1
|
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.
Collapse
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
| |
Collapse
|
2
|
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.
Collapse
Affiliation(s)
| | | | | | - Lijuan Wei
- Department of Gastroenterology and Digestive Endoscopy Center, The Second Hospital of Jilin University, Chang Chun, Jilin, China
| |
Collapse
|
3
|
Gregorio V, Albrizio A, Maimaris S, Scalvini D, Scarcella C, Cambieri P, Biagi F, Schiepatti A. Clinical and laboratory predictors and prevalence of immune reconstitution inflammatory syndrome in patients with Whipple's disease. J Dig Dis 2023; 24:516-521. [PMID: 37616045 DOI: 10.1111/1751-2980.13223] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/01/2023] [Accepted: 08/22/2023] [Indexed: 08/25/2023]
Abstract
OBJECTIVES Whipple's disease (WD) is a rare and potentially fatal infectious disease caused by Tropheryma whipplei. It is characterized by a long prodromal phase that mimics a rheumatological disease, often leading to immunosuppressant treatment. Immune reconstitution inflammatory syndrome (IRIS) is currently the most important complication of WD, requiring prompt recognition and treatment as it can be fatal. However, epidemiological data on IRIS are scarce. We aimed to identify the clinical and laboratory predictors of IRIS at WD diagnosis and to evaluate whether the prevalence of IRIS has changed over time. METHODS Forty-five patients with WD (mean age 52 ± 11 years; 10 females) were followed up between January 2000 and December 2021. Clinical and laboratory data at WD diagnosis were retrospectively collected and compared among patients who developed IRIS and those who did not. RESULTS Erythrocyte sedimentation rate (ESR; 33.4 ± 11.8 mm/h vs 67.1 ± 26.3 mm/h, P < 0.01), platelet (PLT; 234 × 109 /L vs 363 × 109 /L, P < 0.01), and body mass index (22.0 ± 2.0 kg/m2 vs 19.8 ± 3.0 kg/m2 , P = 0.04) differed significantly between patients who subsequently developed IRIS and those who did not. ROC analysis identified ESR ≤46 mm/h (AUROC 0.88, 95% CI 0.72-1.00) and PLT ≤ 327 × 109 /L (AUROC 0.85, 95% CI 0.70-1.00) as optimal cut-off values to discriminate WD patients at a high risk of developing IRIS. Prevalence of IRIS remained stable (22.2%) over time. CONCLUSIONS Low ESR and PLT count at diagnosis help identify WD patients at high risk of developing IRIS. Instead, a greater inflammatory response suggests a lower risk of IRIS. Prevalence of IRIS did not change over two decades.
Collapse
Affiliation(s)
- Virginia Gregorio
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Alessandra Albrizio
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Stiliano Maimaris
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Davide Scalvini
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Chiara Scarcella
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
| | - Patrizia Cambieri
- Department of Microbiology & Virology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Federico Biagi
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| | - Annalisa Schiepatti
- Department of Internal Medicine and Therapeutics, University of Pavia, Pavia, Italy
- Istituti Clinici Scientifici Maugeri, IRCCS, Gastroenterology Unit of Pavia Institute, Pavia, Italy
| |
Collapse
|
4
|
Weber M, Dancygier H, Blasberg T, Wedi E. [Co-occurrence of Whipple's disease and hyperparathyroidism - coincidence or causal relationship?]. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1214-1220. [PMID: 37309099 DOI: 10.1055/a-1984-0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Whipple's disease is a rare infectious disease with multiple clinical manifestations. The disease is named after George Hoyt Whipple, who first recorded the illness in 1907 after conducting the autopsy of a 36-year-old man with weight loss, diarrhea, and arthritis. Under the microscope, Whipple discovered a rod-shaped bacterium in the patient's intestinal wall, which was not confirmed as a new bacterial species until 1992, when it was named Tropheryma whipplei.Recurrence of Whipple's disease can occur years after an initial diagnosis and often manifests with extraintestinal symptoms such as arthritides or skin efflorescences, years before a gastrointestinal complaint. However, the simultaneous occurrence of primary hyperparathyroidism in the present case is a hitherto unknown clinical picture and opens up new questions and perspectives in the context of diagnostics and therapy.
