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Lai LM, Zhu XY, Zhao R, Chen Q, Liu JJ, Liu Y, Yuan L. Tropheryma whipplei detected by metagenomic next-generation sequencing in bronchoalveolar lavage fluid. Diagn Microbiol Infect Dis 2024; 109:116374. [PMID: 38805857 DOI: 10.1016/j.diagmicrobio.2024.116374] [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: 02/06/2024] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 05/30/2024]
Abstract
Whipple's disease is a chronic systemic infectious disease that mainly affects the gastrointestinal tract. In some cases, Tropheryma whipplei can cause infection at the implant site or even throughout the body. In this study, we collected alveolar lavage fluid samples from patients with Tropheryma whipplei from 2020 to 2022, and retrospectively analyzed the clinical data of Tropheryma whipplei positive patients. Patient's past history, clinical manifestations, laboratory examinations, chest CT findings, treatment, and prognosis were recorded. 16 BALFs (70/1725, 4.0 %) from 16 patients were positive for Tropheryma whipplei. 8 patients were male with an average age of 50 years. The main clinical symptoms of patients included fever (9/16), cough (7/16), dyspnea (7/16), and expectoration (5/16), but neurological symptoms and arthralgia were rare. Cardiovascular and cerebrovascular diseases were the most common comorbidity (n=8). The main laboratory characteristics of the patient are red blood cell count, hemoglobin, total protein and albumin below normal levels (11/16), and/or creatinine above normal levels(14/16). Most chest computed tomography mainly show focal or patchy heterogeneous infection (n=5) and pleural effusion (n=8). Among the 6 samples, Tropheryma whipplei was the sole agent, and Klebsiella pneumoniae was the most common detected other pathogens. Metagenomic next-generation sequencing technology has improved the detection rate and attention of Tropheryma whipplei. Further research is needed to distinguish whether Tropheryma whipplei present in respiratory samples is a pathogen or an innocent bystander.
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Affiliation(s)
- Lan Min Lai
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Xin Yu Zhu
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Rui Zhao
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Qiang Chen
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Jiao Jiao Liu
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Yang Liu
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China
| | - Lei Yuan
- Department of Clinical laboratory, The First Affiliated Hospital, Jiangxi Medical College, Nanchang University, Nanchang, Jiangxi, PR China.
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Giardini HAM, Neves FS, Pereira IA, Cordeiro RA. Lyme disease and Whipple's disease: a comprehensive review for the rheumatologist. Adv Rheumatol 2024; 64:16. [PMID: 38438928 DOI: 10.1186/s42358-024-00359-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 02/19/2024] [Indexed: 03/06/2024] Open
Abstract
Despite their rarity, Lyme disease and Whipple's disease are of significant importance in rheumatology, as both can manifest as chronic arthritis, presenting challenges in the differential diagnosis of inflammatory arthropathies. In Lyme disease, arthritis typically emerges as a late manifestation, usually occurring six months after the onset of erythema migrans. The predominant presentation involves mono- or oligoarthritis of large joints, with a chronic or remitting-recurrent course. Even with appropriate antimicrobial treatment, arthritis may persist due to inadequate immunological control triggered by the disease. In contrast, Whipple's disease may present with a migratory and intermittent seronegative poly- or oligoarthritis of large joints, preceding classic gastrointestinal symptoms by several years. Both disorders, particularly Whipple's disease, can be misdiagnosed as more common autoimmune rheumatic conditions such as rheumatoid arthritis and spondyloarthritis. Epidemiology is crucial in suspecting and diagnosing Lyme disease, as the condition is transmitted by ticks prevalent in specific areas of the United States, Europe, and Asia. On the contrary, the causative agent of Whipple's disease is widespread in the environment, yet invasive disease is rare and likely dependent on host genetic factors. In addition to erythema migrans in Lyme disease and gastrointestinal manifestations in Whipple's disease, neurological and cardiac involvement can further complicate the course of both. This article offers a comprehensive review of the epidemiological, pathophysiological, clinical, and therapeutic aspects of both diseases.
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Affiliation(s)
- Henrique Ayres Mayrink Giardini
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, 455- 3º andar- sala 3192 Cerqueira Cesar, CEP:01246-903, Sao Paulo, SP, Brazil.
