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Rasool N. Ophthalmic manifestations of Whipple's disease. Curr Opin Ophthalmol 2024; 35:83-88. [PMID: 37830937 DOI: 10.1097/icu.0000000000000989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
PURPOSE OF REVIEW Whipple's disease is an infectious cause of uveitis that may present with nonspecific findings of intraocular inflammation, which can precede the development of neurologic symptoms and signs. Whipple's disease, then, may evade consideration in the differential diagnosis for uveitis. RECENT FINDINGS Molecular tests can be helpful in identifying the presence of Tropheryma whipplei from ocular specimens. The application of metagenomic sequencing for ocular specimens is promising, as it offers the opportunity to identify the pathogen when suspicion for an intraocular infection is high. Whipple's disease demonstrates the ability to abrogate the host immune response, which gives some insight into its pathogenesis. SUMMARY Whipple's disease should be suspected in patients who have uveitis refractory to anti-inflammatory therapy. Knowledge of this important pathogen can help direct the timely implementation of diagnostic testing.
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Affiliation(s)
- Nailyn Rasool
- Department of Ophthalmology, University of California, San Francisco, San Francisco, California, USA
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Arepalli SR, Thomas AS. Occlusive retinal vasculitis: novel insights into causes, pathogenesis and treatment. Curr Opin Ophthalmol 2022; 33:147-156. [PMID: 35239517 DOI: 10.1097/icu.0000000000000843] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Occlusive retinal vasculitis (ORV) has a large differential diagnosis and varied therapeutic approaches. This review highlights existing and novel causes and treatment options for ORV. RECENT FINDINGS Mutations in CAPN5, TREX1, and TNFAIP3 have been associated with dominantly inherited forms of ORV. Various intraocular therapeutics have been shown to occasionally cause ORV; the most recent medications associated with ORV are vancomycin and brolucizumab. In cases of ORV linked to Behçet's disease, clinical trials support the use of tumor necrosis factor alpha inhibitors. SUMMARY Identification of the underlying etiology of ORV is critical to help guide treatment. Treatment in ORV involves both treatment any underlying infection or autoimmune condition, cessation of the any offending causative agent and local treatment of neovascular complications.
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A Comprehensive Update on Retinal Vasculitis: Etiologies, Manifestations and Treatments. J Clin Med 2022; 11:jcm11092525. [PMID: 35566655 PMCID: PMC9101900 DOI: 10.3390/jcm11092525] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 04/24/2022] [Accepted: 04/27/2022] [Indexed: 12/18/2022] Open
Abstract
Retinal vasculitis is characterized by inflammatory involvement of retinal arterioles, venules and/or capillaries and can be associated with a myriad of systemic and ophthalmic diseases. In this review, we have comprehensively discussed the etiologies, clinical manifestations, and presentations of retinal vasculitis. We have also included newer advances in imaging in retinal vasculitis such as OCTA and widefield imaging.
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The clinical importance of uveomeningeal syndromes. SPEKTRUM DER AUGENHEILKUNDE 2021. [DOI: 10.1007/s00717-021-00500-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Touhami S, Leclercq M, Stanescu-Segall D, Touitou V, Bodaghi B. Differential Diagnosis of Vitritis in Adult Patients. Ocul Immunol Inflamm 2021; 29:786-795. [PMID: 34003716 DOI: 10.1080/09273948.2021.1898001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The term "vitritis" refers to the presence of a cellular infiltration of the vitreous body, usually in the context of an intraocular inflammation, but not exclusively. Intermediate uveitis is the most prominent cause of vitritis, including infectious and auto-immune/auto-inflammatory etiologies. Corticosteroids and immunosuppressive therapies should not be started before ruling out the infectious causes of vitritis, especially in immunosuppressed individuals. Other situations can mimic intermediate uveitis such as amyloidosis and ocular tumors. Primary intraocular lymphoma should always be suspected in case of vitreous infiltrations in individuals aged over 50 years.