Collapse
Affiliation(s)
- Marie Weber
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| | | | - Tobias Blasberg
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| | - Edris Wedi
- Abteilung für Gastroenterologie, Gastrointestinale Onkologie und Interventionelle Endoskopie, Sana Klinikum Offenbach GmbH, Offenbach, Germany
| |
Collapse
|
5
|
Ye H, Hu X, Tong TRSW, Chen S, Li T, Xing F, Chan JFW, Yuen KY, Chiu KHY. Whipple's disease presenting as weight gain and constipation in a Chinese woman. BMC Infect Dis 2023; 23:302. [PMID: 37158848 PMCID: PMC10165756 DOI: 10.1186/s12879-023-08276-y] [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: 02/09/2023] [Accepted: 04/24/2023] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Whipple's disease is a chronic infection due to Tropheryma whipplei, commonly reported in the Caucasian but not in the Chinese population. CASE PRESENTATION A 52-year-old female with good past health, was diagnosed with Whipple's disease, presenting with constipation, unintentional weight gain, and fleeting polyarthralgia. Investigations prior to admission showed raised CA125 and computed tomography of the abdomen showed multiple retroperitoneal mesenteric lymphadenopathies. Extensive investigations performed on secondary causes of weight gain were unrevealing. Subsequent PET-CT scan revealed generalized lymphadenopathy involving the left deep cervical, supraclavicular, and retroperitoneal mesenteric area. Excisional biopsy of the left supraclavicular lymph node was performed, with histology showing infiltrations of Periodic acid-Schiff positive foamy macrophages. T. whipplei DNA was detected in her serum, saliva, stool, and lymph node by PCR targeting the 16S ribosomal RNA gene. She was started on intravenous ceftriaxone, and then stepped down to oral antibiotics for a total of 44 months. The recurrence of fever after 12 days of ceftriaxone raised the suspicion of Immune Reconstitution Inflammatory Syndrome (IRIS). Serial imaging showed a gradual reduction in the size of retroperitoneal lymphadenopathies. Literature review on Whipple's disease in the Chinese population identified 13 reports of detectable T. whipplei DNA in clinical specimens. The majority of the cases were pneumonia, followed by culture-negative endocarditis, encephalitis, and skin and soft tissue infection. However, most patients with pneumonia were diagnosed based on next generation sequencing alone, with the resolution of pulmonary infiltrates without adequate duration of antibiotics, suggesting the possibility of colonization instead of infection. The recommendation of long-term doxycycline suppression after treatment may be supported by the slow response of retroperitoneal lymphadenopathies to antibiotics in our patient. CONCLUSIONS Unintentional weight gain and constipation could be atypical presentations of Whipple's disease. It is a rare disease in the Chinese population despite the advancement of molecular techniques in the diagnosis of infections. A prolonged course of antibiotics may be required due to slow clinical response as documented by serial imaging in our case. The possibility of IRIS should be considered in patients with breakthrough fever during treatment of Whipple's disease.
Collapse
Affiliation(s)
- Haiyan Ye
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Xiao Hu
- Department of Respiratory Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | | | - Shuang Chen
- Department of Pathology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Tao Li
- Department of Radiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Fanfan Xing
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
| | - Jasper Fuk-Woo Chan
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Carol Yu Centre for Infection, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kwok-Yung Yuen
- Department of Infectious Diseases and Microbiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, Guangdong, China
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China
- State Key Laboratory of Emerging Infectious Diseases, Department of Microbiology, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, Carol Yu Centre for Infection, The University of Hong Kong, Pokfulam, Hong Kong Special Administrative Region, China
| | - Kelvin Hei-Yeung Chiu
- Department of Microbiology, Queen Mary Hospital, Pokfulam, Hong Kong Special Administrative Region, China.
| |
Collapse
|
6
|
Friebel J, Schinnerling K, Weigt K, Heldt C, Fromm A, Bojarski C, Siegmund B, Epple HJ, Kikhney J, Moter A, Schneider T, Schulzke JD, Moos V, Schumann M. Uptake of Tropheryma whipplei by Intestinal Epithelia. Int J Mol Sci 2023; 24:ijms24076197. [PMID: 37047170 PMCID: PMC10094206 DOI: 10.3390/ijms24076197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 03/18/2023] [Accepted: 03/21/2023] [Indexed: 03/29/2023] Open
Abstract
Background: Tropheryma whipplei (TW) can cause different pathologies, e.g., Whipple’s disease and transient gastroenteritis. The mechanism by which the bacteria pass the intestinal epithelial barrier, and the mechanism of TW-induced gastroenteritis are currently unknown. Methods: Using ex vivo disease models comprising human duodenal mucosa exposed to TW in Ussing chambers, various intestinal epithelial cell (IEC) cultures exposed to TW and a macrophage/IEC coculture model served to characterize endocytic uptake mechanisms and barrier function. Results: TW exposed ex vivo to human small intestinal mucosae is capable of autonomously entering IECs, thereby invading the mucosa. Using dominant-negative mutants, TW uptake was shown to be dynamin- and caveolin-dependent but independent of clathrin-mediated endocytosis. Complementary inhibitor experiments suggested a role for the activation of the Ras/Rac1 pathway and actin polymerization. TW-invaded IECs underwent apoptosis, thereby causing an epithelial barrier defect, and were subsequently subject to phagocytosis by macrophages. Conclusions: TW enters epithelia via an actin-, dynamin-, caveolin-, and Ras-Rac1-dependent endocytosis mechanism and consecutively causes IEC apoptosis primarily in IECs invaded by multiple TW bacteria. This results in a barrier leak. Moreover, we propose that TW-packed IECs can be subject to phagocytic uptake by macrophages, thereby opening a potential entry point of TW into intestinal macrophages.