| | - Fabricio Souza Neves
- Rheumatology Division, Internal Medicine Department, Health Sciences Center, Universidade Federal de Santa Catarina (UFSC), Florianopolis, SC, Brazil
| | | | - Rafael Alves Cordeiro
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, 455- 3º andar- sala 3192 Cerqueira Cesar, CEP:01246-903, Sao Paulo, SP, Brazil
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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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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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Ruffer N, Holzer MT, Gkanatsas Y, Schinglerová I, Boro D, Krusche M, Kötter I. [Chronic Tropheryma whipplei infection: an important differential diagnosis of refractory polyarthritis]. Z Rheumatol 2023; 82:885-891. [PMID: 35384513 PMCID: PMC10695860 DOI: 10.1007/s00393-022-01194-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Refractory arthritis is a common problem in routine rheumatology practice, and can be a diagnostic challenge. In these cases, chronic Tropheryma whipplei (T. whipplei) infection is an important differential diagnosis that should be considered. OBJECTIVE Based on five clinical cases, this case-based review describes the diagnostic and therapeutic principles in the management of chronic T. whipplei infection. RESULTS Whipple's disease is a multisystemic infectious disease caused by the bacterium T. whipplei. The disease typically manifests with arthralgia, weight loss and diarrhoea. Joint involvement often develops years before gastrointestinal symptoms occur. In addition to systemic manifestations ("classic Whipple's disease"), T. whipplei can also lead to localized joint infections without gastrointestinal involvement. Articular manifestations of systemic and localized T. whipplei infections are commonly misdiagnosed as a sign of various forms of autoimmmune arthritis. DISCUSSION Whipple's disease and localized T. whipplei joint infection should be considered in the diagnostic work-up of refractory arthritis. Synovial fluid analysis by means of specific polymerase chain reaction-based testing for T. whipplei is diagnostically ground-breaking.
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Affiliation(s)
- Nikolas Ruffer
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Marie-Therese Holzer
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland.
- III. Medizinische Klinik, Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
| | - Yannik Gkanatsas
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Izabela Schinglerová
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Damir Boro
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
| | - Martin Krusche
- III. Medizinische Klinik, Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Ina Kötter
- Klinik für Rheumatologie und Immunologie, Klinikum Bad Bramstedt, Bad Bramstedt, Deutschland
- III. Medizinische Klinik, Sektion Rheumatologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
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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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Motwade N. Kerollos K, Osman Taha B. Whipple's Disease; An Overlooked Diagnosis. Middle East J Dig Dis 2023; 15:136-138. [PMID: 37546505 PMCID: PMC10404087 DOI: 10.34172/mejdd.2023.333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 01/08/2023] [Indexed: 08/08/2023] Open
Abstract
Whipple disease is a rare multisystem inflammatory disease. Because fewer than 1000 reported cases have been described, clinical experience with this disorder is sparse. We are reporting a case of a 46-year-old man who presented with fever, weight loss, and polyarthralgia for 2 months, and 1 month of diarrhea. The patient was thoroughly investigated for collagen diseases and COVID-19, with no definite diagnosis. A therapeutic trial by immunosuppressive drugs provided partial remission followed by a marked rebound of the symptoms. His occult blood in stool was positive and subsequent upper endoscopy with proximal small intestinal biopsies showed the pathological features of Whipple's disease. The patient showed a dramatic improvement following treatment with ceftriaxone and trimethoprim-sulfamethoxazole. Despite the rarity of Whipple's disease, its course mimics many rheumatological diseases, inflammatory bowel disease, and COVID-19 disease. It should always be a part of the differential diagnosis of obscure polyarthralgia and chronic diarrhea.
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Ahmad AI, Wikholm C, Pothoulakis I, Caplan C, Lee A, Buchanan F, Kyoo Cho W. Whipple's disease review, prevalence, mortality, and characteristics in the United States: A cross-sectional national inpatient study. Medicine (Baltimore) 2022; 101:e32231. [PMID: 36626499 PMCID: PMC9750640 DOI: 10.1097/md.0000000000032231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Whipple's disease is a rare multiorgan systemic disease caused by Tropheryma whipplei infection that may present with a wide range of signs and symptoms. This study aim to comprehensively review and determine the inpatient prevalence, mortality, risk factors, and reasons for hospitalization of patients with Whipple's disease. ICD-10 codes were used to identify admissions with Whipple's disease during the years 2016 to 2018. Characteristics of admissions with and without Whipple's disease were compared. The most common reasons for hospitalization were identified in admissions with Whipple's disease. The prevalence of Whipple's disease was 4.6 per 1 million hospitalizations during the study period. Whipple's disease admissions were significantly older than other hospitalizations, with a mean age of 60.2 ± 1.6 years compared to 50.0 ± 0.1. Males were more likely to have Whipple's disease and represented approximately two-thirds of hospitalizations. A disproportionate number of admissions occurred in the Midwest. Patients with Whipple's disease were most commonly admitted for gastrointestinal disease, followed by systemic infection, cardiovascular/circulatory disease, musculoskeletal disease, respiratory disease, and neurological disease. High mortality was seen in admissions for central nervous system (CNS) disease. Whipple's disease has heterogeneous presentations for inpatient admissions, and disproportionately affects older males. High hospitalization rates in the Midwest support environmental and occupational disease transmission likely from the soil. Hospitalists should be aware of the various acute, subacute, and chronic presentations of this disease, and that acute presentations may be more common in the inpatient setting.
