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Sztejkowski C, Sibilia J, Danion F, Mertz P, Elodie F, Kassegne L, Boyer P, Puéchal X, Gottenberg JE, Scherlinger M. Combining ts- and a bDMARD in refractory rheumatoid arthritis: an unusual adverse event. Rheumatology (Oxford) 2024; 63:e185-e187. [PMID: 38070160 DOI: 10.1093/rheumatology/kead672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2023] [Indexed: 06/05/2024] Open
Affiliation(s)
- Cédric Sztejkowski
- Centre National de Référence des Maladies Auto-Immunes et Systémiques Rares, Est/Sud-Ouest (RESO), Strasbourg, France
- Service de Rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Jean Sibilia
- Centre National de Référence des Maladies Auto-Immunes et Systémiques Rares, Est/Sud-Ouest (RESO), Strasbourg, France
- Service de Rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, Institut National de la Santé et de la Recherche médicale (INSERM) UMR_S 1109, Strasbourg, France
| | - François Danion
- Laboratoire d'ImmunoRhumatologie Moléculaire, Institut National de la Santé et de la Recherche médicale (INSERM) UMR_S 1109, Strasbourg, France
- Service de Maladie Infectieuse, Centre Hospitalier Universitaire de Strasbourg, quai Louis Pasteur, Strasbourg, France
| | - Philippe Mertz
- Centre National de Référence des Maladies Auto-Immunes et Systémiques Rares, Est/Sud-Ouest (RESO), Strasbourg, France
- Service de Rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Fels Elodie
- Centre National de Référence des Maladies Auto-Immunes et Systémiques Rares, Est/Sud-Ouest (RESO), Strasbourg, France
- Service de Rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Loïc Kassegne
- Service de Pneumologie, Pôle de Pathologie Thoracique, Centre Hospitalier Universitaire de Strasbourg, quai Louis Pasteur, Strasbourg, France
| | - Pierre Boyer
- Institut de Bactériologie, Centre Hospitalier Universitaire de Strasbourg, quai Louis Pasteur, Strasbourg, France
| | - Xavier Puéchal
- Centre de Référence des Maladies Auto-Immunes et Systémiques Rares d'Ile de France, Paris, France
- Service de Médecine Interne, Hôpital Cochin APHP Centre, Paris, France
| | - Jacques-Eric Gottenberg
- Centre National de Référence des Maladies Auto-Immunes et Systémiques Rares, Est/Sud-Ouest (RESO), Strasbourg, France
- Service de Rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
| | - Marc Scherlinger
- Centre National de Référence des Maladies Auto-Immunes et Systémiques Rares, Est/Sud-Ouest (RESO), Strasbourg, France
- Service de Rhumatologie, Centre Hospitalier Universitaire de Strasbourg, Strasbourg, France
- Laboratoire d'ImmunoRhumatologie Moléculaire, Institut National de la Santé et de la Recherche médicale (INSERM) UMR_S 1109, Strasbourg, France
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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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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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Kc P, Ayele FK, Karki S, Waleed MS. Whipple's Disease Mimicking Sarcoidosis. Cureus 2023; 15:e41839. [PMID: 37575808 PMCID: PMC10423070 DOI: 10.7759/cureus.41839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Whipple's disease is a rare systemic disease caused by a Tropheryma whipplei infection. Although older literature reports a low rate of incidence, case reports continue to rise due to increased awareness of the disease. Classic Whipple's disease presents as weight loss, diarrhea, and arthralgia and may involve the heart, central nervous system (CNS), or any other organ system. Some patients with Whipple's disease do not have the classic signs and symptoms of the disease. We present a case of Whipple's disease in a patient with poor appetite, weight loss, and granulomatous inflammation of various organs, including the kidneys and spleen, mimicking sarcoidosis. She had presented three years earlier with acute kidney injury (AKI) and hypercalcemia. The renal biopsy revealed diffuse granulomatous interstitial nephritis. Both AKI and hypercalcemia resolved with prednisone; however, her weight loss and decreased appetite continued. The initial positron emission tomography (PET) scan showed increased fluorodeoxyglucose (FDG) avidity in the spleen and large intestine, and the splenic biopsy revealed non-caseating granulomas. A diagnosis of sarcoidosis was made, and she was started on methotrexate with prednisone. Nevertheless, the weight loss and poor appetite were relentless. A repeat PET scan showed increased FDG avidity in loops of the small and large intestines. A small intestinal biopsy revealed positive periodic acid-Schiff (PAS) and negative acid-fast bacilli (AFB) revealing the diagnosis of Whipple's disease. Whipple's disease should be considered in the differential diagnosis of sarcoidosis, especially in those patients worsening on standard immunosuppression.
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Affiliation(s)
- Pawan Kc
- Rheumatology, Emory University School of Medicine, Atlanta, USA
| | | | - Sabin Karki
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
| | - Madeeha S Waleed
- Internal Medicine, Suburban Community Hospital (Lower Bucks Hospital), Bristol, USA
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Fang Z, Liu Q, Tang W, Yu H, Zou M, Zhang H, Xue H, Lin S, Pei Y, Ai J, Chen J. Experience in the diagnosis and treatment of pneumonia caused by infection with Tropheryma whipplei: A case series. Heliyon 2023; 9:e17132. [PMID: 37484369 PMCID: PMC10361318 DOI: 10.1016/j.heliyon.2023.e17132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/23/2023] [Accepted: 06/08/2023] [Indexed: 07/25/2023] Open
Abstract
Tropheryma whipplei (TW) is the root cause of Whipple's disease (WD), a rare infectious illness leading to multi-organ impairment. A prominent feature of WD is acute pneumonia, which can be exceedingly challenging to diagnose clinically due to the pathogen's surreptitious nature. However and significantly, with the advent of metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF), it offers clinicians a potent tool at their disposal to detect TW infections. The present study conducted a retrospective analysis of clinical data gleaned from five patients in Hunan Province in China. Findings in this study demonstrated the potential of BALF-mNGS in diagnosing pneumonia caused by TW infection.
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Affiliation(s)
- Zhixiong Fang
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Qiong Liu
- Linxiang People’s Hospital, Hunan province, China
| | - Wei Tang
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Hongyin Yu
- Center for Infectious Diseases, The First People's Hospital of Huaihua, Hunan, China
| | - Min Zou
- Department of Respiratory and Critical Care Medicine, The First People’s Hospital of Xiangtan City Affiliated to Nanhua University, Hunan, China
| | - Haiming Zhang
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Haiyan Xue
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Sha Lin
- Department of Infectious Disease and Public Health, Central Hospital of Xiangtan, Hunan province, China
| | - Yi Pei
- Department of Tuberculosis, Changsha Central Hospital, Changsha, China
| | - Jingwen Ai
- Department of Infectious Disease, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jun Chen
- Department of Liver Diseases, Third Hospital of Shenzhen, The Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, Guangdong, China
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Ujaimi Z, Bjursten H, Vucicevic S, Brunnström H, Gilje P, Rasmussen M, Ragnarsson S. Treatment refractory arthritis and stroke - A case of infective endocarditis caused by Tropheryma whipplei. IDCases 2023; 32:e01800. [PMID: 37255692 PMCID: PMC10225878 DOI: 10.1016/j.idcr.2023.e01800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/16/2023] [Indexed: 06/01/2023] Open
Abstract
Whipple´s disease is a rare multisystem condition affecting < 1/1.000.000 per year. The condition often presents with polyarthritis, diarrhea, and intestinal malabsorption. Endocarditis is seen in a minority of these patients, and is typically culture negative, as the causative agent Tropheryma whipplei does not grow in ordinary culture media. We present the case of a 78-year-old man with a history of seronegative polyarthritis that was refractory to treatment with several biological agents for a duration of 5 years prior to presentation to the emergency department with stroke. Echocardiography revealed aortic valve endocarditis with a 3.6 cm vegetation and multiple smaller vegetations. The patient underwent surgery with aortic valve replacement followed by prolonged antibiotic treatment. 16 S rDNA PCR analysis of the resected valve revealed T. whipplei as the causative agent. Two years after surgery and treatment with antibiotics, the patient's previously longstanding arthritis had totally disappeared and all rheumatological treatment had been discontinued.