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Affiliation(s)
- Sarah Touhami
- Department of Ophthalmology, Reference Center in Rare Diseases, DHU Sight Restore, Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Mathilde Leclercq
- Department of Ophthalmology, Reference Center in Rare Diseases, DHU Sight Restore, Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Dinu Stanescu-Segall
- Department of Ophthalmology, Reference Center in Rare Diseases, DHU Sight Restore, Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France.,Centre Nord Exploration Ophtalmologique, Lille, France
| | - Valérie Touitou
- Department of Ophthalmology, Reference Center in Rare Diseases, DHU Sight Restore, Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, Reference Center in Rare Diseases, DHU Sight Restore, Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France
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Case Report: Tropheryma whipplei Infection Presenting with Optic Disc Edema. Optom Vis Sci 2021; 97:1041-1047. [PMID: 33252544 DOI: 10.1097/opx.0000000000001618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Whipple disease is a rare chronic, systemic bacterial infection that predominantly affects the small intestine but also other organs of the body. When left untreated, it can be not only vision threatening but also life threatening because of its central nervous system involvement. Therefore, early detection and treatment are important. PURPOSE We report a rare case of unilateral optic disc edema as a critical identifying sign of Whipple disease. CASE REPORT An asymptomatic 49-year-old African American man presented for an eye examination and was found to have optic nerve edema of the right eye. His best-corrected visual acuity was 20/20 in the right and left eye. He denied symptoms of diplopia, amaurosis fugax, or eye pain. His medical history was significant for HIV with no recent detectable viral load at the time of his eye examination. The patient denied any other infectious risk factors or changes in medical status. Extensive ophthalmic, neuroimaging, and laboratory investigations were completed as a comprehensive approach to rule out more common etiologies for unilateral optic disc edema. This initial workup yielded no identifying etiology, and the patient was monitored closely with frequent examinations with a retina specialist. Soon after his diagnosis of optic nerve edema, the patient developed new symptoms of chronic diarrhea, weight loss, and fatigue requiring hospitalization. Evaluations by internal medicine and gastroenterology, including serological testing, stool analysis, histological and microbiological analysis, esophagogastroduodenoscopy, and gastrointestinal biopsy, confirmed a diagnosis of Whipple disease that was successfully treated with oral antibiotics. CONCLUSIONS Whipple disease is a rare cause of infectious optic nerve edema that may present with other rheumatoid and gastrointestinal symptoms. A comprehensive medical approach for investigating unilateral optic nerve edema is paramount in diagnosing and treating Whipple disease.
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Bosello F, Casalino G, Neri E, Alfano A, Bonora A, Marchini G. Unique Features of Posterior Ocular Involvement of Whipple's Disease in a Patient with No Gastrointestinal Symptoms. Ocul Immunol Inflamm 2021; 30:1168-1171. [PMID: 33545009 DOI: 10.1080/09273948.2020.1859548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Purpose: To describe posterior ocular involvement features of Whipple's disease (WD) in a patient with no gastrointestinal symptoms.Methods: Retrospective case report.Observation: A 53-year-old man with a 2-year history of seronegative arthritis presented with bilateral intraocular inflammation, optic disc edema, and cystoid macular edema (CME) in the left eye. A diagnosis of noninfectious uveitis was made and oral prednisolone was started. Despite initial improvement, after 6 weeks, CME was found in both eyes. Because of the initial response, the anti-tumor necrosis factor agent Adalimumab was started. Twelve weeks after initiation of adalimumab, fundus examination revealed widespread dot-blot retinal hemorrhages and multifocal chorioretinal lesions at the posterior pole and mid-periphery. The chorioretinal lesions appeared as hyperreflective drusen-like deposits located in the sub-retinal pigment epithelium (RPE) space on the tomographic scan. WD was considered and confirmed by polymerase chain reaction test and duodenal biopsy.Conclusion: Posterior ocular involvement in WD may present with a wide clinical spectrum including intraocular inflammation and unique features of sub-RPE deposits, widespread retinal hemorrhages, and optic disc edema.