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Affiliation(s)
- Akram I. Ahmad
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
| | - Colin Wikholm
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Ioannis Pothoulakis
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
| | - Claire Caplan
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Arielle Lee
- Georgetown University School of Medicine, Washington, D.C., USA
| | - Faith Buchanan
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
| | - Won Kyoo Cho
- Department of Internal Medicine, MedStar Washington Hospital Center Rather than Georgetown, Washington, D.C., USA
- Department of Gastroenterology, MedStar Georgetown University Hospital, Washington, D.C., USA
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Henmi Y, Hirata Y, Koubayashi E, Hara A, Naka Y, Kakimoto K, Nouda S, Kawakami K, Takeuchi T, Higuchi K. Endoscopic diagnosis of Whipple disease in a patient without gastrointestinal symptoms: A case report. DEN OPEN 2022; 2:e37. [PMID: 35310739 PMCID: PMC8828164 DOI: 10.1002/deo2.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/30/2022]
Abstract
Whipple's disease is a systemic chronic bacterial infection caused by Tropheryma whipplei, a gram‐positive bacillus. T. whipplei infection in the small intestine often causes malabsorption and is often accompanied by gastrointestinal symptoms such as diarrhea and abdominal pain. In this report, we describe our experience with a case of Whipple's disease in which the affected patient did not have the typical gastrointestinal symptoms. The patient was an 80‐year‐old male who presented with complaints of weight loss and lower leg edema due to malabsorption and shortness of breath during exertion. A blood test revealed a decreased albumin level and an elevated C‐reactive protein level. Endoscopic images revealed diffuse white villi, the presence of which extended from the duodenum to the upper jejunum. We made a diagnosis of Whipple's disease based on pathological findings associated with the duodenum, electron microscopic findings, and findings of polymerase chain reaction (PCR) tests (performed using mucosal tissue). Clinical symptoms and endoscopic findings improved with antibiotics. Real‐time PCR tests were performed for a quantitative evaluation of the effect of treatment. Endoscopy is useful for diagnosing Whipple's disease when there is an absence of gastrointestinal symptoms, and hypoalbuminemia of unknown etiology is observed.
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Affiliation(s)
- Yujiro Henmi
- Moriguchi Keijinkai Hospital Osaka Japan
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | - Yuki Hirata
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | - Eiko Koubayashi
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | | | - Yutaka Naka
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | - Kazuki Kakimoto
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | - Sadaharu Nouda
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
- Midorigaoka Hospital Osaka Japan
| | - Ken Kawakami
- Moriguchi Keijinkai Hospital Osaka Japan
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | - Toshihisa Takeuchi
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
| | - Kazuhide Higuchi
- Second Department of Internal Medicine Osaka Medical and Pharmaceutical University Osaka Japan
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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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Ingegnoli F, Coletto LA, Scotti I, Compagnoni R, Randelli PS, Caporali R. The Crucial Questions on Synovial Biopsy: When, Why, Who, What, Where, and How? Front Med (Lausanne) 2021; 8:705382. [PMID: 34422862 PMCID: PMC8377390 DOI: 10.3389/fmed.2021.705382] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 07/07/2021] [Indexed: 11/13/2022] Open
Abstract
In the majority of joint diseases, changes in the organization of the synovial architecture appear early. Synovial tissue analysis might provide useful information for the diagnosis, especially in atypical and rare joint disorders, and might have a value in case of undifferentiated inflammatory arthritis, by improving disease classification. After patient selection, it is crucial to address the dialogue between the clinician and the pathologist for adequately handling the sample, allowing identifying histological patterns depending on the clinical suspicion. Moreover, synovial tissue analysis gives insight into disease progression helping patient stratification, by working as an actionable and mechanistic biomarker. Finally, it contributes to an understanding of joint disease pathogenesis holding promise for identifying new synovial biomarkers and developing new therapeutic strategies. All of the indications mentioned above are not so far from being investigated in everyday clinical practice in tertiary referral hospitals, thanks to the great feasibility and safety of old and more recent techniques such as ultrasound-guided needle biopsy and needle arthroscopy. Thus, even in rheumatology clinical practice, pathobiology might be a key component in the management and treatment decision-making process. This review aims to examine some essential and crucial points regarding why, when, where, and how to perform a synovial biopsy in clinical practice and research settings and what information you might expect after a proper patient selection.