Collapse
Affiliation(s)
- Julian Friebel
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, 12203 Berlin, Germany
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Katina Schinnerling
- Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andrés Bello, Santiago 8370146, Chile
| | - Kathleen Weigt
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Claudia Heldt
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Anja Fromm
- Institute of Clinical Physiology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Christian Bojarski
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Britta Siegmund
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Hans-Jörg Epple
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Judith Kikhney
- Institute for Microbiology, Infectious Diseases, and Immunology, Biofilmcenter, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- MoKi Analytics GmbH, 12207 Berlin, Germany
| | - Annette Moter
- Institute for Microbiology, Infectious Diseases, and Immunology, Biofilmcenter, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- German Konsiliarlabor for Tropheryma whipplei, 10117 Berlin, Germany
- Moter Diagnostics, 12207 Berlin, Germany
| | - Thomas Schneider
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Jörg D. Schulzke
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Institute of Clinical Physiology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Verena Moos
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Michael Schumann
- Department of Gastroenterology, Infectiology and Rheumatology, Campus Benjamin Franklin, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, 10117 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-513536
| |
Collapse
|
7
|
Friebel J, Witkowski M, Wegner M, Blöbaum L, Lammel S, Schencke PA, Jakobs K, Puccini M, Reißner D, Steffens D, Moos V, Schutheiss HP, Landmesser U, Rauch U. Cytotoxic CD8 + T Cells Are Involved in the Thrombo-Inflammatory Response during First-Diagnosed Atrial Fibrillation. Cells 2022; 12:cells12010141. [PMID: 36611934 PMCID: PMC9818535 DOI: 10.3390/cells12010141] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 12/23/2022] [Accepted: 12/26/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Atrial myopathy and atrial fibrillation (AF) accompany thrombo-inflammation. This facilitates disease progression and promotes major adverse cardiovascular events (MACEs). Thrombin receptor (protease-activated receptor 1, PAR1) signalling is central in mediating thrombo-inflammation. We hypothesised that PAR1 signalling links coagulation and inflammation through cytotoxic CD8+ T lymphocytes in patients presenting with first-diagnosed AF (FDAF). METHODS A total of 210 patients were studied. We included data and blood samples from patients presenting with FDAF (n = 160), cardiac tissue from patients with paroxysmal AF (n = 32) and 20 controls. RESULTS During early AF, a pro-inflammatory and cytotoxic subset of T lymphocytes (CD8+) circulated more frequently when compared to patients with chronic cardiovascular disease but without AF, accompanied by elevated plasma levels of CD8+ effector molecules, which corresponded to biomarkers of adverse cardiac remodelling and atrial dysfunction. Activation of tissue factor (TF) and PAR1 was associated with pro-inflammatory and cytotoxic effector functions. PAR1-related CD8+ cell activation was more frequent in FDAF patients that experienced a MACE. CONCLUSIONS In patients with FDAF, the TF-factor Xa-factor IIa-axis contributes to thrombo-inflammation via PAR1 in CD8+ T cells. Intervening in this cascade might be a promising synergistic approach to reducing disease progression and the vascular complications of AF.
Collapse
Affiliation(s)
- Julian Friebel
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center, 13353 Berlin, Germany
| | - Marco Witkowski
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Department of Cardiovascular & Metabolic Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Max Wegner
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Leon Blöbaum
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Stella Lammel
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Philipp-Alexander Schencke
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Kai Jakobs
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
| | - Marianna Puccini
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Daniela Reißner
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Daniel Steffens
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
| | | | - Ulf Landmesser
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- Berlin Institute of Health at Charité—Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
| | - Ursula Rauch
- Charité Center 11—Department of Cardiology, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, 12203 Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, 10785 Berlin, Germany
- Correspondence: ; Tel.: +49-30-450-513794
| |
Collapse
|
8
|
Barbero-Aznarez P, Perez-Tanoira R, Aguirre-Mollehuanca D, Trascasa-Caño A, Fortes-Alen J, Manzarbeitia-Arrambari F, Castillo-Alvarez J, Montoya-Bordon J, Petkova-Saiz E, Prieto-Perez L. Isolated central nervous system Whipple disease. Surg Neurol Int 2022; 13:477. [DOI: 10.25259/sni_591_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/19/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Whipple disease (WD) is an infection caused by Tropheryma whipplei, which might present in three different forms: classical, localized, and isolated in the central nervous system (CNS).
Methods:
We report the result of a systematic review of the literature on WD unusually presenting with exclusively neurological symptoms, including two previously unpublished cases. A description of two cases with isolated CNS WD was performed, as well as a literature search in Cochrane, Scielo, and PubMed.
Results:
Two male adult patients presented with exclusively neurological symptomatology. Both magnetic resonance imaging (MRI) showed an intracranial mass suggestive of brain tumor. The histopathological examination was consistent with WD, with no systemic involvement. In the review of the literature, 35 cases of isolated CNS WD were retrieved. The median age at diagnosis was 43.5 (IQR 31.5–51.5). In 13 patients, the MRI showed a brain mass consistent with a brain tumor. The most common finding in the biopsy was the periodic-acid Schiff-stained foamy macrophages. Only five cases presented the pathognomonic sign of oculomasticatory myorhythmia. Thirteen cases had an adverse outcome that resulted in death during follow-up, whereas another 13 improved. The other nine patients remained stable or presented moderate improvement.
Conclusion:
Isolated CNS WD is a rare disease that should be considered among the differential diagnosis of CNS mass lesions. Brain biopsy is necessary to establish the diagnosis. It is stressed in the literature that an extended antibiotic course is required to prevent relapses and to control the disease.