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Affiliation(s)
- Francesca Bosello
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
| | | | - Enrico Neri
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
| | - Alessandro Alfano
- Ophthalmology Department, Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Italy
| | - Adriana Bonora
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
| | - Giorgio Marchini
- Department of Neurosciences, Biomedicine and Movement Sciences, Eye Clinic, Ocular Immunology and Neuroophthalmology Service, AOUI-University of Verona, Verona, Italy
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8
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Chiu M, Moore S. Bilateral optic disc swelling in Whipple's disease. Clin Exp Ophthalmol 2017; 45:641-643. [DOI: 10.1111/ceo.12933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 01/04/2017] [Accepted: 02/08/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Mimi Chiu
- Eye Clinic, Christchurch Hospital, Canterbury District Health Board; Christchurch New Zealand
| | - Sacha Moore
- Ophthalmology Department, Nelson Hospital, Nelson Marlborough District Health Board; Nelson New Zealand
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Arriola-Villalobos P, Ruiz-Medrano J, Diaz-Valle D, Benitez Del Castillo JM. [Chronic bilateral panuveitis as first manifestation of Whipple's disease]. Med Clin (Barc) 2016; 146:467-8. [PMID: 26749353 DOI: 10.1016/j.medcli.2015.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 11/11/2015] [Accepted: 11/19/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Pedro Arriola-Villalobos
- Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España; Cooperative Research Network on Age-Related Ocular Pathology, Visual and Life Quality, Instituto de Salud Carlos III, Madrid, España
| | - Jorge Ruiz-Medrano
- Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España.
| | - David Diaz-Valle
- Cooperative Research Network on Age-Related Ocular Pathology, Visual and Life Quality, Instituto de Salud Carlos III, Madrid, España; Servicio de Oftalmología, Departamento de Oftalmología y Otorrinolaringología, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Jose M Benitez Del Castillo
- Cooperative Research Network on Age-Related Ocular Pathology, Visual and Life Quality, Instituto de Salud Carlos III, Madrid, España; Servicio de Oftalmología, Departamento de Oftalmología y Otorrinolaringología, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
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Fanlo-Mateo P, Heras-Mulero H, Jimenez-Bermejo F, Montes-Díaz M. Birdshot-like retinochoroidopathy as onset of Whipple's disease. ARCHIVOS DE LA SOCIEDAD ESPANOLA DE OFTALMOLOGIA 2016; 91:48-49. [PMID: 26560166 DOI: 10.1016/j.oftal.2015.09.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 09/15/2015] [Indexed: 06/05/2023]
Affiliation(s)
- P Fanlo-Mateo
- Unidad Multidisciplinar de Uveítis, Servicio de Medicina Interna, Complejo Hospitalario de Navarra, Pamplona, Navarra, España.
| | - H Heras-Mulero
- Unidad Multidisciplinar de Uveítis, Servicio de Oftalmología, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - F Jimenez-Bermejo
- Unidad Multidisciplinar de Uveítis, Servicio de Medicina Interna, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
| | - M Montes-Díaz
- Servicio de Anatomía Patológica, Complejo Hospitalario de Navarra, Pamplona, Navarra, España
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Tropheryma whipplei Crystalline Keratopathy: Report of a Case and Updated Review of the Literature. Case Rep Ophthalmol Med 2012; 2012:707898. [PMID: 22988534 PMCID: PMC3439939 DOI: 10.1155/2012/707898] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2012] [Accepted: 08/08/2012] [Indexed: 12/17/2022] Open
Abstract
Purpose. To report a case of Tropheryma whipplei infection with crystalline keratopathy and review the recent literature on the presentation, diagnosis, and management of Whipple's disease. Methods. Detailed case presentation and extensive literature search of Pubmed for all years through February 2012 using the following search terms: Whipple's disease, Tropheryma whipplei, corneal deposits, crystalline keratopathy, and uveitis. Relevant articles were retrieved and analyzed. English abstracts were used for non-English articles. Cross-referencing was employed and reference lists from selected articles were used to identify additional pertinent articles. Results. Diagnosis of Whipple's disease remains challenging and untreated infection can result in mortality. Ocular signs and symptoms are usually nonspecific, but several independent cases have reported the presence of intraocular crystals or crystalline-like deposits. Conclusions. The presence of intraocular crystals or crystalline-like deposits may be an identifying feature of ocular Whipple's disease.