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Affiliation(s)
- Francesca Ingegnoli
- Division of Clinical Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milano, Italy.,Department of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Research Center for Environmental Health, Università degli Studi di Milano, Milano, Italy
| | - Lavinia Agra Coletto
- Division of Clinical Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milano, Italy.,Department of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Research Center for Environmental Health, Università degli Studi di Milano, Milano, Italy
| | - Isabella Scotti
- Division of Clinical Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milano, Italy.,Department of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Research Center for Environmental Health, Università degli Studi di Milano, Milano, Italy
| | - Riccardo Compagnoni
- 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milano, Italy.,Department of Biomedical, Surgical and Dental Sciences, Università degli Studi di Milano, Milano, Italy
| | - Pietro Simone Randelli
- 1° Clinica Ortopedica, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milano, Italy.,Laboratory of Applied Biomechanics, Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milano, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, ASST Centro Specialistico Ortopedico Traumatologico Gaetano Pini-CTO, Milano, Italy.,Department of Clinical Sciences & Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Research Center for Environmental Health, Università degli Studi di Milano, Milano, Italy
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12
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DeBoer R, Jayatilaka S, Donato A. Seronegative Arthritis as a Complication of Whipple's Disease. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2021; 14:11795476211017717. [PMID: 34045913 PMCID: PMC8135203 DOI: 10.1177/11795476211017717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Accepted: 04/22/2021] [Indexed: 12/18/2022]
Abstract
Whipple's disease (WD) is an uncommon cause of seronegative arthritis. WD is known for its gastrointestinal symptoms of diarrhea, weight loss, and abdominal pain. However, arthritis may precede gastrointestinal symptoms by 6 to 7 years. We describe a case of an 85-year-old Caucasian male with multiple joint complaints, not responsive to traditional treatments for conditions such as rheumatoid arthritis and osteoarthritis. We suggest that WD be considered for seronegative arthritis especially affecting large joints.
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Affiliation(s)
- Rebecca DeBoer
- Department of Medicine, Reading Hospital, Reading, PA, USA
| | | | - Anthony Donato
- Department of Medicine, Reading Hospital, Reading, PA, USA
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13
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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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14
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Clinical manifestations of Whipple's disease mimicking rheumatic disorders. Reumatologia 2021; 59:104-110. [PMID: 33976464 PMCID: PMC8103404 DOI: 10.5114/reum.2021.105418] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022] Open
Abstract
Whipple’s disease is a rare, chronic, systemic disorder caused by Tropheryma whipplei infection. The most common symptoms are weight loss, arthralgia, diarrhea and abdominal pain. Other organ involvement can also occur in the patients. Joint manifestations may mimic rheumatoid arthritis or spondyloarthritis. Arthalgia, arthritis, spondylodiscitis, bursitis and/or tenosynovitis are seen in the majority of the patients. This explains why some of the symptoms are misdiagnosed as those of rheumatic diseases. Understanding of Whipple’s disease is important for differential diagnostics of several rheumatic symptoms.
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15
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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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16
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Ahn JK, Hwang J, Seo GH. Incidence and risk of developing rheumatic diseases in 19,724 patients with palindromic rheumatism in South Korea: A nationwide population-based study. Joint Bone Spine 2021; 88:105128. [PMID: 33359768 DOI: 10.1016/j.jbspin.2020.105128] [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] [Received: 04/28/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The spectrum of progression of palindromic rheumatism (PR) to chronic diseases is quite variable. Hence, this study aimed to investigate the incidence and risk of developing rheumatic diseases in PR using nationwide, population-based medical claims data from Korea. METHODS We assessed the incidence rate (IR) of PR in the population in the given year. After matching individuals with PR with those without PR (1:10) for age, gender, and the index year, we calculated the hazard ratios (HRs) with 95% confidence intervals (CIs) using the Cox proportional hazard model. RESULTS A total of 19,724 newly diagnosed incident PR cases were identified from 2010 to 2016. The mean age was 50.2±14.9 years. The incidence of PR was 7.02 (95% CI 6.92-7.12) per 100,000 person-years (6.22 and 7.80 in men and women, respectively). During observation, 8.79% patients with PR and 0.30% individuals without PR developed various outcome diseases. Patients with PR had an increased risk of seropositive rheumatoid arthritis (HR 46.51, 95% CI [41.05-52.69]), psoriatic arthritis (44.79 [15.16-132.35]), systemic lupus erythematosus (24.53 [16.15-37.24]), mixed connective tissue disease (22.01 [7.65-63.34]), Behçet's disease (21.04 [13.81-32.06]), Sjögren's syndrome (12.36 [8.54-17.88]), ankylosing spondylitis (9.00 [6.67-12.15]), dermatomyositis/polymyositis (6.14 [2.55-14.82]), and systemic sclerosis (3.75 [1.47-9.58]) compared with individuals without PR. CONCLUSIONS This nationwide, population-based cohort study demonstrated that about one-eleventh of patients with PR eventually develop systemic rheumatic diseases and that patients with PR have an increased risk of developing various rheumatic diseases including seropositive rheumatoid arthritis.
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Affiliation(s)
- Joong Kyong Ahn
- Division of Rheumatology, Department of Internal Medicine, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Jiwon Hwang
- Division of Rheumatology, Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Gi Hyeon Seo
- Health Insurance Review and Assessment Service, Wonju, Republic of Korea.