Collapse
Affiliation(s)
- Pablo Barbero-Aznarez
- Department of Neurosurgery, Instituto Clavel, San Francisco De Asis University Hospital, Madrid, Spain
| | - Ramon Perez-Tanoira
- Department of Microbiology, Principe de Asturias University Hospital, Madrid, Spain
| | | | | | - Jose Fortes-Alen
- Department of Pathology, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | | | | | | | | | - Laura Prieto-Perez
- Internal Medicine, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| |
Collapse
|
9
|
Friebel J, Schinnerling K, Geelhaar‐Karsch A, Allers K, Schneider T, Moos V. Intestinal barrier dysfunction mediates Whipple's disease immune reconstitution inflammatory syndrome (IRIS). Immun Inflamm Dis 2022; 10:e622. [PMID: 35478447 PMCID: PMC9046915 DOI: 10.1002/iid3.622] [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: 02/07/2022] [Revised: 03/17/2022] [Accepted: 03/30/2022] [Indexed: 12/05/2022] Open
Abstract
Background & Aims Classical Whipple's disease (CWD) affects the gastrointestinal tract and causes chronic diarrhea, malabsorption, and barrier dysfunction with microbial translocation (MT). Immune reconstitution inflammatory syndrome (IRIS) is a serious complication during antimicrobial treatment of CWD. The pathomechanisms of IRIS have not been identified and mucosal barrier integrity has not been studied in patients with IRIS CWD. Methods In 96 CWD patients (n = 23 IRIS, n = 73 non‐IRIS) and 30 control subjects, we analysed duodenal morphology by histology, measured serum markers of MT, and proinflammatory cytokines in biopsy supernatants, and correlated microbial translocation with T cell reconstitution and activation. Results Before treatment, duodenal specimens from patients who later developed IRIS exhibited a more pronounced morphological transformation that suggested a disturbed barrier integrity when compared with the non‐IRIS group. Villous atrophy was mediated by increased apoptosis of epithelial cells, which was insufficiently counterbalanced by regenerative proliferation of crypt cells. Pretreatment deficiencies in the mucosal secretion of proinflammatory cytokines and chemokines (e.g., IL‐6, CCL2) in these patients markedly resolved after therapy induction. High serum levels of lipopolysaccharides (LPS), soluble CD14 (sCD14), and LPS‐binding protein (LBP) combined with low endotoxin core antibody (EndoCAb) titres suggested systemic MT in CWD patients developing IRIS. CD4+ T cell count and activation in IRIS CWD patients correlated positively with sCD14 levels and negatively with EndoCAb titres. Furthermore, the degree of intestinal barrier dysfunction and MT was predictive for the onset of IRIS. Conclusion Prolonged MT across a dysfunctional intestinal mucosal barrier due to severe tissue damage favors dysbalanced immune reconstitution and systemic immune activation in IRIS CWD. Therefore, the monitoring of inflammatory and MT markers in CWD patients might be helpful in identifying patients who are at risk of developing IRIS. Therapeutic strategies to reconstitute the mucosal barrier and control inflammation could assist in the prevention of IRIS.
Collapse
Affiliation(s)
- Julian Friebel
- Department of Cardiology Charité‐University Medicine Berlin Germany
- Berlin Institute of Health at Charité‐Universitätsmedizin Berlin, BIH Biomedical Innovation Academy BIH Charité Clinician Scientist Program Berlin Germany
| | - Katina Schinnerling
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Anika Geelhaar‐Karsch
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Kristina Allers
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Thomas Schneider
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology Charité‐University Medicine Berlin Germany
| |
Collapse
|
10
|
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]
|
11
|
Feurle GE, Moos V, Stroux A, Gehrmann-Sommer N, Poddubnyy D, Fiehn C, Schneider T. Differential diagnostic value of rheumatic symptoms in patients with Whipple's disease. Sci Rep 2021; 11:5980. [PMID: 33727566 PMCID: PMC7966399 DOI: 10.1038/s41598-021-85217-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 02/15/2021] [Indexed: 12/17/2022] Open
Abstract
Most patients with Whipple’s disease have rheumatic symptoms. The aim of our prospective, questionnaire-based, non-interventional clinical study was to assess whether these symptoms are useful in guiding the differential diagnosis to the rheumatic disorders. Forty patients with Whipple’s disease, followed by 20 patients for validation and 30 patients with rheumatoid-, 21 with psoriatic-, 15 with palindromic- and 25 with axial spondyloarthritis were recruited for the present investigation. Patients with Whipple’s disease and patients with rheumatic disorders were asked to record rheumatic symptoms on pseudonymized questionnaires. The data obtained were subjected to multiple logistic regression analysis. Episodic pain with rapid onset, springing from joint to joint was most common in patients with palindromic arthritis and second most common and somewhat less conspicuous in Whipple’s disease. Continuous pain in the same joints predominated in patients with rheumatoid-, psoriatic-, and axial spondyloarthritis. Multiple logistic equations resulted in a predicted probability for the diagnosis of Whipple’s disease of 43.4 ± 0.19% (M ± SD) versus a significantly lower probability of 23.8 ± 0.19% (M ± SD) in the aggregate of patients with rheumatic disorders. Mean area under the curve (AUC) ± SD was 0.781 ± 0.044, 95% CI 0.695–0.867, asymptotic significance p < 0.001. The logistic equations predicted probability for the diagnosis of Whipple’s disease in the initial series of 40 patients of 43.4 ± 0.19% was not significantly different in the subsequent 20 patients of 38.2 ± 0.28% (M ± SD) (p = 0.376). The data may be useful in a predictive algorithm for diagnosing Whipple’s disease. The project is registered as clinical study DRK S0001566.
Collapse
Affiliation(s)
- Gerhard E Feurle
- DRK Krankenhaus Neuwied, Eduard Moerikestrasse 12, 56567, Neuwied, Germany.
| | - Verena Moos
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Stroux
- Institut für Biometrie und Klinische Epidemiologie, Charité-Universitätsmedizin Berlin, Berlin Institute of Health, Berlin, Germany
| | - Nadine Gehrmann-Sommer
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Denis Poddubnyy
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Fiehn
- Praxis für Rheumatologie, Klinische Immunologie, Medical Center, Baden-Baden, Germany
| | - Thomas Schneider
- Medizinische Klinik I für Gastroenterologie, Infektiologie und Rheumatologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| |
Collapse
|
12
|
[A 3-week history of intestinal symptoms in a 67-year-old male patient with chronic arthralgia]. Internist (Berl) 2020; 62:433-440. [PMID: 33296012 DOI: 10.1007/s00108-020-00916-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
Whipple disease is an infection caused by the bacterium Tropheryma whipplei. Due to its unspecific clinical symptoms, it is difficult to diagnose and often remains undetected for a long time. The case of a patient who presented with acute intestinal symptoms to the authors' department is reported. The diagnosis of classic Whipple disease was established. The symptoms subsided under antibiotic therapy. Complications in the form of immune reconstitution inflammatory syndrome (IRIS) occurred, requiring immunosuppressive treatment.