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Ocular Whipple's Disease: Therapeutic Strategy and Long-Term Follow-Up. Ophthalmology 2012; 119:1465-9. [DOI: 10.1016/j.ophtha.2012.01.024] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2011] [Revised: 01/11/2012] [Accepted: 01/12/2012] [Indexed: 11/23/2022] Open
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Abstract
PURPOSE To report a novel posterior segment manifestation of Whipple disease. METHOD Single observational case study. RESULTS The white crystalline deposit in the retina, choroiditis, and vitritis resolved with treatment of Whipple disease. CONCLUSION Whipple disease can be associated with panuveitis, multifocal choroiditis, and white crystalline deposits in the anterior segments and retina, a unique clinical finding.
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Inflammatory Bowel Disease and Other Systemic Inflammatory Diseases. Cornea 2011. [DOI: 10.1016/b978-0-323-06387-6.00068-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Scheurer RA, Kosmorsky GS, Hoffman GS, Farver C, Lee MS, Cestari DM. Can't Hear, Can't See, and Too Sore to Play. Surv Ophthalmol 2010; 55:290-6. [DOI: 10.1016/j.survophthal.2009.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Accepted: 09/02/2009] [Indexed: 10/20/2022]
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Abstract
Retinal vasculitis is a sight-threatening intraocular inflammation affecting the retinal vessels. It may occur as an isolated ocular condition, as a manifestation of infectious or neoplastic disorders, or in association with a systemic inflammatory disease. The search for an underlying etiology should be approached in a multidisciplinary fashion based on a thorough history, review of systems, physical examination, and laboratory evaluation. Discrimination between infectious and noninfectious etiologies of retinal vasculitis is important because their treatment is different. This review is based on recently published articles on retinal vasculitis and deals with its clinical diagnosis, its link with systemic diseases, and its laboratory investigation.
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Affiliation(s)
- Ahmed M Abu El-Asrar
- Department of Ophthalmology, College of Medicine, King Saud University, Riyadh, Saudi Arabia.
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Abstract
Whipple’s disease was initially described in 1907. Over the next century, the clinical and pathological features of this disorder have been better appreciated. Most often, weight loss, diarrhea, abdominal and joint pain occur. Occasionally, other sites of involvement have been documented, including isolated neurological disease, changes in the eyes and culture-negative endocarditis. In the past decade, the responsible organism Tropheryma whipplei has been cultivated, its genome sequenced and its antibiotic susceptibility defined. Although rare, it is a systemic infection that may mimic a wide spectrum of clinical disorders and may have a fatal outcome. If recognized, prolonged antibiotic therapy may be a very successful form of treatment.
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Wang RC. Cat-Scratch and Whipple's Diease. Ophthalmology 2009. [DOI: 10.1016/b978-0-323-04332-8.00127-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Abstract
We report a case of a 45-year-old man who complained of progressive vision loss in his right eye. Visual acuity was 20/300 in the right eye and 20/25 in the left eye. Bilateral uveitis intermedia R>L was diagnosed and treated with systemic and local steroids. An internal checkup was also done, and duodenal biopsy identified Whipple's disease. Despite specific antibiotic therapy, the patient's follow-up examination showed increased inflammatory activity R>L and bilateral cataracta complicata. Cataract surgery and pars plana vitrectomy with removal of epiretinal membranes were done. Histologic analysis of the vitreous and epiretinal membranes showed periodic acid-Schiff-positive macrophages, pathognomonic for Whipple's disease. Whipple's disease is a rare but severe disease with multiple manifestations and should be considered a differential diagnosis in uveitis.
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Schneider T, Moos V, Loddenkemper C, Marth T, Fenollar F, Raoult D. Whipple's disease: new aspects of pathogenesis and treatment. THE LANCET. INFECTIOUS DISEASES 2008; 8:179-90. [PMID: 18291339 DOI: 10.1016/s1473-3099(08)70042-2] [Citation(s) in RCA: 218] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
100 years after its first description by George H Whipple, the diagnosis and treatment of Whipple's disease is still a subject of controversy. Whipple's disease is a chronic multisystemic disease. The infection is very rare, although the causative bacterium, Tropheryma whipplei, is ubiquitously present in the environment. We review the epidemiology of Whipple's disease and the recent progress made in the understanding of its pathogenesis and the biology of its agent. The clinical features of Whipple's disease are non-specific and sensitive diagnostic methods such as PCR with sequencing of the amplification products and immunohistochemistry to detect T whipplei are still not widely distributed. The best course of treatment is not completely defined, especially in relapsing disease, neurological manifestations, and in cases of immunoreconstitution after initiation of antibiotic treatment. Patients without the classic symptoms of gastrointestinal disease might be misdiagnosed or insufficiently treated, resulting in a potentially fatal outcome or irreversible neurological damage. Thus, we suggest procedures for the improvement of diagnosis and an optimum therapeutic strategy.