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17
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Rey R M, Orozco LA, Marrugo K, López R, Pérez-Riveros ED, De la Hoz-Valle J, Sierra-Arango F. Whipple disease diagnosed by enteroscopy: first case report in Colombia of an underdiagnosed disease and literature review. BMC Gastroenterol 2020; 20:197. [PMID: 32576148 PMCID: PMC7310292 DOI: 10.1186/s12876-020-01302-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 05/11/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Whipple's disease is a rare systemic disease caused by a gram-positive bacillus called Tropheryma whipplei. First described in 1907 as an intestinal lipodystrophy with histological finding of vacuoles in the macrophages of the intestinal mucous. Usually the symptoms are localized according to the compromised organ. The differential diagnosis is wide. It can be fatal without proper treatment. Recurrence can occur in up to 33% of the cases and usually compromises the neurological system. CASE PRESENTATION This article reports the case of a 46-year-old female patient with a history of a 6-month hypochromic microcytic anemia of unknown cause. She consulted for a 6-months oppressive abdominal pain located in the mesogastrium as well as abdominal distention associated with nausea and liquid stools; in addition, she had an 8-month small and medium joint pain, without edema or erythema. Physical examination without relevant findings. Multiple esophagogastroduodenoscopies with normal gastric and duodenal biopsies findings and a normal colonoscopy were performed. Endoscope capsule showed red spots in the duodenum and ulcerations in the jejunum and proximal ileum covered by fibrin; histological report showed macrophages with positive periodic acid-schiff reaction staining (PAS staining), disgnosing Whipple's disease. Antibiotics were initiated. The patient is currently in the second phase of treatment without gastrointestinal and joint symptoms. CONCLUSION This is the first case reported in Colombia. It is a rare entity and difficult to diagnose reason why it is important to continue with clinical investigations to give more clarity about the onset and appropriate diagnose to avoid the delay in treatment of this entity.
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Affiliation(s)
- Margarita Rey R
- Gastroenterology and Hepatology Department, Digestive Endoscopy Section, Fundación Santa Fe de Bogotá, Cogotá D.C., Colombia.
| | | | | | - Rocio López
- Pathology Department, Fundación Santa Fe de Bogotá, Cogotá D.C., Colombia
| | - Erika D Pérez-Riveros
- Subdirección de Estudios Clínicos y Epidemiología Clínica (SECEC), Fundación Santa Fe de Bogotá, Bogotá D. C., Colombia
| | - José De la Hoz-Valle
- Subdirección de Estudios Clínicos y Epidemiología Clínica (SECEC), Fundación Santa Fe de Bogotá, Bogotá D. C., Colombia
| | - Fernando Sierra-Arango
- Gastroenterology and Hepatology Department, Digestive Endoscopy Section, Fundación Santa Fe de Bogotá and Universidad de los Andes Medical School, Bogotá D.C., Colombia
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18
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Fabian E, Tinchon C, Lueger A, Bauer PK, Mayer-Pickel KI, Raggam RB, Hammer HF, Langner C, Krejs GJ. Clinical-Pathological Conference Series from the Medical University of Graz : Case No 169: A 32-year-old woman with anemia in pregnancy. Wien Klin Wochenschr 2020; 132:322-331. [PMID: 32468113 PMCID: PMC7297834 DOI: 10.1007/s00508-020-01679-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Accepted: 05/07/2020] [Indexed: 11/01/2022]
Affiliation(s)
- Elisabeth Fabian
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christoph Tinchon
- Division of Hematology and Oncology, Department of Internal Medicine, State Hospital Hochsteiermark, Leoben, Austria
| | - Andreas Lueger
- Division of Emergency Medicine, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp K Bauer
- Division of Infectious Diseases and Tropical Medicine, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | | | - Reinhold B Raggam
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Heinz F Hammer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria
| | - Cord Langner
- Department of Pathology, Medical University of Graz, Graz, Austria
| | - Guenter J Krejs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, 8036, Graz, Austria.