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Affiliation(s)
- Ziyad Ujaimi
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Henrik Bjursten
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
| | - Sanja Vucicevic
- Department of Infection Medicine, Kristianstad Hospital, Sweden
| | - Hans Brunnström
- Department of Pathology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Patrik Gilje
- Department of Cardiology, Lund University, Skåne University Hospital, Lund, Sweden
| | - Magnus Rasmussen
- Department of Infection Medicine, Lund University, Skåne University Hospital, Lund, Sweden
| | - Sigurdur Ragnarsson
- Department of Cardiothoracic Surgery, Lund University, Skåne University Hospital, Lund, Sweden
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Motwade N. Kerollos K, Osman Taha B. Whipple's Disease; An Overlooked Diagnosis. Middle East J Dig Dis 2023; 15:136-138. [PMID: 37546505 PMCID: PMC10404087 DOI: 10.34172/mejdd.2023.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/08/2023] [Indexed: 08/08/2023] Open
Abstract
Whipple disease is a rare multisystem inflammatory disease. Because fewer than 1000 reported cases have been described, clinical experience with this disorder is sparse. We are reporting a case of a 46-year-old man who presented with fever, weight loss, and polyarthralgia for 2 months, and 1 month of diarrhea. The patient was thoroughly investigated for collagen diseases and COVID-19, with no definite diagnosis. A therapeutic trial by immunosuppressive drugs provided partial remission followed by a marked rebound of the symptoms. His occult blood in stool was positive and subsequent upper endoscopy with proximal small intestinal biopsies showed the pathological features of Whipple's disease. The patient showed a dramatic improvement following treatment with ceftriaxone and trimethoprim-sulfamethoxazole. Despite the rarity of Whipple's disease, its course mimics many rheumatological diseases, inflammatory bowel disease, and COVID-19 disease. It should always be a part of the differential diagnosis of obscure polyarthralgia and chronic diarrhea.
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Dagdeviren S, Lee RT, Wu N. Physiological and Pathophysiological Roles of Thioredoxin Interacting Protein: A Perspective on Redox Inflammation and Metabolism. Antioxid Redox Signal 2023; 38:442-460. [PMID: 35754346 PMCID: PMC9968628 DOI: 10.1089/ars.2022.0022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 06/12/2022] [Indexed: 11/12/2022]
Abstract
Significance: Thioredoxin interacting protein (TXNIP) is a member of the arrestin fold superfamily with important cellular functions, including cellular transport, mitochondrial energy generation, and protein cycling. It is the only arrestin-domain protein known to covalently bind to thioredoxin and plays roles in glucose metabolism, inflammation, apoptosis, and cancer. Recent Advances: The crystal structure of the TXNIP-thioredoxin complex provided details about this fascinating interaction. Recent studies showed that TXNIP is induced by endoplasmic reticulum (ER) stress, activates NLR family pyrin domain containing 3 (NLRP3) inflammasomes, and can regulate glucose transport into cells. The tumor suppressor role of TXNIP in various cancer types and the role of TXNIP in fructose absorption are now described. Critical Issues: The influence of TXNIP on redox state is more complex than its interaction with thioredoxin. Future Directions: It is incompletely understood which functions of TXNIP are thioredoxin-dependent. It is also unclear whether TXNIP binding can inhibit glucose transporters without endocytosis. TXNIP-regulated control of ER stress should also be investigated further. Antioxid. Redox Signal. 38, 442-460.
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Affiliation(s)
- Sezin Dagdeviren
- Department of Stem Cell and Regenerative Biology and the Harvard Stem Cell Institute, Harvard University, Cambridge, Massachusetts, USA
| | - Richard T. Lee
- Department of Stem Cell and Regenerative Biology and the Harvard Stem Cell Institute, Harvard University, Cambridge, Massachusetts, USA
| | - Ning Wu
- Van Andel Institute, Grand Rapids, Michigan, USA
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Doussiere M, Sobhy Danial JM, Barthomeuf C, Tesson JR, Beauvillain Q, Goeb V. Diagnosis of Whipple's disease with pseudorheumatoid nodules in a patient treated with biologics for rheumatoid polyarthritis. Rheumatol Adv Pract 2023; 7:rkad002. [PMID: 36726734 PMCID: PMC9887464 DOI: 10.1093/rap/rkad002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Affiliation(s)
- Marie Doussiere
- Correspondence to: Marie Doussiere, Service de Rhumatologie, Université de Picardie Jules Verne, CHU Amiens-Picardie, 80054 Amiens, France. E-mail:
| | - Jean-Marc Sobhy Danial
- Service de Rhumatologie, Université de Picardie Jules Verne, CHU Amiens-Picardie, Amiens, France
| | - Clémence Barthomeuf
- Service d’Anatomie et Cytologie Pathologiques, Université de Picardie Jules Verne, CHU Amiens-Picardie, Amiens, France
| | - Jean-René Tesson
- Service d’Anatomie et Cytologie Pathologiques, Université de Picardie Jules Verne, CHU Amiens-Picardie, Amiens, France
| | - Quentin Beauvillain
- Service de Dermatologie, Université de Picardie Jules Verne, CHU Amiens-Picardie, Amiens, France
| | - Vincent Goeb
- Service de Rhumatologie, Université de Picardie Jules Verne, CHU Amiens-Picardie, Amiens, France
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Choueiry R, Faddoul J, Najjar J, Ghorra C, Mansour J, Safi N, Amara J. An unusual presentation of Whipple’s disease: adenopathies, polyarthralgia and dermatomyositis-like symptoms. EXPLORATION OF MEDICINE 2022. [DOI: 10.37349/emed.2022.00113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Whipple’s disease (WD) is a rare systemic disease caused by gram-positive bacillus bacteria that invades multiple organs mainly the intestinal epithelium. Its manifestation is not only limited to the gastrointestinal tract but it also affects the joints, muscle and skin. This is a case of a 54-year-old male patient with a medical history of chronic arthritis presenting with bilateral progressive calves pain, anterior tibial hyperpigmentation, joints pain, anemia and weight loss. He was misdiagnosed as rheumatoid arthritis, for which he was treated by immunosuppressors for several years with no amelioration. After advanced investigations, he was found to have multiple retroperitoneal and mesenteric adenopathies, with an incidental finding of a mesojejunal mass during laparoscopy, from which the biopsies revealed the presence of histiocytosis and numerous intra-cytoplasmic particles with positive periodic acid–Schiff (PAS) suggesting the diagnosis of WD. Endoscopy was done and intestinal histology with polymerase chain reaction (PCR) test confirmed the diagnosis of WD. The patient was then treated with antibiotics (ceftriaxone and trimethoprim-sulfamethoxazole) with a remarkable clinical amelioration. To be aware of WD as a potential etiology behind malabsorption, musculoskeletal and skin abnormalities, is the first step in order to establish the diagnosis and provide adequate treatment, thus, improving the patient’s quality of life. WD is a rare, without antibiotic treatment deadly systemic infectious disease caused by the ubiquitary Gram-positive bacterium Tropheryma whipplei. This article aims to report a case marked with dermatomyositis like presentation that had a missed and delayed diagnosis.