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Affiliation(s)
- Thomas Schneider
- Medical Department I, Charité-University Medicine Berlin, Campus Benjamin Franklin, Berlin, Germany
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Abstract
PURPOSE OF REVIEW The availability of and advantages in molecular technology and immunology have led to an improved understanding of the etiology and pathogenesis of Whipple disease. As this rare infection represents a model disease reflecting the input of novel findings into clinical medicine and therapy, this review intends to highlight newer findings and put them in context. RECENT FINDINGS Sequencing of 16S rRNA allowed the phylogeny of the bacterium to be determined. The culture and subsequent genome analysis have led to improved diagnosis and monitoring of the disease, for example by PCR or immunohistochemistry. New experimental approaches hint of defects in T-cell and macrophage immunity in patients. Antibiotic therapy will soon be based on data from the first prospective therapy study. SUMMARY Within a few years the findings from molecular genetics and immunology as well as concerted research activities from the European Consortium on Whipple Disease which established a data and material bank could be translated into clinical medicine. Thus, for patients with Whipple disease an improved basis for diagnosis and therapy have been achieved.
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Abstract
Knowledge about Whipple's disease began to emerge in 1907, when George Hoyt Whipple recognized the first case of the disease that now bears his name. He reported the case of a 36-year-old physician with "a gradual loss of weight and strength, stools consisting chiefly of neutral fat and fatty acids, indefinite abdominal signs, and a peculiar multiple arthritis" (1). Findings at autopsy consisted of poly-serositis, aortic valve vegetations and deposition of fat in the intestinal mucosa and regional lymph nodes with marked infiltration by foamy macrophages (1). It was originally thought to be a disorder of fat metabolism, and the term 'intestinal lipodystrophy' was proposed. Whipple's disease has since been recognized as a rare, multivisceral, chronic disease with a clinical presentation dominated by a symptom triad of diarrhea, weight loss and malabsorption. However, digestive symptoms are often preceded for months or years by other symptoms, the most common being arthralgia, although cardiovascular, neurological or pulmonary involvement may be more prominent at times. Once considered the ideal case report, recent characterization ofTropheryma whippeliiby means of broad range bacterial ribosomal DNA polymerase chain reaction (PCR) analysis (2,3) and its subsequent cultivation (4) has led to a veritable explosion of individual case reports, case series and hitherto unrecognized manifestations of the disease, such that it is now considered an underdiagnosed infectious disease (5). It is timely to provide an update on new developments in Whipple's disease.
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Affiliation(s)
- Robin Ray
- Neuro-ophthalmology Service, Baylor College of Medicine, 6565 Fannin NC-205, Houston, TX 77030, USA
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Affiliation(s)
- Pedro Bermejo
- Servicio de Neurología, Hospital Universitario Puerta de Hierro, Madrid, España.
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Abstract
Bacterial, fungal, viral, and parasitic pathogens all cause systemic infection and can spread to the eye. Dissemination of pathogens via the bloodstream can lead to direct involvement of the eye. Visual loss is common in bacterial or fungal endophthalmitis, and toxoplasmosis is a major cause of ocular morbidity and poor vision after congenital or acquired infection. Some infections cause intraocular damage by indirect mechanisms (eg, HIV-mediated immunosuppression), leading to opportunistic infections such as cytomegalovirus infection, periocular nerve involvement due to leprosy, and hypersensitivity reactions in tuberculosis. Eye symptoms might indicate the outcome of an underlying infection, such as development of retinal ischaemia in severe malaria, which is associated with a poor prognosis. Successful outcome for patients with ocular infection depends on close collaboration between clinicians identifying and treating underlying disease, specialist ophthalmic review, and ophthalmic interventional skills (when needed).