Collapse
|
13
|
Cancio M, Ciccocioppo R, Rocco PRM, Levine BL, Bronte V, Bollard CM, Weiss D, Boelens JJ, Hanley PJ. Emerging trends in COVID-19 treatment: learning from inflammatory conditions associated with cellular therapies. Cytotherapy 2020; 22:474-481. [PMID: 32565132 PMCID: PMC7252029 DOI: 10.1016/j.jcyt.2020.04.100] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 12/18/2022]
Abstract
Coronavirus disease 2019 (SARS-CoV2) is an active global health threat for which treatments are desperately being sought. Even though most people infected experience mild to moderate respiratory symptoms and recover with supportive care, certain vulnerable hosts develop severe clinical deterioration. While several drugs are currently being investigated in clinical trials, there are currently no approved treatments or vaccines for COVID-19 and hence there is an unmet need to explore additional therapeutic options. At least three inflammatory disorders or syndromes associated with immune dysfunction have been described in the context of cellular therapy. Specifically, Cytokine Release Syndrome (CRS), Immune Reconstitution Inflammatory Syndrome (IRIS), and Secondary Hemophagocytic Lymphohistiocytosis (sHLH) all have clinical and laboratory characteristics in common with COVID19 and associated therapies that could be worth testing in the context of clinical trials. Here we discuss these diseases, their management, and potential applications of these treatment in the context of COVID-19. We also discuss current cellular therapies that are being evaluated for the treatment of COVID-19 and/or its associated symptoms.
Collapse
Affiliation(s)
- Maria Cancio
- Memorial Sloan Kettering Cancer Center, New York, New York, USA.
| | - Rachele Ciccocioppo
- Department of Medicine, A.O.U.I Policlinico G.B Rossi and University of Verona, Verona, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal university of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Bruce L Levine
- Center for Cellular Immunotherapies and Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vincenzo Bronte
- Department of Medicine, A.O.U.I Policlinico G.B Rossi and University of Verona, Verona, Italy
| | - Catherine M Bollard
- Center for Cancer and Immunology Research, Center for Cancer and Blood Disorders, Children's National Hospital and the George Washington University Cancer Center, George Washington University, Washington, DC, USA
| | - Daniel Weiss
- University of Vermont Medical Center, Burlington, Vermont, USA
| | | | - Patrick J Hanley
- Center for Cancer and Immunology Research, Center for Cancer and Blood Disorders, Children's National Hospital and the George Washington University Cancer Center, George Washington University, Washington, DC, USA
| |
Collapse
|
14
|
Moter A, Janneck M, Wolters M, Iking-Konert C, Wiessner A, Loddenkemper C, Hartleben B, Lütgehetmann M, Schmidt J, Langbehn U, Janssen S, Geelhaar-Karsch A, Schneider T, Moos V, Rohde H, Kikhney J, Wiech T. Potential Role for Urine Polymerase Chain Reaction in the Diagnosis of Whipple's Disease. Clin Infect Dis 2020; 68:1089-1097. [PMID: 30351371 PMCID: PMC6424077 DOI: 10.1093/cid/ciy664] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2018] [Accepted: 08/07/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Whipple's disease (WD) is a rare infection with Tropheryma whipplei that is fatal if untreated. Diagnosis is challenging and currently based on invasive sampling. In a case of WD diagnosed from a kidney biopsy, we observed morphologically-intact bacteria within the glomerular capsular space and tubular lumens. This raised the questions of whether renal filtration of bacteria is common in WD and whether polymerase chain reaction (PCR) testing of urine might serve as a diagnostic test for WD. METHODS We prospectively investigated urine samples of 12 newly-diagnosed and 31 treated WD patients by PCR. As controls, we investigated samples from 110 healthy volunteers and patients with excluded WD or acute gastroenteritis. RESULTS Out of 12 urine samples from independent, therapy-naive WD patients, 9 were positive for T. whipplei PCR. In 3 patients, fluorescence in situ hybridization visualized T. whipplei in urine. All control samples were negative, including those of 11 healthy carriers with T. whipplei-positive stool samples. In our study, the detection of T. whipplei in the urine of untreated patients correlated in all cases with WD. CONCLUSIONS T. whipplei is detectable by PCR in the urine of the majority of therapy-naive WD patients. With a low prevalence but far-reaching consequences upon diagnosis, invasive sampling for WD is mandatory and must be based on a strong suspicion. Urine testing could prevent patients from being undiagnosed for years. Urine may serve as a novel, easy-to-obtain specimen for guiding the initial diagnosis of WD, in particular in patients with extra-intestinal WD.