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Affiliation(s)
- Randa Choueiry
- Internal Medicine and Clinical Immunology Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon; Internal Medicine and Clinical Immunology Department, Lebanese Hospital Geitaoui, Beirut, Lebanon
| | - Joelle Faddoul
- Internal Medicine and Clinical Immunology Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon; Internal Medicine and Clinical Immunology Department, Lebanese Hospital Geitaoui, Beirut, Lebanon
| | - Jacqueline Najjar
- Internal Medicine and Clinical Immunology Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Claude Ghorra
- Anatomo Pathology Department, Lebanese Hospital Geitaoui, Beirut, Lebanon; Anatomo Pathology Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Josiane Mansour
- Anatomo Pathology Department, Lebanese Hospital Geitaoui, Beirut, Lebanon; Anatomo Pathology Department, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
| | - Neemtallah Safi
- Gastroenterology Department, Lebanese Hospital Geitaoui, Beirut, Lebanon
| | - Joseph Amara
- Gastroenterology Department, Lebanese Hospital Geitaoui, Beirut, Lebanon
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12
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Naser JA, Fogwe D, Ho M, Corsini Campioli C, Shah A. Hiding in Plain Sight. N Engl J Med 2022; 387:2075-2081. [PMID: 36449424 DOI: 10.1056/nejmcps2205021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Affiliation(s)
- Jwan A Naser
- From the Division of General Internal Medicine, Department of Internal Medicine (J.A.N., D.F., M.H.), and the Division of Public Health, Infectious Diseases, and Occupational Medicine (C.C.C., A.S.), Mayo Clinic, Rochester, MN
| | - Delvise Fogwe
- From the Division of General Internal Medicine, Department of Internal Medicine (J.A.N., D.F., M.H.), and the Division of Public Health, Infectious Diseases, and Occupational Medicine (C.C.C., A.S.), Mayo Clinic, Rochester, MN
| | - Matthew Ho
- From the Division of General Internal Medicine, Department of Internal Medicine (J.A.N., D.F., M.H.), and the Division of Public Health, Infectious Diseases, and Occupational Medicine (C.C.C., A.S.), Mayo Clinic, Rochester, MN
| | - Cristina Corsini Campioli
- From the Division of General Internal Medicine, Department of Internal Medicine (J.A.N., D.F., M.H.), and the Division of Public Health, Infectious Diseases, and Occupational Medicine (C.C.C., A.S.), Mayo Clinic, Rochester, MN
| | - Aditya Shah
- From the Division of General Internal Medicine, Department of Internal Medicine (J.A.N., D.F., M.H.), and the Division of Public Health, Infectious Diseases, and Occupational Medicine (C.C.C., A.S.), Mayo Clinic, Rochester, MN
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13
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Muacevic A, Adler JR, Ramasamy D, Kumar S. Whipple's Disease (WD) Without Arthropathy in an Immunocompromised Patient. Cureus 2022; 14:e31659. [PMID: 36545168 PMCID: PMC9761016 DOI: 10.7759/cureus.31659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2022] [Indexed: 11/21/2022] Open
Abstract
Whipple's disease (WD) is a rare disorder caused by the pathogen Tropheryma whipplei (T. whipplei). We report a unique presentation of WD in which the patient did not exhibit arthralgia which is characteristic of this disease. A 67-year-old man with a history of chronic hepatitis B infection and human immunodeficiency virus (HIV) infection presented with weight loss, nausea, vomiting, and myalgia. Endoscopy demonstrated erythema in the gastric body, lymphangiectasia of the duodenum, and increased granularity of the terminal ileum. Mucosal biopsies revealed macrophages in the lamina propria with focal histiocytic aggregates throughout the small bowel and cecum, consistent with WD. Confirmatory T. whipplei polymerase chain reaction(PCR) testing was positive. WD is a rare diagnosis that must be considered in the differential diagnoses of patients presenting with unexplained nausea, vomiting, diarrhea, and anemia. Furthermore, in patients with HIV, the possibilities would also include opportunistic gastrointestinal pathogens. Classic WD is characterized by diarrhea, weight loss, abdominal pain, and extra-intestinal involvement manifesting as joint pain. We describe a case of WD occurring in a patient with HIV, without the disease's characteristic joint involvement.
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14
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Mohammed F, Kurtom M, Brant A, Sampath R. Whipple's disease unmasked by TNF inhibitor therapy for treatment of seronegative rheumatoid arthritis. BMJ Case Rep 2022; 15:e250693. [PMID: 35863856 PMCID: PMC9310182 DOI: 10.1136/bcr-2022-250693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a patient with seronegative rheumatoid arthritis diagnosed with Whipple's disease following treatment of tumour necrosis factor inhibitor (TNFI) therapy. Whipple's disease should be considered in patients with seronegative rheumatoid arthritis and other unexplained multisystem illness. The TNFI therapy and immunosuppressive therapies can unmask latent Whipple's disease.
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Affiliation(s)
- Fahad Mohammed
- Neuroscience, Duke University Trinity College of Arts and Sciences, Durham, North Carolina, USA
| | - Muhannad Kurtom
- Medicine, UNC Health Blue Ridge, Morganton, North Carolina, USA
| | - Andrew Brant
- Pathology, UNC Health Blue Ridge, Morganton, North Carolina, USA
| | - Rahul Sampath
- Infectious Disease, UNC Health Blue Ridge, Morganton, North Carolina, USA
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15
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Design of a Multi-Epitope Vaccine against Tropheryma whipplei Using Immunoinformatics and Molecular Dynamics Simulation Techniques. Vaccines (Basel) 2022; 10:vaccines10050691. [PMID: 35632446 PMCID: PMC9147804 DOI: 10.3390/vaccines10050691] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 12/15/2022] Open
Abstract
Whipple’s disease is caused by T. whipplei, a Gram-positive pathogenic bacterium. It is considered a persistent infection affecting various organs, more likely to infect males. There is currently no licensed vaccination available for Whipple’s disease; thus, the development of a chimeric peptide-based vaccine against T. whipplei has the potential to be tremendously beneficial in preventing Whipple’s disease in the future. The present study aimed to apply modern computational approaches to generate a multi-epitope-based vaccine that expresses antigenic determinants prioritized from the core proteome of two T. whipplei whole proteomes. Using an integrated computational approach, four immunodominant epitopes were found from two extracellular proteins. Combined, these epitopes covered 89.03% of the global population. The shortlisted epitopes exhibited a strong binding affinity for the B- and T-cell reference set of alleles, high antigenicity score, nonallergenic nature, high solubility, nontoxicity, and excellent binders of DRB1*0101. Through the use of appropriate linkers and adjuvation with a suitable adjuvant molecule, the epitopes were designed into a chimeric vaccine. An adjuvant was linked to the connected epitopes to boost immunogenicity and efficiently engage both innate and adaptive immunity. The physiochemical properties of the vaccine were observed favorable, leading toward the 3D modeling of the construct. Furthermore, the vaccine’s binding confirmation to the TLR-4 critical innate immune receptor was also determined using molecular docking and molecular dynamics (MD) simulations, which shows that the vaccine has a strong binding affinity for TLR4 (−29.4452 kcal/mol in MM-GBSA and −42.3229 kcal/mol in MM-PBSA). Overall, the vaccine described here has a promising potential for eliciting protective and targeted immunogenicity, subject to further experimental testing.
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16
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Boumaza A, Ben Azzouz E, Arrindell J, Lepidi H, Mezouar S, Desnues B. Whipple's disease and Tropheryma whipplei infections: from bench to bedside. THE LANCET INFECTIOUS DISEASES 2022; 22:e280-e291. [DOI: 10.1016/s1473-3099(22)00128-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/28/2022] [Accepted: 02/02/2022] [Indexed: 12/13/2022]
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17
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Clarke MCC, Price RN. Delayed Diagnosis of Whipple’s Disease Complicated by Jarisch–Herxheimer Reaction to Ceftriaxone Treatment: A Case Report and Literature Review. Trop Med Infect Dis 2022; 7:tropicalmed7030040. [PMID: 35324587 PMCID: PMC8954982 DOI: 10.3390/tropicalmed7030040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 01/25/2023] Open
Abstract
Whipple’s disease is a rare chronic infection caused by the actinomycete Tropheryma whipplei. Patients commonly present with gastrointestinal symptoms. We present a case of classic Whipple’s disease complicated by a probable Jarisch–Herxheimer reaction following the initiation of ceftriaxone treatment.
