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Haslbauer JD, Wiegand C, Hamelin B, Ivanova VS, Menter T, Savic Prince S, Tzankov A, Mertz KD. Two cases demonstrate an association between Tropheryma whipplei and pulmonary marginal zone lymphoma. Infect Agent Cancer 2024; 19:33. [PMID: 39068468 PMCID: PMC11282790 DOI: 10.1186/s13027-024-00597-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 07/15/2024] [Indexed: 07/30/2024] Open
Abstract
BACKGROUND Marginal zone lymphomas of mucosa-associated lymphatic tissues (MZL of MALT) are a group of indolent B-cell neoplasms, which are thought to arise from chronic antigenic stimulation of B-cells either due to underlying chronic infection or autoimmune disease. Little is known about potential causative pathogens in pulmonary MZL (PMZL), although some data suggests a potential role of Achromobacter (A.) xylosoxidans. METHODS An index case of chronic pulmonary colonisation with Tropheryma (T.) whipplei and subsequent development of PMZL was identified by T. whipplei specific PCR and metagenomic next genome sequencing (mNGS). This case prompted a retrospectively conducted analysis of T. whipplei-specific PCRs in lung tissue from PMZL patients (n = 22), other pulmonary lymphomas, and normal controls. Positive results were confirmed by mNGS. A systematic search for T. whipplei and A. xylosoxidans in our in-house mNGS dataset comprising autopsy lungs, lung biopsies and lung resection specimens (n = 181) was subsequently performed. RESULTS A 69-year-old patient presented with weight loss and persistent pulmonary consolidation. Subsequent mNGS analysis detected T. whipplei in the resected lung specimen. An antibiotic regimen eventually eliminated the bacterium. However, the consolidation persisted, and the diagnosis of PMZL was made in a second lung resection specimen. A second case of T. whipplei-associated PMZL was subsequently detected in the retrospectively analysed PMZL cohort. Both cases showed comparatively few mutations and no mutations in genes encoding for NF-κB pathway components, suggesting that T. whipplei infection may substitute for mutations in these PMZL. None of the samples in our in-house dataset tested positive for T. whipplei. In contrast, A. xylosoxidans was frequently found in both autopsy lungs and lung biopsy / resection specimens that were not affected by PMZL (> 50%). CONCLUSIONS Our data suggests that T. whipplei colonisation of lungs may trigger PMZL as a potential driver. Systematic analyses with larger cohorts should be conducted to further support this hypothesis. The frequent detection of A. xylosoxidans in lung tissue suggests that it is a common component of the pulmonary microbiome and therefore less likely to trigger lymphomas.
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Affiliation(s)
- J D Haslbauer
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - C Wiegand
- Institute of Pathology, Cantonal Hospital Baselland, Mühlemattstrasse 11, CH-4410, Liestal, Switzerland
| | - B Hamelin
- Institute of Pathology, Cantonal Hospital Baselland, Mühlemattstrasse 11, CH-4410, Liestal, Switzerland
| | - V S Ivanova
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - T Menter
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - S Savic Prince
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
| | - A Tzankov
- Institute of Medical Genetics and Pathology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - K D Mertz
- Institute of Pathology, Cantonal Hospital Baselland, Mühlemattstrasse 11, CH-4410, Liestal, Switzerland.
- University of Basel, Basel, Switzerland.
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Saffioti C, Nebiolo M, Caorsi R, Mesini A, Severino M, Brisca G, Castagnola E, Gattorno M. Whipple Disease Presenting as Isolated Transverse Myelitis with Permanent Neurological Damage in a Patient with Systemic Lupus Erythematosus: A Case Report of a Difficult Diagnosis with a Literature Review. Infect Dis Rep 2024; 16:269-280. [PMID: 38525769 PMCID: PMC10961757 DOI: 10.3390/idr16020022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 03/03/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024] Open
Abstract
We describe an atypical case of Whipple disease exclusively involving the spinal cord in an adolescent receiving immunosuppressive therapy for systemic lupus erythematosus. The diagnosis was particularly difficult since lupus and Whipple disease can present similar clinical features and the patient's prolonged contact with sewage was initially not mentioned. A literature review of the clinical, imaging, diagnostic, and therapeutic challenges of Whipple disease is also performed.
