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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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Mecklenburg J, Moos V, Moter A, Siebert E, Nave AH, Schneider T, Ruprecht K, Euskirchen P. The spectrum of central nervous system involvement in Whipple's disease. Eur J Neurol 2023; 30:3417-3429. [PMID: 35852414 DOI: 10.1111/ene.15511] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE To assess the clinical spectrum of central nervous system (CNS) involvement as well as cerebrospinal fluid (CSF) and neuroimaging findings in patients with Whipple's disease (WD) and to analyze the association of neurological symptoms with CSF and imaging findings. METHODS Neurological involvement was retrospectively analyzed in a series of 36 patients diagnosed with WD at a single center between 1992 and 2019. Findings of 81 comprehensive CSF examinations from 36 patients, including polymerase chain reaction (PCR) tests for Tropheryma whipplei (TW) in CSF from 35 patients, were systematically evaluated. The prevalence of ischemic stroke in patients with WD was compared to a matched control cohort. RESULTS Neurological symptoms occurred in 23 of 36 (63.9%) patients, with cognitive, motor, and oculomotor dysfunction being most frequent. TW was detected by PCR in CSF of 13 of 22 (59.1%) patients with and four of 13 (30.8%, p = 0.0496) patients without neurological symptoms. Total CSF protein (p = 0.044) and lactate (p = 0.035) were moderately elevated in WD with neurologic symptoms compared with WD without. No intrathecal immunoglobulin synthesis was observed. Three of 36 (8.3%) patients had hydrocephalus due to aqueductal stenosis. Patients with WD had an unexpectedly high prevalence of ischemic stroke (10/36, 27.7%) compared to matched controls (10/360, 3.2%). CONCLUSIONS Neurological involvement in patients with WD is common. Detection of TW DNA in CSF is only partly associated with neurological symptoms. Elevated CSF parameters suggest CNS parenchymal infection. Stroke is a hitherto underrecognized manifestation of WD. These findings suggest that mechanisms beyond CNS infection contribute to the spectrum of CNS involvement in WD.
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Affiliation(s)
- Jasper Mecklenburg
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Verena Moos
- Medical Department of Gastroenterology, Rheumatology and Infectious Diseases, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Annette Moter
- Institute for Microbiology, Infectious Diseases and Immunology, Biofilmcenter, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- MoKi Analytics and Moter Diagnostics, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Alexander Heinrich Nave
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Berlin, Germany
- Deutsches Zentrum für Herz-Kreislauferkrankungen (DZHK), Partner Site Berlin, Berlin, Germany
| | - Thomas Schneider
- Medical Department of Gastroenterology, Rheumatology and Infectious Diseases, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Klemens Ruprecht
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Philipp Euskirchen
- Department of Neurology, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Song X, Duan R, Duan L, Wei L. Current knowledge of the immune reconstitution inflammatory syndrome in Whipple disease: a review. Front Immunol 2023; 14:1265414. [PMID: 37901208 PMCID: PMC10611461 DOI: 10.3389/fimmu.2023.1265414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 09/25/2023] [Indexed: 10/31/2023] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by exaggerated and dysregulated inflammatory responses that occur as a result of reconstitution of adaptive or innate immunity. A wide range of microorganisms have been found to be associated with IRIS, such as human immunodeficiency virus (HIV), Mycobacterium and actinobacteria. Whipple disease (WD) is an infectious disorder caused by the Gram-positive bacterium Tropheryma whipplei (T. whipplei) and IRIS also serves as a complication during its treament. Although many of these pathological mechanisms are shared with related inflammatory disorders, IRIS in WD exhibits distinct features and is poorly described in the medical literature. Novel investigations of the intestinal mucosal immune system have provided new insights into the pathogenesis of IRIS, elucidating the interplay between systemic and local immune responses. These insights may be used to identify monitoring tools for disease prevention and to develop treatment strategies. Therefore, this review synthesizes these new concepts in WD IRIS to approach the feasibility of manipulating host immunity and immune reconstitution of inflammatory syndromes from a newer, more comprehensive perspective and study hypothetical options for the management of WD IRIS.
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Affiliation(s)
| | | | | | - Lijuan Wei
- Department of Gastroenterology and Digestive Endoscopy Center, The Second Hospital of Jilin University, Chang Chun, Jilin, China
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[Massive pancarditis-autopsy report]. PATHOLOGIE (HEIDELBERG, GERMANY) 2023; 44:132-138. [PMID: 36592174 PMCID: PMC9807089 DOI: 10.1007/s00292-022-01170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 11/28/2022] [Indexed: 01/03/2023]
Abstract
We report on a 69-year-old man suffering from chronic progressive oligoarthritis (localized in metacarpal and knee joints), which clinically was interpreted as steroid-sensitive seronegative chronic arthritis. The patient died from sudden death at the emergency department after a 4-week history of increasing cough and dyspnea (meanwhile obtaining negative testing results for SARS-CoV-2). During the autopsy, we found massive pancarditis affecting all cardiac compartments, in particular exhibiting constrictive pericarditis, myocarditis, and multivalvular endocarditis. Microscopically, interstitial myocarditis could be observed. Performing extensive molecular analyses, we detected Tropheryma whipplei in the tissue specimens of the heart, but not in various duodenal tissue probes or in the synovial membrane. Taken together, in the present case the cause of death was acute cardiac failure due to multivalvular pancarditis due to T. whipplei. Besides from classical symptoms and morphological signs, Whipple's disease may present with various features. Regarding the differential diagnosis of a chronic multisystem disorder with aspects of hitherto unknown arthralgia, Whipple's disease should be considered.