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19
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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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20
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Epidemiology of Whipple's Disease in the USA Between 2012 and 2017: A Population-Based National Study. Dig Dis Sci 2019; 64:1305-1311. [PMID: 30488239 PMCID: PMC6499665 DOI: 10.1007/s10620-018-5393-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 11/22/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Prior studies on the epidemiology of Whipple's disease are limited by small sample size and case series design. We sought to characterize the epidemiology of Whipple's disease in the USA utilizing a large population-based database. METHODS We queried a commercial database (Explorys Inc, Cleveland, OH), an aggregate of electronic health record data from 26 major integrated healthcare systems in the USA. We identified a cohort of patients with a diagnosis of Whipple's disease based on systemized nomenclature of medical terminology (SNOMED CT) codes. We calculated the overall and age-, race-, ethnicity, and gender-based prevalence of Whipple's disease and prevalence of associated diagnoses using univariate analysis. RESULTS A total of 35,838,070 individuals were active in the database between November 2012 and November 2017. Of these, 350 individuals had a SNOMED CT diagnosis of Whipple's disease, with an overall prevalence of 9.8 cases per 1 million. There was no difference in prevalence based on sex. However, prevalence of Whipple's disease was higher in Caucasians, non-Hispanics, and individuals > 65 years old. Individuals with a diagnosis of Whipple's disease were more likely to have associated diagnoses/findings of arthritis, CNS disease, endocarditis, diabetes, malignancy, dementia, vitamin D deficiency, iron deficiency, chemotherapy, weight loss, abdominal pain, and lymphadenopathy. CONCLUSIONS To our knowledge, this is the largest study to date examining the epidemiology of Whipple's disease. In this large population-based study, the overall prevalence of Whipple's disease in the USA is 9.8 cases per 1 million people. It affects men and women at similar rates and is more common in Caucasians, non-Hispanics, and people > 65 years old.
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21
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Sluszniak M, Tarner IH, Thiele A, Schmeiser T. [The rich diversity of Whipple's disease]. Z Rheumatol 2018; 78:55-65. [PMID: 30552512 DOI: 10.1007/s00393-018-0573-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Whipple's disease (WD) is a rare, chronic multiorgan disease which can caused by Tropheryma whipplei, a ubiquitous gram positive bacterium. Detection of T. whipplei is mostly performed histologically using periodic acid-Schiff (PAS) staining in affected tissues to visualize characteristic PAS-positive macrophages and by the polymerase chain reaction (PCR). Clinically, WD is often characterized by gastrointestinal symptoms (diarrhea, colic-like abdominal pain and weight loss). Arthritis is a common presentation of WS, often leading to a misdiagnosis of seronegative rheumatoid arthritis and as a consequence to immunosuppressive therapy. The clinical presentation of WD is highly polymorphic affecting different organ systems (e. g. cardiac or neurological manifestation) and making an appropriate clinical diagnosis and even the diagnostic process itself difficult. This article reports on three cases presenting with completely different leading symptoms (initially misdiagnosed as seronegative rheumatoid arthritis, spondyloarthritis and adult onset of Still's disease, respectively) that illustrate the rich diversity of WD. The cases were chosen to draw attention to the fact that although WD is mainly associated with the field of gastroenterology and gastrointestinal (GI) involvement is common, it may appear without GI symptoms. In cases of a clinical suspicion of WD, diagnostic efforts should be made to detect the bacterium in the affected organ. The German S2k guidelines on GI infections and WD published in January 2015 summarized the current state of the art for WD. The currently recommended primary treatment is antibiotics that can infiltrate the cerebrospinal fluid, e. g. ceftriaxone, followed by cotrimoxazole, which should be maintained over several months.
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Affiliation(s)
- M Sluszniak
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland.
| | - I H Tarner
- Abt. für Rheumatologie, Klinische Immunologie, Osteologie und Physikalische Medizin, Kerckhoff-Klinik GmbH Bad Nauheim, Bad Nauheim, Deutschland.,Lehrstuhl für Innere Medizin mit Schwerpunkt Rheumatologie, Justus-Liebig-Universität Gießen, Gießen, Deutschland
| | - A Thiele
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
| | - T Schmeiser
- Klinik für Rheumatologie, Immunologie und Osteologie, Krankenhaus St. Josef Wuppertal, Bergstr. 6-12, 42105, Wuppertal, Deutschland
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22
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Ben Azzouz E, Boumaza A, Mezouar S, Bardou M, Carlini F, Picard C, Raoult D, Mège JL, Desnues B. Tropheryma whipplei Increases Expression of Human Leukocyte Antigen-G on Monocytes to Reduce Tumor Necrosis Factor and Promote Bacterial Replication. Gastroenterology 2018; 155:1553-1563. [PMID: 30076840 DOI: 10.1053/j.gastro.2018.07.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 07/10/2018] [Accepted: 07/27/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Infection with Tropheryma whipplei has a range of effects-some patients can be chronic carriers without developing any symptoms, whereas others can develop systemic Whipple disease, characterized by a lack a protective inflammatory immune response. Alterations in HLA-G function have been associated with several diseases. We investigated the role of HLA-G during T whipplei infection. METHODS Sera, total RNA, and genomic DNA were collected from peripheral blood from 22 patients with classic Whipple's disease, 19 patients with localized T whipplei infections, and 21 asymptomatic carriers. Levels of soluble HLA-G in sera were measured by enzyme-linked immuosorbent assay, and expressions of HLA-G and its isoforms were monitored by real-time polymerase chain reaction. HLA-G alleles were identified and compared with a population of voluntary bone marrow donors. Additionally, monocytes from healthy subjects were stimulated with T whipplei, and HLA-G expression was monitored by real-time polymerase chain reaction and flow cytometry. Bacterial replication was assessed by polymerase chain reaction in the presence of HLA-G or inhibitor of tumor necrosis factor (TNF) (etanercept). RESULTS HLA-G mRNAs and levels of soluble HLA-G were significantly increased in sera from patients with chronic T whipplei infection compared with sera from asymptomatic carriers and control individuals. No specific HLA-G haplotypes were associated with disease or T whipplei infection. However, T whipplei infection of monocytes induced expression of HLA-G, which was associated with reduced secretion of TNF compared with noninfected monocytes. A neutralizing antibody against HLA-G increased TNF secretion by monocytes in response to T whipplei, and a TNF inhibitor promoted bacteria replication. CONCLUSIONS Levels of HLA-G are increased in sera from patients with T whipplei tissue infections, associated with reduced production of TNF by monocytes. This might promote bacteria colonization in patients.