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Affiliation(s)
- Marcus C C Clarke
- Division of Medicine, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, NT 0810, Australia
| | - Ric N Price
- Division of Medicine, Royal Darwin Hospital, 105 Rocklands Dr, Tiwi, NT 0810, Australia
- Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Ellengowan Dr, Casuarina, NT 0810, Australia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford OX1 2JD, UK
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18
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Meudec L, Jelin G, Goossens J, Forien M, Jacquier H, Dieudé P, Ottaviani S. Whipple disease mimicking polymyalgia rheumatica with initial response to tocilizumab. Intern Med J 2021; 51:2151-2152. [PMID: 34939291 DOI: 10.1111/imj.15281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 09/10/2020] [Accepted: 09/16/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Loic Meudec
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Rhumatologie, Hôpital Bichat, Paris, France
| | - Germain Jelin
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Rhumatologie, Hôpital Bichat, Paris, France
| | - Julia Goossens
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Rhumatologie, Hôpital Bichat, Paris, France
| | - Marine Forien
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Rhumatologie, Hôpital Bichat, Paris, France
| | - Hervé Jacquier
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Bactériologie-Virologie, Hôpital Lariboisière, Paris, France
| | - Philippe Dieudé
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Rhumatologie, Hôpital Bichat, Paris, France
| | - Sébastien Ottaviani
- Université Paris Diderot, Sorbonne Paris Cité, UFR de Médecine, Paris, France.,AP-HP, Service de Rhumatologie, Hôpital Bichat, Paris, France
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19
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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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20
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Wang S, Xia D, Wu J, Jia D, Li L, Xu S. Severe Pneumonia Caused by Infection With Tropheryma whipplei Complicated With Acinetobacter baumannii Infection: A Case Report Involving a Young Woman. Front Public Health 2021; 9:729595. [PMID: 34760862 PMCID: PMC8575073 DOI: 10.3389/fpubh.2021.729595] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Whipple's disease is a very rare systemic infectious disease, and very few cases have been reported. However, it can be fatal if not diagnosed and treated appropriately. The major clinical manifestations of this disease are usually digestive and nervous system symptoms. The majority of patients are male and between 40 and 50 years old. Although respiratory symptoms of this disease have rarely been reported, they pose a serious threat to the lives of the patients, especially when they progress to severe pneumonia. During admission to the hospital, Acinetobacter baumannii infection makes treatment more difficult. While most patients are middle-aged men, more attention should be given to the diagnosis and treatment of affected young women. To our knowledge, the case presented in the study is the first case of Tropheryma whipplei infection that resulted in severe pneumonia and was complicated by A. baumannii infection during treatment. We hope that our study can serve as a reference for the diagnosis and treatment of related cases in the future.
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Affiliation(s)
- Sheng Wang
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Demeng Xia
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China.,Health Clinic, Liberation Army Unit 91666, Zhoushan, China
| | - Jianghong Wu
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Dandan Jia
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Li
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Shuogui Xu
- Department of Emergency, Changhai Hospital, Naval Medical University, Shanghai, China
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21
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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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22
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Delarbre D, Gan L, Antoine C, Poisnel E, Cambon A, Dutasta F, Paris JF, Simon F, Defuentes G. [Diagnostic issues of Whipple's disease during chronic inflammatory rheumatism: About three cases]. Rev Med Interne 2021; 42:801-804. [PMID: 34218934 DOI: 10.1016/j.revmed.2021.06.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 06/08/2021] [Accepted: 06/16/2021] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Whipple's disease (WD) can mimic chronic inflammatory rheumatism leading to incorrect prescription of tumor necrosis factor inhibitors (TNFI). Several complicated cases of WD have been reported during TNFI treatment which is strongly suspected to modify the host-pathogen relationship. Tropheryma whipplei asymptomatic carriage is high in the general population, making the diagnosis of WD more difficult face to unexplained arthritis. OBSERVATIONS We report three observations that illustrate situations for which the detection of T. whipplei might be valuable to investigate the differential diagnosis of inflammatory rheumatism. CONCLUSION The decision to check for T. whipplei infection should rely on individual clinical assessment. It should be considered in the absence of clinical response or in case of worsening of an inflammatory rheumatism under TNFI treatment, especially in front of atypical features. A systematic screening for T. whipplei before anti-TNF treatment seems unjustified since asymptomatic carriers are frequent.
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Affiliation(s)
- D Delarbre
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France.
| | - L Gan
- Service de pathologie digestive, Hôpital d'instruction des armées Sainte-Anne, 1 boulevard Sainte-Anne, 83000 Toulon, France
| | - C Antoine
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France
| | - E Poisnel
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France
| | - A Cambon
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France
| | - F Dutasta
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France
| | - J F Paris
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France
| | - F Simon
- CEO & directeur scientifique, RISK&VIR, France; Inserm-IRD-Aix Marseille université, unité des virus émergents, France
| | - G Defuentes
- Service de médecine interne, Hôpital d'instruction des armées Sainte-Anne, 1, boulevard Sainte Anne, 83000 Toulon, France
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23
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Boumaza A, Mezouar S, Bardou M, Raoult D, Mège JL, Desnues B. Tumor Necrosis Factor Inhibitors Exacerbate Whipple's Disease by Reprogramming Macrophage and Inducing Apoptosis. Front Immunol 2021; 12:667357. [PMID: 34093562 PMCID: PMC8173622 DOI: 10.3389/fimmu.2021.667357] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/05/2021] [Indexed: 12/23/2022] Open
Abstract
Tropheryma whipplei is the agent of Whipple’s disease, a rare systemic disease characterized by macrophage infiltration of the intestinal mucosa. The disease first manifests as arthralgia and/or arthropathy that usually precede the diagnosis by years, and which may push clinicians to prescribe Tumor necrosis factor inhibitors (TNFI) to treat unexplained arthralgia. However, such therapies have been associated with exacerbation of subclinical undiagnosed Whipple’s disease. The objective of this study was to delineate the biological basis of disease exacerbation. We found that etanercept, adalimumab or certolizumab treatment of monocyte-derived macrophages from healthy subjects significantly increased bacterial replication in vitro without affecting uptake. Interestingly, this effect was associated with macrophage repolarization and increased rate of apoptosis. Further analysis revealed that in patients for whom Whipple’s disease diagnosis was made while under TNFI therapy, apoptosis was increased in duodenal tissue specimens as compared with control Whipple’s disease patients who never received TNFI prior diagnosis. In addition, IFN-γ expression was increased in duodenal biopsy specimen and circulating levels of IFN-γ were higher in patients for whom Whipple’s disease diagnosis was made while under TNFI therapy. Taken together, our findings establish that TNFI aggravate/exacerbate latent or subclinical undiagnosed Whipple’s disease by promoting a strong inflammatory response and apoptosis and confirm that patients may be screened for T. whipplei prior to introduction of TNFI therapy.