Collapse
Affiliation(s)
- Annette Moter
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Matthias Janneck
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Manuel Wolters
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | | | - Alexandra Wiessner
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | | | - Björn Hartleben
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | - Julia Schmidt
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Ulrike Langbehn
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| | - Sabrina Janssen
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Anika Geelhaar-Karsch
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Thomas Schneider
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Verena Moos
- Medical Department I, Gastroenterology, Infectious Diseases and Rheumatology, Charité-Universitätsmedizin Berlin, Germany
| | - Holger Rohde
- Institute of Medical Microbiology, Virology and Hygiene, University Hospital Hamburg-Eppendorf
| | - Judith Kikhney
- Biofilmcenter and German Consiliary Laboratory for Tropheryma whipplei, German Heart Center Berlin.,Institute of Microbiology, Infectious Diseases and Immunology, Charité-Universitätsmedizin Berlin
| | - Thorsten Wiech
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg-Eppendorf
| |
Collapse
|
15
|
Fontana M, Cerri S, Bernardelli G, Brugioni L, Clini E, Tonelli R. Unusual effectiveness of systemic steroids in Whipple disease. Pulmonology 2020; 26:415-417. [PMID: 32192939 DOI: 10.1016/j.pulmoe.2020.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 02/10/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- M Fontana
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Italy
| | - S Cerri
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Italy
| | - G Bernardelli
- University Hospital of Modena, Pathologic Anatomy Unit, Modena, Italy
| | - L Brugioni
- University Hospital of Modena, Internal and Emergency Medicine Unit, Modena, Italy
| | - E Clini
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Italy.
| | - R Tonelli
- University Hospital of Modena, Respiratory Diseases Unit, Department of Medical and Surgical Sciences, University of Modena Reggio Emilia, Italy; Clinical and Experimental Medicine PhD Program, University of Modena Reggio Emilia, Italy
| |
Collapse
|
16
|
Lagier JC, Raoult D. Whipple's disease and Tropheryma whipplei infections: when to suspect them and how to diagnose and treat them. Curr Opin Infect Dis 2019; 31:463-470. [PMID: 30299363 DOI: 10.1097/qco.0000000000000489] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The delay between first clinical signs and diagnosis of Whipple's disease and Tropheryma whipplei infections is more than 6 years, and relapses are frequently observed, resulting in a need for clinicians to be aware of this infection. RECENT FINDINGS 18 FDG-PET is useful in the diagnosis and the follow-up of patients (particularly in case of neurological involvement). Histological involvement remains the goldstandard for classic Whipple's disease diagnosis. PCR performed on biopsies of fluid is the main tool for the diagnosis of localized chronic infections. PCR performed on urine samples should become an important role of noninvasive diagnostic strategies, while T. whipplei PCR performed on saliva and stool lack specificity. Because of lifetime susceptibility to T. whipplei and in-vitro susceptibility data, a 1-year course of doxycycline and hydroxychloroquine followed by a lifelong treatment by doxycycline is recommended for Whipple's disease, localized endocarditis and encephalitis. SUMMARY Clinical involvement of the different T. whipplei infections is well described, as well as the treatment of Whipple's disease, endocarditis and encephalitis. The place of PCR performed on urine remains to be clarified for diagnosis of localized T. whipplei infections and acute infections as well as the optimal treatment for arthritis and acute infections.
Collapse
|
17
|
Loiodice A, Losurdo G, Iannone A, Rossi R, Fiore MG, Piscitelli D. Transmission electron microscopy helpfulness in Whipple's disease masked by immunosuppressant therapy for arthritis. APMIS 2017; 126:92-96. [PMID: 29154446 DOI: 10.1111/apm.12782] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Accepted: 09/17/2017] [Indexed: 12/22/2022]
Abstract
A 61-year-old woman received a diagnosis of undifferentiated non-erosive arthritis in 2010 and assumed methotrexate and steroids in 2014. After 1 year, she experienced watery diarrhea, vomiting, fever, weight loss, and severe hypoalbuminemia, thus being admitted into our Unit. Esophagogastroduodenoscopy showed duodenal lymphangiectasia and duodenal biopsy samples several foamy PAS-positive macrophages and villous subtotal atrophy. Transmission electron microscope demonstrated several extracellular and intracellular rod-shaped bacteria (Tropheryma whipplei). Therefore, we diagnosed Whipple's disease. Our patient assumed doxycycline/hydroxychloroquine with prompt remission of gastrointestinal symptoms. At 1 year of follow-up, she was symptom-free, histological reassessment showed almost complete mucosal healing and transmission electron microscope demonstrated bacteria breaking/disappearance. The present report demonstrates that: (i) rheumatological manifestations are common onset symptoms of Whipple's disease; (ii) immunosuppressive therapy may delay the diagnosis and worsen clinical presentation; (iii) transmission electron microscopy for specific bacteria detection/disappearance is an helpful diagnostic tool, when available.
Collapse
Affiliation(s)
- Alessandra Loiodice
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Giuseppe Losurdo
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Andrea Iannone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Roberta Rossi
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Maria Grazia Fiore
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| | - Domenico Piscitelli
- Section of Pathology, Department of Emergency and Organ Transplantation, University 'Aldo Moro' of Bari, Bari, Italy
| |
Collapse
|
18
|
Clinical Manifestations, Treatment, and Diagnosis of Tropheryma whipplei Infections. Clin Microbiol Rev 2017; 30:529-555. [PMID: 28298472 DOI: 10.1128/cmr.00033-16] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Whipple's disease is a rare infectious disease that can be fatal if left untreated. The disease is caused by infection with Tropheryma whipplei, a bacterium that may be more common than was initially assumed. Most patients present with nonspecific symptoms, and as routine cultivation of the bacterium is not feasible, it is difficult to diagnose this infection. On the other hand, due to the generic symptoms, infection with this bacterium is actually quite often in the differential diagnosis. The gold standard for diagnosis used to be periodic acid-Schiff (PAS) staining of duodenal biopsy specimens, but PAS staining has a poor specificity and sensitivity. The development of molecular techniques has resulted in more convenient methods for detecting T. whipplei infections, and this has greatly improved the diagnosis of this often missed infection. In addition, the molecular detection of T. whipplei has resulted in an increase in knowledge about its pathogenicity, and this review gives an overview of the new insights in epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of Tropheryma whipplei infections.