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Affiliation(s)
- Eya Ben Azzouz
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France
| | - Asma Boumaza
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France
| | - Soraya Mezouar
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France
| | - Matthieu Bardou
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France
| | | | - Christophe Picard
- Aix-Marseille Univ, CNRS, EFS, ADES UMR 7268, Marseille, France; Laboratoire d'immunogénétique, Établissement Français du Sang Provence Alpes Côte d'Azur Corse, Marseille, France
| | - Didier Raoult
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France
| | - Jean-Louis Mège
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France
| | - Benoit Desnues
- Aix Marseille Univ, IRD, APHM, MEPHI, IHU-Mediterranee Infection, Marseille, France.
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Wartique L, Lagier JC, Raoult D, Jamilloux Y, Sève P. Mesenteric lymphadenitis as a presenting feature of Whipple's disease: Value of PCR analysis. Int J Infect Dis 2018; 75:15-17. [PMID: 30096359 DOI: 10.1016/j.ijid.2018.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 08/01/2018] [Accepted: 08/02/2018] [Indexed: 12/17/2022] Open
Abstract
Whipple's disease (WD) is a rare chronic and systemic infection caused by the ubiquitous actinomycete Tropheryma whipplei. A case of localized infection with mesenteric adenopathy associated with a prolonged unexplained fever is reported herein. Screening by PCR on saliva and stool was positive, and T. whipplei was formally identified by specific PCR on duodenal and mesenteric adenopathy biopsies. Histological analysis did not demonstrate periodic acid-Schiff-positive macrophages or positive T. whipplei immunochemistry in either the duodenal mucosa or mesenteric nodes. Treatment with hydroxychloroquine and doxycycline allowed a rapid resolution of symptoms, and subsequent saliva and stool PCR results were negative.
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Affiliation(s)
- Lucie Wartique
- Department of Internal Medicine, Grand Hôpital de Charleroi, Charleroi, Belgium
| | | | - Didier Raoult
- Aix Marseille Université, IRD, MEPHI, IHU - Méditerranée Infection, Marseille, France
| | - Yvan Jamilloux
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Pascal Sève
- Department of Internal Medicine, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France.
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Herbette M, Cren JB, Joffres L, Lucas C, Ricard E, Salliot C, Guinard J, Perdriger A, Solau-Gervais E, Bouvard B, Saraux A. Usefulness of polymerase chain reaction for diagnosing Whipple's disease in rheumatology. PLoS One 2018; 13:e0200645. [PMID: 30020975 PMCID: PMC6051605 DOI: 10.1371/journal.pone.0200645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 06/30/2018] [Indexed: 12/17/2022] Open
Abstract
Objectives To determine when Tropheryma whipplei polymerase chain reaction (PCR) is appropriate in patients evaluated for rheumatological symptoms. Methods In a retrospective observational study done in rheumatology units of five hospitals, we assessed the clinical and radiological signs that prompted T. whipplei PCR testing between 2010 and 2014, the proportion of patients diagnosed with Whipple’s disease, the number of tests performed and the number of diagnoses according to the number of tests, the patterns of Whipple’s disease, and the treatments used. Diagnostic ascertainment was based on 1- Presence of at least one suggestive clinical finding; 2- at least one positive PCR test, and 3- a response to antibiotic therapy described by the physician as dramatic, including normalization of C Reactive Protein. Results At least one PCR test was performed in each of 267 patients. Rheumatic signs were peripheral arthralgia (n = 239, 89%), peripheral arthritis (n = 173, 65%), and inflammatory back pain (n = 85, 32%). Whipple’s disease was diagnosed in 13 patients (4.9%). The more frequently positive tests were saliva and stool. In the centres with no diagnoses of Whipple’s disease, arthritis was less common and constitutional symptoms more common. The group with Whipple’s disease had a higher proportion of males, older age, and greater frequency of arthritis. The annual incidence ranged across centres from 0 to 3.6/100000 inhabitants. Conclusion Males aged 40–75 years with unexplained intermittent seronegative peripheral polyarthritis, including those without constitutional symptoms, should have T. whipplei PCR tests on saliva, stool and, if possible, joint fluid.