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Affiliation(s)
- W A Lynn
- Department of Infectious Diseases, Ealing Hospital, Southall, UK.
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Abstract
BACKGROUND The uveo-meningeal syndromes are a group of disorders that share involvement of the uvea, retina, and meninges. REVIEW SUMMARY We review the clinical manifestations of uveitis and describe the infectious, inflammatory, and neoplastic conditions associated with the uveo-meningeal syndrome. CONCLUSIONS Inflammatory or autoimmune diseases are probably the most common clinically recognized causes of true uveo-meningeal syndromes. These entities often cause inflammation of various tissues in the body, including ocular structures and the meninges (eg, Wegener granulomatosis, sarcoidosis, Behcet disease, Vogt-Koyanagi-Harada syndrome, and acute posterior multifocal placoid pigment epitheliopathy). The association of an infectious uveitis with an acute or chronic meningoencephalitis is unusual but occasionally the eye examination may suggest an infectious etiology or even a specific organism responsible for a meningeal syndrome. One should consider the diagnosis of primary ocular-CNS lymphoma in patients 40 years of age or older with bilateral uveitis, especially with prominent vitritis, that fails to respond to treatment or who has associated neurologic findings. A paraneoplastic disorder has been described in patients who have combined optic neuritis and retinitis defined serologically by the presence of a paraneoplastic IgG autoantibody CRMP-5-IgG. These patients may have an inflammatory vitritis and may have signs of cerebrospinal fluid inflammation.
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Affiliation(s)
- Paul W Brazis
- Department of Ophthalmology, Mayo Clinic--Jacksonville, FL 32224, USA.
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Abstract
OBJECTIVES Detailed review of the manifestations of eye involvement in the context of rheumatic diseases. METHODS An OVID Medline search of the rheumatology and ophthalmology English literature related to the eye manifestations of human rheumatic diseases from 1966 to the present was conducted by the authors. RESULTS Analysis of 300 recent and consecutive rheumatology consultations from a large Veterans Administration Healthcare System shows that 4% are referred for eye manifestations of suspected rheumatic diseases, most commonly, anterior uveitis and keratoconjunctivitis sicca (KCS). Ocular involvement is common in the rheumatic diseases but varies among the different disorders. A literature review indicated that the most common ocular manifestations of rheumatic diseases include keratoconjunctivitis sicca, anterior uveitis, and scleritis. The most serious eye complications of the inherited connective tissue disorders are lens involvement with cataract formation or subluxation. The most significant side effects of the drugs used to treat rheumatic diseases are the maculopathy associated with anti-malarial agents and cataracts and glaucoma associated with corticosteroid use. Although many of the eye manifestations are easily recognizable, consultation with an ophthalmologist is usually necessary for optimal treatment and prevention of complications. CONCLUSIONS The rheumatologist, in coordination with the ophthalmologist, can play a major role in detecting and managing the eye involvement in his patients to save this important sense. Understanding the varied manifestations of eye disease will permit the rheumatologist to better evaluate the activity of the rheumatic disease.
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Affiliation(s)
- F Hamideh
- Department of Medicine, University of California, Irvine, Medical Center, Orange, CA, USA
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Ferrari MDL, Vilela EG, Faria LC, Couto CA, Salgado CJ, Leite VR, Brasileiro Filho G, Bambirra EA, Mendes CM, Carvalho SDC, de Oliveira CA, da Cunha AS. Whipple's disease. Report of five cases with different clinical features. Rev Inst Med Trop Sao Paulo 2001; 43:45-50. [PMID: 11246283 DOI: 10.1590/s0036-46652001000100009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Whipple's disease (WD) is a rare systemic disease of infectious etiology which involves the small intestine but can virtually affect any organ. We present here five cases (four males and one female) ranging in age from 20 to 59 years. All patients had intestinal involvement associated or not with clinical manifestations linked to this organ. Vegetation in the tricuspid valve was observed in one patient, suggesting endocarditis caused by Tropheryma whippelii, with disappearance of the echocardiographic alterations after treatment. In one of the male patients the initial clinical manifestation was serologically negative spondylitis, with no diarrhea occurring at any time during follow-up. Ocular involvement associated with intestinal malabsorption and significant weight loss were observed in one case. In the other two cases, diarrhea was the major clinical manifestation. All patients were diagnosed by histological examination of the jejunal mucosa and, when indicated, of extraintestinal tissues by light and electron microscopy. After antibiotic treatment, full remission of symptoms occurred in all cases. A control examination of the intestinal mucosa performed after twelve months of treatment with sulfamethoxazole-trimethoprim revealed the disappearance of T. whippelii in four patients. The remaining patient was lost to follow-up.