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Ahmad AI, Wikholm C, Pothoulakis I, Caplan C, Lee A, Buchanan F, Kyoo Cho W. Whipple's disease review, prevalence, mortality, and characteristics in the United States: A cross-sectional national inpatient study. Medicine (Baltimore) 2022; 101:e32231. [PMID: 36626499 PMCID: PMC9750640 DOI: 10.1097/md.0000000000032231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Whipple's disease is a rare multiorgan systemic disease caused by Tropheryma whipplei infection that may present with a wide range of signs and symptoms. This study aim to comprehensively review and determine the inpatient prevalence, mortality, risk factors, and reasons for hospitalization of patients with Whipple's disease. ICD-10 codes were used to identify admissions with Whipple's disease during the years 2016 to 2018. Characteristics of admissions with and without Whipple's disease were compared. The most common reasons for hospitalization were identified in admissions with Whipple's disease. The prevalence of Whipple's disease was 4.6 per 1 million hospitalizations during the study period. Whipple's disease admissions were significantly older than other hospitalizations, with a mean age of 60.2 ± 1.6 years compared to 50.0 ± 0.1. Males were more likely to have Whipple's disease and represented approximately two-thirds of hospitalizations. A disproportionate number of admissions occurred in the Midwest. Patients with Whipple's disease were most commonly admitted for gastrointestinal disease, followed by systemic infection, cardiovascular/circulatory disease, musculoskeletal disease, respiratory disease, and neurological disease. High mortality was seen in admissions for central nervous system (CNS) disease. Whipple's disease has heterogeneous presentations for inpatient admissions, and disproportionately affects older males. High hospitalization rates in the Midwest support environmental and occupational disease transmission likely from the soil. Hospitalists should be aware of the various acute, subacute, and chronic presentations of this disease, and that acute presentations may be more common in the inpatient setting.
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Affiliation(s)
- Akram I. Ahmad
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
| | - Colin Wikholm
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Ioannis Pothoulakis
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
| | - Claire Caplan
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Arielle Lee
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Faith Buchanan
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
| | - Won Kyoo Cho
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, D.C., USA
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He YT, Peterson K, Crothers J, Dejace J, Hale AJ. Endocarditis and systemic embolization from Whipple's disease. IDCases 2021; 24:e01105. [PMID: 33868927 PMCID: PMC8047165 DOI: 10.1016/j.idcr.2021.e01105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/29/2021] [Accepted: 03/29/2021] [Indexed: 11/20/2022] Open
Abstract
Whipple’s disease (WD), caused by infection with the organism Tropheryma whipplei, is a rare disease that classically presents with diarrhea, weight loss, and polyarthralgia. Less commonly, Whipple’s Disease can presentation with endocarditis or neurologic infections. The authors report a patient with Whipple’s Disease endocarditis whose initial presentation was acute lower extremity arterial occlusion, and review current literature regarding the epidemiology, diagnosis, treatment, and prognosis of Whipple’s Disease endocarditis.
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Affiliation(s)
- Yu Ting He
- University of Vermont Medical Center, Burlington, VT, United States
| | | | - Jessica Crothers
- University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Jean Dejace
- University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
| | - Andrew J. Hale
- University of Vermont Medical Center, Larner College of Medicine at the University of Vermont, Burlington, VT, United States
- Corresponding author at: University of Vermont Medical Center, Infectious Disease Unit, 111 Colchester Avenue, Mailstop 115 SM2, Burlington, VT 05401, United States.
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Refractory Effusions, Crumbly Bones, Mystifying Cachexia and an Absent Mind: An Unusual Presentation of Whipple's Disease with Review of Literature. AMERICAN JOURNAL OF MEDICAL CASE REPORTS 2021; 9:348-353. [PMID: 33884291 PMCID: PMC8057725 DOI: 10.12691/ajmcr-9-7-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Whipple's disease is a bacterial infection caused by Tropheryma whipplei and is known to cause perplexing clinical presentations, making its diagnosis challenging. The beginning by the involvement of the gastrointestinal tract, Whipple's disease can slowly progress to affect almost any organ system and lead to chronic multi-system inflammatory disease. Hereby, we present a middle age man who initially manifested with shortness of breath and chronic weight loss. He subsequently developed pleuro-pericardial effusion, ascites, mesenteric lymphadenopathy, possible myocarditis, and severe osteopenia with multiple vertebral fractures during his illness. Esophagogastroduodenoscopy with the biopsy and subsequent molecular confirmation of disease led to the confirmation of WD. Therapeutic management included two separate antibiotic regimens in an attempt to address the refractory course of WD in this patient.
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