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Affiliation(s)
- Asma Boumaza
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Soraya Mezouar
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Matthieu Bardou
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Didier Raoult
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Jean-Louis Mège
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
| | - Benoit Desnues
- Aix Marseille Univ, IRD, APHM, MEPHI, Marseille, France.,IHU-Méditerranée Infection, Marseille, France
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24
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Drug Response Diversity: A Hidden Bacterium? J Pers Med 2021; 11:jpm11050345. [PMID: 33922920 PMCID: PMC8146020 DOI: 10.3390/jpm11050345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 04/12/2021] [Accepted: 04/22/2021] [Indexed: 11/27/2022] Open
Abstract
Interindividual heterogeneity in response to treatment is a real public health problem. It is a factor that can be responsible not only for ineffectiveness or fatal toxicity but also for hospitalization due to iatrogenic effects, thus increasing the cost of patient care. Several research teams have been interested in what may be at the origin of these phenomena, particularly at the genetic level and the basal activity of organs dedicated to the inactivation and elimination of drug molecules. Today, a new branch is being set up, explaining the enigmatic part that could not be explained before. Pharmacomicrobiomics attempts to investigate the interactions between bacteria, especially those in the gut, and drug response. In this review, we provide a state of the art on what this field has brought as new information and discuss the challenges that lie ahead to see the real application in clinical practice.
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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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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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Kukull B, Mahlow J, Hale G, Perry LJ. Whipple's disease: a fatal mimic. AUTOPSY AND CASE REPORTS 2021; 11:e2020237. [PMID: 34277495 PMCID: PMC8101681 DOI: 10.4322/acr.2020.237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/01/2020] [Indexed: 11/23/2022] Open
Abstract
Whipple’s Disease, a rare diagnosis caused by the slow-growing bacterium Tropheryma whipplei, most often presents with the classically described signs of malabsorption due to gastrointestinal colonization. However, it can also have signs and symptoms that clinically overlap with rheumatic diseases, potentially resulting in misdiagnosis. Furthermore, treatment with modern potent biologic immunosuppressive agents and classic disease modifying anti-rheumatic drugs (DMARDs) can lead to serious exacerbation of undiagnosed infections. We present the case of a middle-aged woman with long term complaints of arthalgias, who was diagnosed with seronegative rheumatoid arthritis and subsequently treated for almost 7 years with such immunosuppressive therapies. The patient’s disease course included chronic diarrhea that abruptly intensified and culminated in fatal hypovolemic shock/sepsis. A diagnosis of WD was made by autopsy examination, wherein several organ systems were found to be heavily involved by Tropheryma whipplei organisms, and their identification was confirmed with histochemical and molecular evaluation. Notably, most bacterial organisms were located deeply in the submucosa/muscularis of affected organs, a practical reminder to practicing pathologists that challenges the classic histopathologic description of Whipple disease as an infiltration of predominantly lamina propria, and the potential for sampling bias in typically superficial endoscopic biopsies during routine procedures.
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Affiliation(s)
- Benjamin Kukull
- University of Utah School of Medicine, Department of Pathology, Salt Lake City, UT, USA
| | - Jonathon Mahlow
- University of Utah School of Medicine, Department of Pathology, Salt Lake City, UT, USA
| | - Gillian Hale
- University of Utah School of Medicine, Department of Pathology, Salt Lake City, UT, USA
| | - Lindsey J Perry
- University of Utah School of Medicine, Department of Pathology, Salt Lake City, UT, USA
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28
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Alsarhani WK, Alkhalifah MI, Alkatan HM, Alsolami AL, Maktabi AMY, Alsuhaibani AH. Whipple's disease scleral nodules: a novel presentation in 2 consecutive patients. BMC Ophthalmol 2020; 20:413. [PMID: 33066757 PMCID: PMC7566054 DOI: 10.1186/s12886-020-01695-4] [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: 07/22/2020] [Accepted: 10/13/2020] [Indexed: 11/10/2022] Open
Abstract
Background Whipple’s disease (WD) is a rare, chronic, infection caused by gram-positive filamentous aerobic actinobacterium Tropheryma whipplei occurs classically in the gastrointestinal tract and shows histopathologically foamy macrophages with typical numerous PAS-positive, non-acid fast particles. Ocular WD in the form of uveitis may occur in the absence of systemic disease but has not been reported to present with scleral manifestation. We describe for the first time to the best of our knowledge 2 cases of scleral nodules with typical histopathological morphology of WD and without systemic involvement. Case presentation The first was a 53-year old diabetic male farmer who presented with 2 nontender right eye scleral nodules for 3 months, had a negative systemic workup, and surgical excision showed Periodic acid Schiff (PAS)-positive eosinophilic structures inside macrophages. Grocott’s methenamine silver (GMS) stain and acid-fast bacilli (AFB) stain of the tissue itself were negative. The second case was a 60-year old male who presented with an asymptomatic superior scleral nodule for 4 months, which showed similar appearance and negative GMS and AFB stains. Conclusion WD should be included in the differential diagnosis of scleral nodules even in the absence of systemic symptoms. Surgical excision without systemic treatment resulted in successful outcome without recurrence.
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Affiliation(s)
- Waleed K Alsarhani
- Ophthalmology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Muhannad I Alkhalifah
- Ophthalmology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hind M Alkatan
- Ophthalmology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia. .,Pathology Department, College of Medicine, King Saud University Medical city, King Saud University, Riyadh, Saudi Arabia.
| | - Afaf L Alsolami
- Pathology Department, College of Medicine, King Saud University Medical city, King Saud University, Riyadh, Saudi Arabia
| | - Azza M Y Maktabi
- Pathology and Laboratory Medicine, King Khaled Eye Specialist Hospital, Riyadh, Saudi Arabia
| | - Adel H Alsuhaibani
- Ophthalmology Department, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Duss FR, Jaton K, Vollenweider P, Troillet N, Greub G. Whipple disease: a 15-year retrospective study on 36 patients with positive polymerase chain reaction for Tropheryma whipplei. Clin Microbiol Infect 2020; 27:910.e9-910.e13. [PMID: 32896657 DOI: 10.1016/j.cmi.2020.08.036] [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: 04/24/2020] [Revised: 08/16/2020] [Accepted: 08/26/2020] [Indexed: 12/14/2022]
Abstract
Our institution has performed microbiological diagnosis of Tropheryma whipplei since 2001, initially with a PCR targeting 16S rRNA before the development of a quantitative PCR in 2012. Here we report the clinical characteristics of a cohort of patients suffering from Whipple disease (WD) and evaluate the impact of these molecular techniques. Patients with a positive PCR for T. whipplei between 2001 and 2016 were retrospectively collected from microbiological databases. Two infectious diseases specialists reviewed their medical records and classified them as definite WD, probable WD or carriage of T. whipplei without disease. A total of 1153 samples were tested for T. whipplei; 76 samples taken from 36 patients were positive. Fifteen were considered as presenting a definite WD, seven as a probable WD and 14 as carriers. Median age was 56.4 years (extremes, 6.6-76.1). Median time from symptoms to diagnosis was 3 years (2.5 months to 13.3 years). About 60% were immunosuppressed. The most frequent clinical presentations were joint pain (16/22), weight loss (15/22) and/or digestive tract disorder (15/22); 41% had neurological manifestations, 32% pulmonary involvement and 32% lymphadenopathies. Bacterial load in faeces or saliva were 88 425 copies/mL (IQR 6175-292 725) in definite and probable WD and 311 copies/mL (IQR 253-2090) in carriers, respectively. We observed a 90% PPV above 32 200 copies/mL in faeces. WD is a chronic multisystemic disease with frequent pulmonary involvement. Underlying immunodeficiency is commonly observed leading to more complex clinical presentation. Positive T. whipplei PCR in both stool and saliva has a high positive predictive value. Moreover, patients with WD present higher bacterial load in faeces with a threshold of >32 200 copies/mL predicting ongoing infection.
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Affiliation(s)
- François-Régis Duss
- Department of Internal Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Katia Jaton
- Institute of Microbiology, University of Lausanne, Lausanne, Switzerland
| | - Peter Vollenweider
- Department of Internal Medicine, University Hospital of Lausanne, Lausanne, Switzerland
| | - Nicolas Troillet
- Department of Infectious Diseases Valais Hospital, Sion, Switzerland
| | - Gilbert Greub
- Institute of Microbiology, University of Lausanne, Lausanne, Switzerland.