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Affiliation(s)
- Carolina Saffioti
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (C.S.); (A.M.); (E.C.)
| | - Marta Nebiolo
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, 16132 Genoa, Italy;
| | - Roberta Caorsi
- Rheumatolgy and Autoinflammatory Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (R.C.); (M.G.)
| | - Alessio Mesini
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (C.S.); (A.M.); (E.C.)
| | | | - Giacomo Brisca
- Paediatric and Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy
| | - Elio Castagnola
- Pediatric Infectious Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (C.S.); (A.M.); (E.C.)
| | - Marco Gattorno
- Rheumatolgy and Autoinflammatory Diseases Unit, IRCCS Istituto Giannina Gaslini, 16147 Genoa, Italy; (R.C.); (M.G.)
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3
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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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Obst W, Hoffmann A, Weigt J, Canbay A, Malfertheiner P, Arnim UV. Whipple's Disease - delay of diagnosis by immunosuppressive therapy; a case-series report. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1002-1008. [PMID: 36963424 DOI: 10.1055/a-1890-5878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
BACKGROUND Risk factors for the development of Whipple's disease (WD) are largely unknown. Case reports, case series, and reviews suggest immunosuppressive therapy as a potential triggering factor in WD. The low incidence of WD and non-specific symptoms at disease onset contribute to the frequent delay of diagnosis. We describe our centre´s experience on differences in the clinical presentation of patients with classic WD compared to patients with "masked" WD because of immunosuppressive therapy. METHODS In this retrospective case series, 8 patients were included. Diagnosis of WD was confirmed by histological staining of duodenal biopsies revealing T. whipplei within foamy macrophages or by PCR- based detection of specific T. whipplei DNA. Clinical manifestations, laboratory data, and medication have been recorded over a period of 19 years. Subgroup analyses for the two different variants of WD were performed. RESULTS Seven of eight patients were initially diagnosed with rheumatic disease (polyarthritis, polymyalgia rheumatica). One patient was correctly diagnosed at the beginning without any medication. Three patients were on immunosuppressive therapy and being treated with disease-modifying drugs (DMARDs), three patients were receiving low-dose cortisone in combination with non-steroidal anti- inflammatory drugs (NSAIDs), and one patient was receiving NSAIDs only. All patients presented with increased parameters of inflammation and with clinical and/or laboratory signs of a malabsorption. From the onset of first symptoms, diagnosis of WD took a median of 36 months (range: 6-120 months). The time between onset of joint complaints and onset of gastrointestinal symptoms was 36 months (range: 0-117 months). WD patients receiving immunosuppressive therapy, compared to those not receiving it, had a longer duration of gastrointestinal symptoms (12 months versus 6 months) and reported a greater weight loss (20,3 kg versus 7,8 kg) up to diagnosis of WD. CONCLUSIONS Immunosuppressive drugs may delay the diagnosis of WD and prolong the course of T. whipplei infection with deterioration of clinical symptoms. If a patient with rheumatic complaints develops gastrointestinal symptoms, diagnosis of WD should be considered and proper diagnostic investigation carried out.
