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Abstract
ABSTRACT Whipple disease (WD) is a rare bacterial infectious disease that is classically characterized by years of arthralgia, followed by malabsorption, diarrhea, and weight loss. However, WD may manifest in virtually any organ system, and patients with WD rarely develop subcutaneous erythema nodosum-like lesions. We report a case of a 51-year-old man diagnosed with WD who subsequently developed widely distributed erythematous subcutaneous nodules after 5 months of antibiotic therapy.
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Sanchez A, Del Giudice P, Mantion C, Mazellier S, Boukari F, Roger PM, Courjon J. Erythematous skin nodules during treatment of Whipple's disease. Infect Dis Now 2020; 51:397-399. [PMID: 33075401 DOI: 10.1016/j.medmal.2020.10.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 04/17/2020] [Accepted: 10/08/2020] [Indexed: 11/26/2022]
Affiliation(s)
- A Sanchez
- Dermatologie/dermatology, hôpital de l'Archet, centre hospitalier universitaire de Nice, Nice, France
| | - P Del Giudice
- Unité de maladies infectieuses et dermatologie/infectious disease and dermatology unit, hôpital Bonnet, centre hospitalier intercommunal Fréjus-Saint-Raphaël, Fréjus, France
| | - C Mantion
- Infectiologie/infectiology, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de Saint-Antoine-de-Ginestière, 06200 Nice, France
| | - S Mazellier
- Anatomopathologie/anatomic pathology, hôpital de l'Archet, centre hospitalier universitaire de Nice, Nice, France
| | - F Boukari
- Dermatologie/dermatology, hôpital de l'Archet, centre hospitalier universitaire de Nice, Nice, France
| | - P-M Roger
- Infectiologie/infectiology, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de Saint-Antoine-de-Ginestière, 06200 Nice, France; Infectiologie/infectiology, CHU de Pointe-à-Pitre, Pointe-à-Pitre, France
| | - J Courjon
- Infectiologie/infectiology, hôpital de l'Archet, centre hospitalier universitaire de Nice, 151, route de Saint-Antoine-de-Ginestière, 06200 Nice, France; Université Côte d'Azur, Côte d'Azur, France; Inserm, U1065, centre méditerranéen de médecine moléculaire/mediterranean center of molecular medicine, C3M, virulence microbienne et signalisation inflammatoire/microbial virulence and inflammatory signalization, Nice, France.
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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: 82] [Impact Index Per Article: 11.7] [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.
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van der Bent S, van Vugt M, Amir A, van der Wal A, Mekkes J. Cutaneous manifestations in treated Whipple's disease. Int J Dermatol 2017; 56:e82-e84. [PMID: 28181229 DOI: 10.1111/ijd.13479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 09/10/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Sebastiaan van der Bent
- Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Michèle van Vugt
- Division of Internal Medicine, Department of Infectious Diseases, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Avital Amir
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Allard van der Wal
- Department of Pathology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Jan Mekkes
- Department of Dermatology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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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.
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Hmamouchi I, Costes V, Combe B, Morel J. Scurvy as the presenting illness of Whipple's disease exacerbated by treatment with etanercept in a patient with ankylosing spondylitis. J Rheumatol 2010; 37:1077-8. [PMID: 20439534 DOI: 10.3899/jrheum.091301] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Erythema nodosum–like lesions in treated Whipple's disease: Signs of immune reconstitution inflammatory syndrome. J Am Acad Dermatol 2009; 60:277-88. [DOI: 10.1016/j.jaad.2008.09.024] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 09/11/2008] [Accepted: 09/21/2008] [Indexed: 11/20/2022]
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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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Al-Hamoudi W, Habbab F, Nudo C, Nahal A, Flegel K. Eosinophilic vasculitis: a rare presentation of Whipple's disease. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2007; 21:189-91. [PMID: 17377649 PMCID: PMC2657688 DOI: 10.1155/2007/326174] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Whipple's disease is a multisystem infectious disease caused by the bacterium Tropheryma whippelii. A case with an unusual presentation is reported. A 66-year-old man presented with a febrile vasculitic rash on his forearms. An extensive rheumatological, hematological and infectious workup gave negative results, apart from mild anemia and eosinophilia. An abdominal computed tomography revealed a retroperitoneal lymphadenopathy, and a skin biopsy revealed an eosinophilic vasculitis. This diverted the work toward ruling out a lymphoma or a vasculitic process. A lymph node biopsy was then performed and showed a diffuse neutrophilic inflammation with abundant foamy macrophages, fat necrosis and lipogranuloma formation. These findings were considered to be nonspecific and no further pathological investigation was carried out. After a course of corticosteroids, diarrhea and weight loss predominated and subsequently a diagnosis of Whipple's disease was confirmed on a small-bowel biopsy. Lymph node involvement was then confirmed on re-evaluation using the appropriate stains.
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Juárez Y, España S, Fernández-Díaz ML, Lueiro M. Escorbuto e ictiosis adquirida asociadas a enfermedad de Whipple. ACTAS DERMO-SIFILIOGRAFICAS 2006; 97:587-90. [PMID: 17173764 DOI: 10.1016/s0001-7310(06)73472-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
The skin manifestations, except for hyperpigmentation, are uncommon in Whipple's disease (WD). We present the case of a 48-year-old male with chronic diarrhea and long course general syndrome associated to neurological manifestations. Skin examination revealed lesions in the lower limbs and gums that were clinically consistent with scurvy and were confirmed by histological study and measurement of blood vitamin C levels. Furthermore, he had lesions that were clinically and histologically consistent with acquired ichthyosis. The digestive tract biopsy study showed non-necrotizing epithelioid granulomas without the presence of PAS positive macrophages. The patient was diagnosed of Whipple's disease through the identification of genomic fragments of Tropheryma Whippelii by PCR in duodenal samples. He was treated with antibiotics for two years with resolution of the cutaneous and digestive picture but with partial improvement of the neurological symptoms. In the literature reviewed, we did not find any case of acquired ichthyosis associated to WD and only one of scurvy secondary to this rare disease.
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Affiliation(s)
- Y Juárez
- Servicio de Dermatología, Complejo Hospitalario Xeral-Calde, San Roque 25, 27002 Lugo, Spain.
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Friedmann AC, Perera GK, Jayaprakasam A, Forgacs I, Salisbury JR, Creamer D. Whipple's disease presenting with symmetrical panniculitis. Br J Dermatol 2004; 151:907-11. [PMID: 15491437 DOI: 10.1111/j.1365-2133.2004.06179.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Specific cutaneous involvement in Whipple's disease is extremely rare. The condition usually runs a chronic course, with symptoms preceding diagnosis by years or even decades. We report a 44-year-old man who presented with a rapid onset of progressive, extensive, symmetrical plaques of panniculitis affecting the inner thighs and forearms. He had accompanying large joint arthritis and was profoundly anaemic. Biopsy of the subcutis revealed a florid septal panniculitis with infiltration of the septa by foamy macrophages containing intracellular granules that stained strongly with periodic acid-Schiff reagent. A similar but more intense infiltrate was seen in the small bowel lamina propria, and a diagnosis of Whipple's disease was made. Symmetrical panniculitis has not previously been reported as a manifestation of Whipple's disease.
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Affiliation(s)
- A C Friedmann
- Department of Dermatology, King's College Hospital, Denmark, Hill, London SE5 9RS, UK.
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