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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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Sullivan A, Shrestha P, Basnet S, Herb R, Zagorski E. A rare case of Whipple's disease with endocarditis in a patient with dextrocardia. SAGE Open Med Case Rep 2020; 8:2050313X20936952. [PMID: 32655867 PMCID: PMC7328352 DOI: 10.1177/2050313x20936952] [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: 09/16/2019] [Accepted: 05/31/2020] [Indexed: 12/18/2022] Open
Abstract
We report a case of an elderly Caucasian male with past medical history of dextrocardia
with situs inversus totalis, polymyalgia rheumatica, history of cryptogenic stroke, and
severe mitral regurgitation with mitral valve prolapse, who presented with acute heart
failure symptoms, including severe dyspnea on exertion and worsening lower extremity edema
in the setting of immunosuppression with steroids for a year-old diagnosis of polymyalgia
rheumatica. One month prior to this presentation, the patient suffered a transient
ischemic attack and during the workup, his transthoracic echocardiography showed
myxomatous degeneration of posterior mitral leaflet, partially flail, with severe mitral
regurgitation, which required mitral valve replacement. Genome sequencing of mitral valve
anterior leaflet pathology detected Tropheryma whipplei as a causal agent
of culture-negative endocarditis. The patient was treated with 6 weeks of ceftriaxone and
ampicillin–sulbactam and further continued trimethoprim–sulfamethoxazole for 1 year. He
continued antibiotic treatment with resolution of shortness of breath along with
arthralgia.
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Affiliation(s)
- Abigayle Sullivan
- Department of Internal Medicine, Reading Hospital-Tower Health System, PA, USA
| | - Pragya Shrestha
- Department of Internal Medicine, Reading Hospital-Tower Health System, PA, USA
| | - Sijan Basnet
- Department of Internal Medicine, Reading Hospital-Tower Health System, PA, USA
| | - Ronald Herb
- Department of Internal Medicine, Reading Hospital-Tower Health System, PA, USA
| | - Emily Zagorski
- Department of Internal Medicine, Reading Hospital-Tower Health System, PA, USA
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32
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Wither Away: Weight Loss and Persistent Inflammation in a Woman With Whipple Disease. Am J Med 2020; 133:e223-e226. [PMID: 31678352 DOI: 10.1016/j.amjmed.2019.08.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 08/30/2019] [Accepted: 08/30/2019] [Indexed: 11/22/2022]
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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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34
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Kutlu O, Erhan SŞ, Gökden Y, Kandemir Ö, Tükek T. Whipple's Disease: A Case Report. Med Princ Pract 2020; 29:90-93. [PMID: 30763942 PMCID: PMC7024871 DOI: 10.1159/000498909] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 02/04/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Whipple's disease is a very rare systemic infectious disease with an annual incidence of 3 in one million, which may be fatal if not diagnosed and treated appropriately. CLINICAL PRESENTATION AND INTERVENTION Herein we describe a 49-year-old patient admitted to the hospital with symptoms of severe malabsorption and diagnosed with Whipple's disease. The diagnosis was based on the histopathological findings of small intestine biopsies and PCR analysis. CONCLUSION Whipple's disease should be kept in mind while dealing with patients with severe malabsorption, even in the absence of accompanying features of the disease.
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Affiliation(s)
- Orkide Kutlu
- Department of Internal Medicine, Okmeydanı Education and Research Hospital, Istanbul, Turkey,
| | - Selma Şengiz Erhan
- Department of Pathology, Okmeydanı Education and Research Hospital, Istanbul, Turkey
| | - Yasemin Gökden
- Department of Internal Medicine, Okmeydanı Education and Research Hospital, Istanbul, Turkey
| | - Özlem Kandemir
- Department of Internal Medicine, Okmeydanı Education and Research Hospital, Istanbul, Turkey
| | - Tufan Tükek
- Istanbul University Faculty of Medicine, Istanbul, Turkey
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Seronegative Arthritis and Whipple Disease: Risk of Misdiagnosis in the Era of Biologic Agents. Case Rep Rheumatol 2019; 2019:3410468. [PMID: 31737398 PMCID: PMC6815603 DOI: 10.1155/2019/3410468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/06/2019] [Accepted: 09/11/2019] [Indexed: 12/17/2022] Open
Abstract
We report 2 cases of Whipple disease (WD), previously diagnosed as seronegative polyarthritis and treated for several years with immunosuppressive agents, accordingly. Both cases had been treated over years with cDMARDs and bDMARDs. The first patient was a 48-year-old male, who developed a life-threatening disease characterized by fever, significant weight loss, and bloody diarrhoea, supported with RBC transfusions. The second patient was a 55-year-old man, presenting with arthritis, fever, serositis, lymphadenopathy, thoracic rash, and systemic inflammation; at the beginning he was diagnosed as adult onset Still's disease. He was treated with steroids and antitumour necrosis factor agents, but showed no improvement. Both patients were eventually treated with antimicrobial therapy for WD with dramatic improvement and no clinical relapse in 6 months. This paper reviews the literature on WD mimicking chronic inflammatory arthritis. WD may lead to chronic seronegative arthritis that might often be misrecognized. Importantly, patients treated with bDMARDs and glucocorticoids might develop a life-threatening disease. Therefore, WD should be suspected and excluded in patients showing resistance or frequent recurrence of chronic arthritis, if seronegative, under treatment with bDMARDs, especially in the presence of new, unexpected sign and/or symptoms.
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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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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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Wylezinski LS, Gray JD, Polk JB, Harmata AJ, Spurlock CF. Illuminating an Invisible Epidemic: A Systemic Review of the Clinical and Economic Benefits of Early Diagnosis and Treatment in Inflammatory Disease and Related Syndromes. J Clin Med 2019; 8:E493. [PMID: 30979036 PMCID: PMC6518102 DOI: 10.3390/jcm8040493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 12/12/2022] Open
Abstract
Healthcare expenditures in the United States are growing at an alarming level with the Centers for Medicare and Medicaid Services (CMS) projecting that they will reach $5.7 trillion per year by 2026. Inflammatory diseases and related syndromes are growing in prevalence among Western societies. This growing population that affects close to 60 million people in the U.S. places a significant burden on the healthcare system. Characterized by relatively slow development, these diseases and syndromes prove challenging to diagnose, leading to delayed treatment against the backdrop of inevitable disability progression. Patients require healthcare attention but are initially hidden from clinician's view by the seemingly generalized, non-specific symptoms. It is imperative to identify and manage these underlying conditions to slow disease progression and reduce the likelihood that costly comorbidities will develop. Enhanced diagnostic criteria coupled with additional technological innovation to identify inflammatory conditions earlier is necessary and in the best interest of all healthcare stakeholders. The current total cost to the U.S. healthcare system is at least $90B dollars annually. Through unique analysis of financial cost drivers, this review identifies opportunities to improve clinical outcomes and help control these disease-related costs by 20% or more.
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Affiliation(s)
- Lukasz S Wylezinski
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- IQuity, Inc., Nashville, TN 37203, USA.
| | | | | | | | - Charles F Spurlock
- Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN 37232, USA.
- IQuity, Inc., Nashville, TN 37203, USA.