Collapse
|
19
|
Erythema Nodosum Leprosum-Like Lesions Are a Histopathologic Pattern in Whipple's Disease and a Sign of the Immune Reconstitution Inflammatory Syndrome: A Case Series and Review of the Literature. Am J Dermatopathol 2017; 39:259-266. [PMID: 28098596 DOI: 10.1097/dad.0000000000000641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Inflammatory and subcutaneous nodules can arise in treated and untreated cases of Whipple disease (WD). The inflammatory immune reconstitution syndrome describes paradoxical clinical inflammatory worsening of a preexisting condition because of a return of immune function. Clinicopathologic examination of 4 patients with WD who presented with erythema nodosum leprosum (ENL)-like lesions and the findings of a systematic review of this phenomenon revealed that ENL-like lesions occurred in predominantly middle-aged male patients who suffered from WD, mostly on the legs. Patients showed a nonvasculitic, mostly septal panniculits with neutrophils, macrophages, and lymphocytes. Numerous bacteria-laden periodic acid-Schiff + macrophages and free bacilli were detected in the dermis, as well as subcutaneous septae and adipose lobules. These lesions occurred in both untreated and treated patients as part of inflammatory immune reconstitution syndrome. In conclusion, ENL-like lesions represent a characteristic histopathologic pattern associated with WD, which can occur in different contexts whenever there is a change in the immunological status of the patient. This change can be triggered by antimicrobial treatment, immunomodulatory and immunosuppressant therapy, or occur spontaneously, rarely.
Collapse
|
20
|
“Immune reconstitution inflammatory syndrome”—a rare complication of Whipple’s disease. Eur J Clin Microbiol Infect Dis 2016; 35:1045-6. [DOI: 10.1007/s10096-016-2626-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/15/2016] [Indexed: 10/22/2022]
|
21
|
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.
Collapse
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
| |
Collapse
|
22
|
Marth T. Systematic review: Whipple's disease (Tropheryma whipplei infection) and its unmasking by tumour necrosis factor inhibitors. Aliment Pharmacol Ther 2015; 41:709-24. [PMID: 25693648 DOI: 10.1111/apt.13140] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 01/10/2015] [Accepted: 02/04/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND The classical form of Whipple's disease (WD), clinically characterised by arthropathy, diarrhoea and weight loss, is rare. Recently, other more frequent forms of Tropheryma whipplei infection have been recognised. The clinical spectrum includes an acute, self-limiting disease in children, localised forms affecting cardiac valves or the central nervous system without intestinal symptoms, and asymptomatic carriage of T. whipplei which is found in around 4% of Europeans. Genomic analysis has shown that T. whipplei represents a host-dependent or opportunistic bacterium. It has been reported that the clinical course of T. whipplei infection may be influenced by medical immunosuppression. AIM To identify associations between immunomodulatory treatment and the clinical course of T. whipplei infection. METHODS A PubMed literature search was performed and 19 studies reporting on immunosuppression, particularly therapy with tumour necrosis factor inhibitors (TNFI) prior to the diagnosis in 41 patients with Whipple?s disease, were evaluated. RESULTS As arthritis may precede the diagnosis of WD by many years, a relevant percentage (up to 50% in some reports) of patients are treated with immunomodulatory drugs or with TNFI. Many publications report on a complicated Whipple?s disease course or T. whipplei endocarditis following medical immunosuppression, particularly after TNFI. Standard diagnostic tests such as periodic acid-Schiff stain used to diagnose Whipple?s disease often fail in patients who are pre-treated by TNFI. CONCLUSIONS In cases of doubt, Whipple?s disease should be excluded before therapy with TNFI. The fact that immunosuppressive therapy contributes to the progression of T. whipplei infection expands our pathogenetic view of this clinical entity.
Collapse
Affiliation(s)
- T Marth
- Division of Internal Medicine, Krankenhaus Maria Hilf, Daun, Germany
| |
Collapse
|
23
|
Abstract
PURPOSE OF REVIEW Chronic infections of the small intestine cause significant morbidity and mortality globally. This review focuses on the recent advances in the field of our understanding of selected intestinal infections. RECENT FINDINGS Primary and secondary immunodeficiency increase the susceptibility to many chronic intestinal infections. Endoscopy and intestinal biopsies are central to establishing a diagnosis of these conditions. Tuberculosis (TB) remains a major global health challenge. Emerging therapeutic agents to counteract multidrug-resistant strains have shown clinical efficacy, but concerns regarding mortality remain. PCR-based diagnostic TB tests have the potential to reduce diagnostic delays, but remain to be validated for intestinal infections. Adjunctive diagnostic imaging modalities can differentiate infections from Crohn's disease with increasing accuracy. Whipple's disease remains rare, but there have been substantial advances in our understanding of the causative organism Tropheryma whipplei. Extended treatment with broad-spectrum antibiotics is effective in most cases. The narrow therapeutic window and limited armamentarium for treating invasive filamentous fungal infections contribute to their significant morbidity and high rates of mortality. SUMMARY The speed and accuracy of diagnosing chronic intestinal infections have improved with recent imaging and laboratory methodologies. Significant research opportunities remain for clinicians and scientists to improve the diagnostic accuracy and clinical outcomes of chronic intestinal infections.