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Affiliation(s)
- M de L Ferrari
- Department of Medicine, Faculty of Medicine, Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
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Abstract
Whipple's disease is a systemic bacterial infection and the common though not invariable manifestations are diarrhoea, weight loss, abdominal pain, and arthralgia. Arthritis or arthralgia may be the only presenting symptom, predating other manifestations by years. Virtually all organs in the body may be affected, with protean clinical manifestations. Various immunological abnormalities, some of which may be epiphenomena, are described. The causative organism is Tropheryma whippelii. The disease is uncommon though lethal if not treated. Recent data suggest the disease occurs in an older age group than previously described. The characteristic histopathological features are found most often in the small intestine. These are variable villous atrophy and distension of the normal villous architecture by an infiltrate of foamy macrophages with a coarsely granular cytoplasm, which stain a brilliant magenta colour with PAS. These pathognomonic PAS positive macrophages may also be present in the peripheral and mesenteric lymph nodes and various other organs. The histological differential diagnoses include histoplasmosis and Mycobacterium avium-intercellulare complex. The clinical diagnosis of Whipple's disease may be elusive, especially if gastrointestinal symptoms are not present. A unique sign of CNS involvement, if present, is oculofacial-skeletal myorhythmia or oculomasticatory myorhythmia, both diagnostic of Whipple's disease. A small bowel biopsy is often diagnostic, though in about 30% of patients no abnormality is present. In patients with only CNS involvement, a stereotactic brain biopsy can be done under local anaesthetic. A recent important diagnostic test is polymerase chain reaction of the 16S ribosomal RNA of Tropheryma whippelii. Whipple's disease is potentially fatal but responds dramatically to antibiotic treatment. In this review the current recommended treatments are presented. The response to treatment should be monitored closely, as relapses are common. CNS involvement requires more vigorous treatment because there is a high rate of recurrence after apparently successful treatment.
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Affiliation(s)
- R N Ratnaike
- Department of Medicine, The Queen Elizabeth Hospital, Woodville, South Australia 5011, Australia
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32
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Abstract
Ocular findings in diseases affecting primarily the digestive tract are relatively rare; however, it is important for the physician to recognize these relationships, appropriately uncover symptoms related to the eye disease, and have the patient evaluated by an ophthalmologist if indicated. In addition, ocular inflammation may be the first indication of bowel disease (e.g., uveitis in Crohn's disease). This article describes the associations between ocular diseases and gastrointestinal diseases and their causes, signs, symptoms, prognosis, and treatment.
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Affiliation(s)
- M L Nakla
- Department of Ophthalmology, Allegheny University of the Health Sciences-Hahnemann University Hospital, Philadelphia, Pennsylvania, USA
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33
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Nishimura JK, Cook BE, Pach JM. Whipple disease presenting as posterior uveitis without prominent gastrointestinal symptoms. Am J Ophthalmol 1998; 126:130-2. [PMID: 9683160 DOI: 10.1016/s0002-9394(98)00084-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE To describe the clinical presentation and course of Whipple disease in an adult. METHODS A 34-year-old man with phthisis bulbi in the right eye secondary to uveitis-induced neovascular glaucoma presented with severe acute posterior uveitis in the left eye. He underwent esophagogastroduodenoscopy and jejunal biopsy for evaluation of anemia. The posterior uveitis was treated with a subtenon injection of triamcinolone. RESULT The diagnosis of Whipple disease was confirmed by polymerase chain reaction analysis of the jejunal biopsy that demonstrated Tropheryma whippelii rDNA. CONCLUSION Although Whipple disease is typically evident with malabsorption, it can also present as uveitis without prominent gastrointestinal symptoms.