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Melenotte C, Drancourt M, Gorvel JP, Mège JL, Raoult D. Post-bacterial infection chronic fatigue syndrome is not a latent infection. Med Mal Infect 2019; 49:140-149. [DOI: 10.1016/j.medmal.2019.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 01/15/2019] [Indexed: 01/20/2023]
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40
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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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Krusche M, Boro D, Bertolini J, Kötter I. [Rare erosive arthritis and dermatitis syndrome in Whipple's disease]. Z Rheumatol 2019; 78:180-182. [PMID: 30719572 DOI: 10.1007/s00393-019-0602-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Whipple's disease is a rare infectious disease, which can affect various organ systems. Arthritis is a common symptom and therefore the infection is often misdiagnosed as seronegative rheumatoid arthritis. In rare cases an infection with Tropheryma whipplei can also cause skin lesions, such as subcutaneous nodules, erythema nodosum or vasculitis. This article reports the case of a 77-year-old female patient with erosive joint changes, persistently elevated serological inflammation markers and recurrent ulcerative lesions of the lower extremities, which were initially misdiagnosed as rheumatoid vasculitis. In cases of a clinically suspected infection with Tropheryma whipplei an early biopsy of the affected organ system is essential for the diagnosis.
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Affiliation(s)
- M Krusche
- Rheumatologie, Immunologie, Nephrologie, AK Altona, Paul-Ehrlich-Str. 1, 22763, Hamburg, Deutschland.
| | - D Boro
- Rheumatologie, Immunologie, Nephrologie, AK Altona, Paul-Ehrlich-Str. 1, 22763, Hamburg, Deutschland
| | - J Bertolini
- Hanse Histologikum - Institut für Pathologie, Paul-Ehrlich-Str. 1, 22763, Hamburg, Deutschland
| | - I Kötter
- Rheumatologie, Immunologie, Nephrologie, AK Altona, Paul-Ehrlich-Str. 1, 22763, Hamburg, Deutschland
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42
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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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43
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Bally JF, Méneret A, Roze E, Anderson M, Grabli D, Lang AE. Systematic review of movement disorders and oculomotor abnormalities in Whipple's disease. Mov Disord 2018; 33:1700-1711. [DOI: 10.1002/mds.27419] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 03/20/2018] [Accepted: 03/25/2018] [Indexed: 12/19/2022] Open
Affiliation(s)
- Julien F. Bally
- Movement Disorders Research Center, Toront Western Hospital; Toronto Ontario Canada
- Department of Neurology; University Hospitals of Geneva; Geneva Switzerland
| | - Aurélie Méneret
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Neurologie; Paris France
| | - Emmanuel Roze
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Neurologie; Paris France
| | - Melanie Anderson
- Library and Information Services; University Health Network; Toronto Ontario Canada
| | - David Grabli
- AP-HP, Hôpital de la Pitié-Salpêtrière, Département de Neurologie; Paris France
| | - Anthony E. Lang
- Movement Disorders Research Center, Toront Western Hospital; Toronto Ontario Canada
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44
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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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45
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Isolated Knee Arthritis as Early and Only Symptom of Whipple's Disease. Case Rep Med 2018; 2018:3417934. [PMID: 29977302 PMCID: PMC5994299 DOI: 10.1155/2018/3417934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 04/18/2018] [Accepted: 05/07/2018] [Indexed: 12/17/2022] Open
Abstract
We report a case of isolated Whipple's disease involving the knee of a 64-year-old female patient who presented recurrent monoarthritis whose origin was not clear. Initially, the cause of the gradually invalidating symptoms was related to a meniscal lesion and a diffuse minor grade chondropathy, but pain and functional impairment suggested that more exams were needed. Biopsies were performed during arthroscopy. The histology showed highly inflammatory infiltrates with PAS staining negative for Tropheryma while PCR revealed the infection with Tropheryma whipplei. This, following the recommendation of a rheumatologist and infectious disease specialist, led to biopsies of the gastrointestinal tract and analysis of the cerebrospinal fluid that showed no other organ involvement. This confirms the scientific literature that an isolated monoarthritis without involvement of the gastrointestinal tract caused by this bacterium is rare but can occur as an early manifestation of potentially fatal systemic disease. Moreover, a review of the scientific literature showed the uncertainty about epidemiology of this rare disease, suggesting that more and specific data are required.
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46
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Secondary immune thrombocytopenia (ITP) as an initial presentation of Whipple's disease. IDCases 2018; 12:e4-e6. [PMID: 29942787 PMCID: PMC6010930 DOI: 10.1016/j.idcr.2017.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 05/12/2017] [Indexed: 11/28/2022] Open
Abstract
Immune thrombocytopenia (ITP) is a heterogeneous autoimmune disease characterized by low platelet count that has been associated with a number of chronic infections but rarely described as a manifestation of Whipple’s disease (WD). We present a case of Whipple’s disease in a patient initially diagnosed with ITP. A 46-year old male in the fifth decade of life presented with presumed idiopathic ITP and was treated with several therapies including corticosteroids, rituximab, and thrombopoietin receptor agonists. Several years later, he developed weight loss and worsening arthralgias. He was found to have evidence of WD in a jejunal lymph node, the duodenum, and the cerebral spinal fluid (CSF). His diagnosis of WD, as a cause of secondary ITP, came a full 8 years after he was discovered to have thrombocytopenia and over 4 years after he was diagnosed with ITP. WD is an uncommon, multiorgan system disease caused by the actinomycete Tropheryma whipplei. Whipple’s disease presents a diagnostic challenge due to the wide array of possible presenting clinical manifestations, as well as a prolonged time course with separation of symptoms over many years. While T. whipplei is ubiquitous in the environment, few individuals develop clinical disease, raising the prospect that select immunodeficiencies, both singular or in combination, may play a role in infection. While rare, in the appropriate clinical setting, one should consider infection with T. whipplei in addition to other chronic infections as a cause of secondary ITP regardless of how long ago the diagnosis of ITP was made.
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47
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Glaser C, Rieg S, Wiech T, Scholz C, Endres D, Stich O, Hasselblatt P, Geißdörfer W, Bogdan C, Serr A, Häcker G, Voll RE, Thiel J, Venhoff N. Whipple's disease mimicking rheumatoid arthritis can cause misdiagnosis and treatment failure. Orphanet J Rare Dis 2017; 12:99. [PMID: 28545554 PMCID: PMC5445468 DOI: 10.1186/s13023-017-0630-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/11/2017] [Indexed: 12/18/2022] Open
Abstract
Background Whipple’s disease, a rare chronic infectious disorder caused by Tropheryma whipplei, may present with predominant joint manifestations mimicking rheumatoid arthritis (RA). Methods A retrospective single-center cohort study of seven patients was performed. Clinical symptoms were assessed by review of medical charts and Whipple’s disease was diagnosed by periodic-acid-Schiff-stain and/or Tropheryma whipplei-specific polymerase-chain-reaction. Results Median age at disease onset was 54 years, six patients were male. Median time to diagnosis was 5 years. All patients presented with polyarthritis with a predominantly symmetric pattern. Three had erosive arthritis. Affected joints were: wrists (5/7), metacarpophalangeal joints (MCPs) (5/7), knees (5/7), proximal interphalangeal joints (PIPs) (3/7), hips (2/7), elbow (2/7), shoulder (2/7). All patients had increased C-reactive-protein concentrations, while rheumatoid factor and anti-CCP-antibodies were absent, and were initially (mis)classified as RA-patients according to EULAR/ACR-criteria (median DAS28 4.3). Six patients received antirheumatic treatment consisting of prednisone with methotrexate and/or leflunomide, three were additionally treated with at least one biologic agent (abatacept, adalimumab, etanercept, rituximab, tocilizumab). Most patients showed insufficient treatment response. In all patients Tropheryma whipplei was detected in synovial fluid by polymerase-chain-reaction; in three patients the diagnosis of Whipple’s disease was further ascertained by periodic-acid-Schiff-staining. Gastrointestinal symptoms and other extra-articular manifestations were absent, mild or non-specific. Treatment was initiated with trimethoprin/sulfamethoxazole in five and doxycycline/hydroxychloroquine in two patients and had to be adapted in five patients. Finally, all patients had good treatment responses with improvement of arthritis and extra-articular manifestations. Conclusion Whipple’s disease is rare and can mimic rheumatoid arthritis. Especially patients with seronegative rheumatoid arthritis with a prolonged disease course and insufficient treatment response should be reevaluated for Whipple’s disease.