Collapse
Affiliation(s)
- Billy Bourke
- aNational Centre for Paediatric Gastroenterology, Our Lady's Children's Hospital bNational Children's Research Centre, Crumlin, Dublin cUCD School of Medicine and Medical Science dConway Institute, University College Dublin, Belfield, Dublin, Ireland
| | | |
Collapse
|
24
|
Peregrin J, Malikova H. Primary Whipple disease of the brain: case report with long-term clinical and MRI follow-up. Neuropsychiatr Dis Treat 2015; 11:2461-9. [PMID: 26445540 PMCID: PMC4590553 DOI: 10.2147/ndt.s92066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Whipple disease (WD) is a rare systemic disorder caused by the bacteria Tropheryma whipplei. In its classic form, it manifests with gastrointestinal problems including diarrhea, abdominal pain, and weight loss. However, various other systems can be affected, including the central nervous system (CNS). Even more rarely, the CNS is primarily affected without gastrointestinal symptoms and with a negative small bowel biopsy. The incidence of primary CNS WD is unknown. We report the case of a young female with the primary CNS form of WD. In this report, we highlight the main clinical features and diagnostic procedures that lead to the diagnosis and comment on the treatment and clinical response. We stress the importance of neuroimaging and brain biopsy. A unique feature of this case is that the patient has been followed up for 12 years. At the time of diagnosis, no neurological manifestations were detected, although a tumor-like lesion in the right temporal lobe and hypothalamic infiltration were present on magnetic resonance imaging (MRI). The first neurological manifestations developed 2 years later despite recommended antibiotic treatment, with cognitive impairment developing more than 10 years later. According to the MRI findings and clinical course, the disease was active for several years when multiple lesions on MRI appeared despite antibiotic therapy. In the discussion, we compare the present case with similar cases previously reported and we elaborate on the similarities and discrepancies in clinical features, diagnostic procedures, results, and treatment options.
Collapse
Affiliation(s)
- Jan Peregrin
- Department of Neurology, Charles University, Prague, Czech Republic
| | - Hana Malikova
- Department of Radiology, Na Homolce Hospital, Charles University, Prague, Czech Republic ; Second Faculty of Medicine, Institute of Anatomy, Charles University, Prague, Czech Republic
| |
Collapse
|
25
|
Vayssade M, Tournadre A, D'Incan M, Soubrier M, Dubost JJ. Immune reconstitution inflammatory syndrome during treatment of Whipple's disease. Joint Bone Spine 2014; 82:122-4. [PMID: 25553832 DOI: 10.1016/j.jbspin.2014.09.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/07/2014] [Indexed: 12/17/2022]
Abstract
Immune reconstitution inflammatory syndrome is a rare complication of the treatment of Whipple's disease. Here, we report the case of a 65-year-old man treated for Whipple's disease affecting the joints, with positive Tropheryma whipplei PCR in CSF, who developed fever and nodular eruption on the trunk, arms and face in association with biological inflammatory syndrome 10 days after initiation of antimicrobial treatment. Skin manifestations and the patient's general condition improved on corticosteroids (0.5mg/kg prednisone), but as steroids were gradually tapered, new nodules appeared below a prednisone dose of 10-15mg. One year after starting treatment, lumbar puncture showed asymptomatic meningitis with negative T. whipplei PCR results which had regressed spontaneously. Two years after the diagnosis, on prednisone 5mg daily and antimicrobial treatment, the patient had only transient, episodic nodular rash without fever or inflammatory syndrome.
Collapse
Affiliation(s)
- Marielle Vayssade
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Anne Tournadre
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Michel D'Incan
- Department of Dermatology, Estaing Hospital, Clermont-Ferrand 1 University, 1 place Lucie-et-Raymond-Aubrac, 63003 Clermont-Ferrand cedex 1 France
| | - Martin Soubrier
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France
| | - Jean-Jacques Dubost
- Department of Rheumatology, Clermont-Ferrand 1 University, G. Montpied Hospital, 58, rue Montalembert, BP 69, 63003 Clermont-Ferrand cedex 1, France.
| |
Collapse
|
26
|
Lagier JC, Fenollar F, Raoult D. Maladie de Whipple et infections à Tropheryma whipplei. Quand l’interniste doit y penser ? Comment les traiter ? Rev Med Interne 2014; 35:801-7. [DOI: 10.1016/j.revmed.2014.04.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/03/2014] [Accepted: 04/22/2014] [Indexed: 12/17/2022]
|
27
|
Lagier JC, Raoult D. Immune reconstitution inflammatory syndrome associated with bacterial infections. Expert Opin Drug Saf 2014; 13:341-50. [DOI: 10.1517/14740338.2014.887677] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jean-Christophe Lagier
- Aix-Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, Faculté de Médecine, 27 Boulevard Jean Moulin, 13385 Marseille Cedex 5, France
| | - Didier Raoult
- Aix-Marseille Université, URMITE, UM63, CNRS 7278, IRD 198, INSERM 1095, Faculté de Médecine, 27 Boulevard Jean Moulin, 13385 Marseille Cedex 5, France ;
| |
Collapse
|
28
|
|