. The group with Whipple’s disease had a higher proportion of males, older age, and greater frequency of arthritis. The annual incidence ranged across centres from 0 to 3.6/100000 inhabitants. Conclusion Males aged 40–75 years with unexplained intermittent seronegative peripheral polyarthritis, including those without constitutional symptoms, should have T. whipplei PCR tests on saliva, stool and, if possible, joint fluid.
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Affiliation(s)
- Marion Herbette
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest, France
| | | | | | | | - Emilie Ricard
- Rheumatology and bacteriology Units, CHR, Orléans, France
| | - Carine Salliot
- Rheumatology and bacteriology Units, CHR, Orléans, France
| | - Jérôme Guinard
- Rheumatology and bacteriology Units, CHR, Orléans, France
| | | | | | | | - Alain Saraux
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Université de Brest, LabEx IGO, Brest, France
- * E-mail:
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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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Ankli B, Khanlari B, Pegios V, Zettl A, Daikeler T. Whipple's disease mimicking an auto-inflammatory disease with myositis and soft tissue inflammation. Joint Bone Spine 2018; 85:645-646. [PMID: 29378265 DOI: 10.1016/j.jbspin.2018.01.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/17/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Barbara Ankli
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland; Department of Rheumatology, Bethesda Hospital Basel, Basel, Switzerland.
| | - Bettina Khanlari
- Infectious Diseases, Bethesda Hospital Basel, Basel, Switzerland
| | - Vassilios Pegios
- Department of Radiology, Bethesda Hospital Basel, Basel, Switzerland
| | - Andreas Zettl
- Department of Histopathology, Viollier Laboratory Basel, Basel, Switzerland
| | - Thomas Daikeler
- Department of Rheumatology, University Hospital Basel, Basel, Switzerland
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Loiodice A, Losurdo G, Iannone A, Rossi R, Fiore MG, Piscitelli D. Transmission electron microscopy helpfulness in Whipple's disease masked by immunosuppressant therapy for arthritis. APMIS 2017; 126:92-96. [PMID: 29154446 DOI: 10.1111/apm.12782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/17/2017] [Indexed: 12/22/2022]
Abstract
A 61-year-old woman received a diagnosis of undifferentiated non-erosive arthritis in 2010 and assumed methotrexate and steroids in 2014. After 1 year, she experienced watery diarrhea, vomiting, fever, weight loss, and severe hypoalbuminemia, thus being admitted into our Unit. Esophagogastroduodenoscopy showed duodenal lymphangiectasia and duodenal biopsy samples several foamy PAS-positive macrophages and villous subtotal atrophy. Transmission electron microscope demonstrated several extracellular and intracellular rod-shaped bacteria (Tropheryma whipplei). Therefore, we diagnosed Whipple's disease. Our patient assumed doxycycline/hydroxychloroquine with prompt remission of gastrointestinal symptoms. At 1 year of follow-up, she was symptom-free, histological reassessment showed almost complete mucosal healing and transmission electron microscope demonstrated bacteria breaking/disappearance. The present report demonstrates that: (i) rheumatological manifestations are common onset symptoms of Whipple's disease; (ii) immunosuppressive therapy may delay the diagnosis and worsen clinical presentation; (iii) transmission electron microscopy for specific bacteria detection/disappearance is an helpful diagnostic tool, when available.
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Affiliation(s)
- Alessandra Loiodice
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Roberta Rossi
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Maria Grazia Fiore
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Domenico Piscitelli
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
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