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Affiliation(s)
- J K Nishimura
- Department of Ophthalmology, Mayo Clinic and Mayo Foundation, Rochester, MN 55905, USA
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Wechsler B, Fior R, Reux I, Cassou N, Phuc LH, Merle-Beral H, Ziza JM, Godeau P. [Uveitis: late complication of undiagnosed Whipple disease]. Rev Med Interne 1995; 16:687-90. [PMID: 7481157 DOI: 10.1016/0248-8663(96)80772-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We report a case of severe chronic bilateral uveitis in a 60-year-old white man without neurological manifestations. Spondylarthritis and isolated malabsorption suggested the diagnosis of Whipple's disease. A normal duodenal biopsy delated the diagnosis, who was secondarily demonstrated an adenopathy biopsy and macrophage study on vitrectomy sample (macrophage distended by periodic acid-Schiff positive material). With 1 year follow-up the uveitis was rapidly and completely cured by an antibiotic association (rifampicin and trimethoprim-sulfamethoxazol). The characteristics of ocular involvement in Whipple's disease and treatment of the disease are discussed.
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Affiliation(s)
- B Wechsler
- Service de médecine interne, CHU Pitié-Salpêtrière, Paris, France
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35
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Rickman LS, Freeman WR, Green WR, Feldman ST, Sullivan J, Russack V, Relman DA. Brief report: uveitis caused by Tropheryma whippelii (Whipple's bacillus). N Engl J Med 1995; 332:363-6. [PMID: 7529892 DOI: 10.1056/nejm199502093320604] [Citation(s) in RCA: 135] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- L S Rickman
- Division of Infectious Diseases, University of California, San Diego 92103-8951
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36
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Affiliation(s)
- D Gaist
- Roskilde Amts Sygehus Køge, Dept. of Medicine, Denmark
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37
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Playford RJ, Schulenburg E, Herrington CS, Hodgson HJ. Whipple's disease complicated by a retinal Jarisch-Herxheimer reaction: a case report. Gut 1992; 33:132-4. [PMID: 1371261 PMCID: PMC1373879 DOI: 10.1136/gut.33.1.132] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Abstract
A 36 year old white man was diagnosed as having Whipple's disease after a prolonged illness of lethargy, night sweats, and weight loss associated with lymphadenopathy and splenomegaly. Biopsy specimen of an inguinal lymph node confirmed the presence of periodic acid Schiff positive macrophages and culture gave a pure growth of Corynebacterium jeikeium. Twelve hours after the introduction of oral co-trimoxazole and streptomycin the patient's condition deteriorated. He became confused, feverish, and developed florid retinal vasculitis with associated visual impairment. Both the systemic symptoms and the retinal vasculitis responded to treatment with corticosteroids and his vision returned to normal. We think this was a Jarisch-Herxheimer reaction not previously described in Whipple's disease and advise inspection of the fundi of such patients before starting treatment.
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Affiliation(s)
- R J Playford
- Gastroenterology Unit, Royal Postgraduate Medical School, Hammersmith Hospital, London
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38
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McClellan KA, Coster DJ. Uveitis: a strategy for diagnosis. AUSTRALIAN AND NEW ZEALAND JOURNAL OF OPHTHALMOLOGY 1987; 15:227-41. [PMID: 3314914 DOI: 10.1111/j.1442-9071.1987.tb00076.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Uveitis may be the first presentation of a wide variety of underlying ocular and systemic diseases. It is important for the ophthalmologist to make a specific diagnosis in order to instigate specific therapy and give an accurate prognosis. The ability to recognise the clinical patterns of uveitis and to initiate appropriate investigations should form the basis of the ophthalmologist's management of the condition. To this end, we have considered uveitis under four major patterns of presentation--anterior uveitis, intermediate uveitis, posterior uveitis, and panuveitis--with subclasses within each of these four groups. We have outlined both the investigations which facilitate diagnosis of the possible underlying causes of inflammation and the interpretation of the results of such investigations.
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Affiliation(s)
- K A McClellan
- Department of Ophthalmology, Flinders Medical Centre, Bedford Park, South Australia
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40
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 33-1985. Bilateral uveal disorder unresponsive to corticosteroid therapy. N Engl J Med 1985; 313:436-43. [PMID: 3894967 DOI: 10.1056/nejm198508153130708] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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