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Affiliation(s)
- Cornelia Glaser
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Siegbert Rieg
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, Faculty of Medicine, University Hospital Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Thorsten Wiech
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg, Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christine Scholz
- Private Practice for Rheumatology, Bertoldstraße 8, 79098, Freiburg, Germany
| | - Dominique Endres
- Section of Experimental Neuropsychiatry, Department of Psychiatry, Faculty of Medicine, University of Freiburg, Hauptstraße 5, 79104, Freiburg, Germany
| | - Oliver Stich
- Department of Neurology, Medical Center, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Peter Hasselblatt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, Faculty of Medicine, University Hospital Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Walter Geißdörfer
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3-5, 91054, Erlangen, Germany
| | - Christian Bogdan
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3-5, 91054, Erlangen, Germany
| | - Annerose Serr
- Institute for Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Hermann-Herder-Str. 11, 79104, Freiburg, Germany
| | - Georg Häcker
- Institute for Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Hermann-Herder-Str. 11, 79104, Freiburg, Germany
| | - Reinhard E Voll
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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Vindigni SM, Taylor J, Quilter LAS, Hyun TS, Liu C, Rosinski SL, Rakita RM, Fredricks DN, Damman CJ. Tropheryma whipplei infection (Whipple's disease) in a patient after liver transplantation. Transpl Infect Dis 2016; 18:617-24. [PMID: 27258480 DOI: 10.1111/tid.12562] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Revised: 02/05/2016] [Accepted: 04/03/2016] [Indexed: 01/01/2023]
Abstract
Whipple's disease (WD) is a rare infection caused by the bacterium Tropheryma whipplei that can affect multiple organs and most commonly occurs in the immunocompetent host. Only 3 cases of WD have been reported in the setting of immunosuppression for organ transplantation. Here, we report the first case of WD, to our knowledge, in a patient after liver transplantation with comorbid graft-versus-host-disease. We discuss the diagnostic challenges in this setting and the value of electron microscopy and in situ hybridization methods for confirming the infection. WD may be under-diagnosed in immunosuppressed transplant patients because the disease can present with atypical clinical and histological features that suggest other conditions.
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Affiliation(s)
- S M Vindigni
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - J Taylor
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - L A S Quilter
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - T S Hyun
- Department of Pathology, University of Washington, Seattle, Washington, USA.,Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - C Liu
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - S L Rosinski
- Seattle Cancer Care Alliance, Seattle, Washington, USA
| | - R M Rakita
- Division of Allergy and Infectious Diseases, Department of Medicine, University of Washington, Seattle, Washington, USA
| | - D N Fredricks
- Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
| | - C J Damman
- Division of Gastroenterology, Department of Medicine, University of Washington, Seattle, Washington, USA.,Gastroenterology/Hepatology Section, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
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49
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Marth T, Moos V, Müller C, Biagi F, Schneider T. Tropheryma whipplei infection and Whipple's disease. THE LANCET. INFECTIOUS DISEASES 2016; 16:e13-22. [PMID: 26856775 DOI: 10.1016/s1473-3099(15)00537-x] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 12/01/2015] [Accepted: 12/11/2015] [Indexed: 12/12/2022]
Abstract
Recent advances in medical microbiology, epidemiology, cellular biology, and the availability of an expanded set of diagnostic methods such as histopathology, immunohistochemistry, PCR, and bacterial culture have improved our understanding of the clinical range and natural course of Tropheryma whipplei infection and Whipple's disease. Interdisciplinary and transnational research activities have contributed to the clarification of the pathogenesis of the disorder and have enabled controlled trials of different treatment strategies. We summarise the current knowledge and new findings relating to T whipplei infection and Whipple's disease.
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Affiliation(s)
- Thomas Marth
- Division of Internal Medicine, Krankenhaus Maria Hilf, Daun, Germany.
| | - Verena Moos
- Charité-University Medicine Berlin, Campus Benjamin Franklin, Division of Infectious Diseases, Berlin, Germany
| | - Christian Müller
- University Clinic of Internal Medicine III, Allgemeines Krankenhaus Vienna, Vienna, Austria
| | - Federico Biagi
- First Department of Internal Medicine, IRCCS Foundation Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Thomas Schneider
- Charité-University Medicine Berlin, Campus Benjamin Franklin, Division of Infectious Diseases, Berlin, Germany
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50
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Alozie A, Zimpfer A, Köller K, Westphal B, Obliers A, Erbersdobler A, Steinhoff G, Podbielski A. Arthralgia and blood culture-negative endocarditis in middle Age Men suggest tropheryma whipplei infection: report of two cases and review of the literature. BMC Infect Dis 2015; 15:339. [PMID: 26282628 PMCID: PMC4539700 DOI: 10.1186/s12879-015-1078-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Accepted: 07/31/2015] [Indexed: 11/22/2022] Open
Abstract
Background Whipple’s disease is a rare, often multisystemic chronic infectious disease caused by the rod-shaped bacterium Tropheryma whipplei. Very rarely the heart is involved in the process of the disease, leading to culture-negative infective endocarditis. Up to 20 % of all infective endocarditis are blood culture-negative and therefore a diagnostic challenge. We present two unusual cases of culture-negative infective endocarditis encountered in two different patients with prior history of arthralgia. A history of rheumatic arthritis or even a transient arthralgia should put Tropheryma whipplei on the top of differentials in patients of this age group presenting with culture-negative infective endocarditis, especially in cases of therapy resistance to antirheumatic agents. Case presentation The first patient was a 55 year-old Caucasian male with culture-negative Whipple-related adhesive pericarditis and endocarditis of the aortic valve. Importantly, the patient reported a 15-year history of therapy resistant sero-negative migratory polyarthritis. Aortic valve endocarditis developed during treatment with tocilizumab. The second patient was a 65-year-old male patient with no prior history of the classic Whipple’s disease who presented with a culture-negative aortic valve endocarditis. His past medical history revealed episodes of transient arthralgia, which he was not treated for however, due to the self-limiting nature of the symptoms. Both patients underwent aortic valve replacement surgery. During surgery, pericardectomy was necessary in the first patient due to adhesive pericarditis. Post surgery both patients were started on long-term treatment with trimetoprim-sulfamethoxazol. At 1-year follow-up of both patients, echocardiographic and clinical assessment revealed no signs of persistent infection. Both men reported negative history of arthralgia during the one year period post surgery. Conclusion Tropheryma whipplei culture negative-infective endocarditis is an emerging clinical entity, predominantly found in middle-aged and older men with a history of arthralgia. These data highlight the need for ruling out Whipple’s disease in patients with a history of arthralgia prior to initiation of biological agents in treatment of rheumatoid arthritis. There is also a need to assess for Tropheryma whipplei in all patients with culture- negative infective endocarditis.
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Affiliation(s)
- Anthony Alozie
- Department of Cardiac Surgery, University Hospital Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Annette Zimpfer
- Institute of Pathology, University Hospital Rostock, Strempelstr. 14, 18055, Rostock, Germany.
| | - Kerstin Köller
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Rostock, Schillingallee 70, 18055, Rostock, Germany.
| | - Bernd Westphal
- Department of Cardiac Surgery, University Hospital Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Annette Obliers
- Institute of Pathology, University Hospital Rostock, Strempelstr. 14, 18055, Rostock, Germany.
| | - Andreas Erbersdobler
- Institute of Pathology, University Hospital Rostock, Strempelstr. 14, 18055, Rostock, Germany.
| | - Gustav Steinhoff
- Department of Cardiac Surgery, University Hospital Rostock, Schillingallee 35, 18057, Rostock, Germany.
| | - Andreas Podbielski
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Rostock, Schillingallee 70, 18055, Rostock, Germany.
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