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Affiliation(s)
- Wilfried Obst
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
| | - Armin Hoffmann
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jochen Weigt
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
| | - Ali Canbay
- Department of Medicine, Ruhr University Bochum, Bochum, Germany
| | - Peter Malfertheiner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
| | - Ulrike von Arnim
- Department of Gastroenterology, Hepatology and Infectious diseases, Otto von Guericke Universität Magdeburg, Magdeburg, Germany
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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] [Accepted: 07/12/2022] [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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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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Bulut K, Markova A, Canbay AE, Schmidt WE, Kahraman A. Whipple's disease - a rare and challenging complication in a patient with Crohn's disease. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2022; 60:598-601. [PMID: 35176806 DOI: 10.1055/a-1747-3666] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Whipple's disease (WD) is a rare and infectious condition leading to multi-organ impairment caused by Tropheryma whipplei (TW), a ubiquitously occurring bacterium. TW can be detected in tissues by histological detection of PAS ("periodic acid-ship reaction")-positive macrophages and by polymerase-chain-reaction (PCR). Clinically, WD is often characterized by diarrhea, abdominal pain, and weight loss. These symptoms are also typical for a flare in Crohn's disease (CD) and, therefore, can lead to fatal misdiagnosis and wrong treatment by using biologics (e.g., anti-TNF-α). CASE REPORT We here report a young male patient with pre-existing CD. The patient's symptoms were misinterpreted as a flare of CD and illustrate the multifaceted nature of WD. After intensifying immunosuppressive therapy, the patient developed therapy-refractory diarrhea with several opportunistic infections with a final, fatal outcome. CONCLUSION Patients with inflammatory bowel disease (IBD) are not only at risk from infectious complications known with clostridium difficile or cytomegalovirus (CMV); infection with WD should also be ruled out by endoscopy and biopsy before the escalation of the immunosuppressive regime.
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Affiliation(s)
- Kerem Bulut
- Clinic for Internal Medicine and Gastroenterology, St. Clemens-Hospital Geldern, Germany
| | - Antoaneta Markova
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Germany
| | - Ali E Canbay
- Department of Internal Medicine, Knappschaftskrankenhaus, Ruhr-University Bochum, Germany
| | - Wolfgang E Schmidt
- Department of Internal Medicine, St. Josef Hospital, Ruhr-University Bochum, Germany
| | - Alisan Kahraman
- Gastroenterology and Hepatology, Max Grundig Clinic, Bühl/Baden, Bühl, Germany.,Department of Gastroenterology and Hepatology, University Clinic of Essen, Germany
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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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Abstract
Whipple disease (WD) is a rare infectious systemic disease. Rheumatologists are at the frontline of WD diagnosis due to the early rheumatological manifestations. An early diagnosis is crucial, as usual anti-rheumatic drugs, especially TNF inhibitors, may worsen the disease course. We conducted a retrospective multicentre national study from January 2010 to April 2020 to better characterize the rheumatological features of WD. Classic WD (CWD) was defined by positive periodic acid-Schiff (PAS) staining of a small-bowel biopsy sample, and non-CWD (NCWD) was defined by negative PAS staining of a small-bowel biopsy sample but at least one positive Tropheryma whipplei (TW) polymerase chain reaction (PCR) for a digestive or extradigestive specimen. Sixty-eight patients were enrolled, including 11 CWD patients. Twenty patients (30%) received TNF inhibitors during the WD course, with inefficacy or symptom worsening. More digestive symptoms and systemic biological features were observed in CWD patients than in NCWD patients, but both patient groups had similar outcomes, especially concerning the response to antibiotics and relapse rate. Stool and saliva TW PCR sensitivity were both 100% for CWD and 75% for NCWD and 89% and 60% for small-bowel biopsy sample PCR, respectively. WD encountered in rheumatology units has many presentations, which might result from different pathophysiologies that are dependent on host immunity. Given the heterogeneous presentations and the presence of chronic carriage, multiple TW PCR tests on samples from specific rheumatological sites when possible should be performed, but samples from nonspecific digestive and extradigestive sites also have great value.
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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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12
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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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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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14
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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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15
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Abstract
In recent years, it has become apparent that Tropheryma whipplei not only causes a chronic multisystemic infection which is often preceded by arthropathies for many years, well known as 'classical' Whipple's disease, but also clinically becomes manifest with localized organ affections and acute (transient) infections in children. T. whipplei is found ubiquitously in the environment and colonizes in some healthy carriers. In this review, we highlight new aspects of this enigmatic infectious disorder.
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16
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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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17
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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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18
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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.
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Affiliation(s)
- T Marth
- Division of Internal Medicine, Krankenhaus Maria Hilf, Daun, Germany
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