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Affiliation(s)
- Marion Herbette
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest, France
| | | | | | | | - Emilie Ricard
- Rheumatology and bacteriology Units, CHR, Orléans, France
| | - Carine Salliot
- Rheumatology and bacteriology Units, CHR, Orléans, France
| | - Jérôme Guinard
- Rheumatology and bacteriology Units, CHR, Orléans, France
| | | | | | | | - Alain Saraux
- Rheumatology Unit, Hôpital de la Cavale Blanche, Brest, France
- UMR1227, Lymphocytes B et Autoimmunité, Université de Brest, LabEx IGO, Brest, France
- * E-mail:
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Saito H, Shiode J, Ohya S, Yao A, Saito S, Fujii M, Itoh M, Ishiyama S, Fujiwara A, Nasu J, Yoshioka M, Yamamoto K. Whipple's Disease with Long-term Endoscopic Follow-up. Intern Med 2018; 57:1707-1713. [PMID: 29434152 PMCID: PMC6047986 DOI: 10.2169/internalmedicine.9631-17] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
A 72-year-old man presented with anorexia and 15-kg weight loss over 3 years. Endoscopy revealed yellow, shaggy mucosa alternating with erythematous, eroded mucosa in the duodenum. Biopsy specimens showed massive infiltration of periodic acid-Schiff-positive macrophages in the lamina propria, consistent with Whipple's disease. The patient was treated with intravenous ceftriaxone for four weeks, followed by oral trimethoprim-sulfamethoxazole. His condition improved, and he gradually gained weight. Although the endoscopic findings improved with continuous trimethoprim-sulfamethoxazole administration, macrophage infiltration of the duodenal mucosa persisted. However, the patient has been symptom-free for eight years.
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Affiliation(s)
- Hiroaki Saito
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
- Saito Clinic, Japan
| | - Junji Shiode
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Shogen Ohya
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
- Kawaguchi-Medical Clinic, Japan
| | - Atsushi Yao
- Department of Internal Medicine (Nephrology), Kanto Rosai Hospital, Japan
| | - Shunsuke Saito
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Masakuni Fujii
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Mamoru Itoh
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Shuhei Ishiyama
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Akiko Fujiwara
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Junichiro Nasu
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Masao Yoshioka
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
| | - Kazuhide Yamamoto
- Department of Internal Medicine, Okayama Saiseikai General Hospital, Japan
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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: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Whipple's disease is a rare infectious disease that can be fatal if left untreated. The disease is caused by infection with Tropheryma whipplei, a bacterium that may be more common than was initially assumed. Most patients present with nonspecific symptoms, and as routine cultivation of the bacterium is not feasible, it is difficult to diagnose this infection. On the other hand, due to the generic symptoms, infection with this bacterium is actually quite often in the differential diagnosis. The gold standard for diagnosis used to be periodic acid-Schiff (PAS) staining of duodenal biopsy specimens, but PAS staining has a poor specificity and sensitivity. The development of molecular techniques has resulted in more convenient methods for detecting T. whipplei infections, and this has greatly improved the diagnosis of this often missed infection. In addition, the molecular detection of T. whipplei has resulted in an increase in knowledge about its pathogenicity, and this review gives an overview of the new insights in epidemiology, pathogenesis, clinical manifestations, diagnosis, and treatment of Tropheryma whipplei infections.
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Whipple's disease. J Neurol Sci 2017; 377:197-206. [DOI: 10.1016/j.jns.2017.01.048] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Revised: 12/16/2016] [Accepted: 01/15/2017] [Indexed: 11/24/2022]
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Glaser C, Rieg S, Wiech T, Scholz C, Endres D, Stich O, Hasselblatt P, Geißdörfer W, Bogdan C, Serr A, Häcker G, Voll RE, Thiel J, Venhoff N. Whipple's disease mimicking rheumatoid arthritis can cause misdiagnosis and treatment failure. Orphanet J Rare Dis 2017; 12:99. [PMID: 28545554 PMCID: PMC5445468 DOI: 10.1186/s13023-017-0630-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 04/11/2017] [Indexed: 12/18/2022] Open
Abstract
Background Whipple’s disease, a rare chronic infectious disorder caused by Tropheryma whipplei, may present with predominant joint manifestations mimicking rheumatoid arthritis (RA). Methods A retrospective single-center cohort study of seven patients was performed. Clinical symptoms were assessed by review of medical charts and Whipple’s disease was diagnosed by periodic-acid-Schiff-stain and/or Tropheryma whipplei-specific polymerase-chain-reaction. Results Median age at disease onset was 54 years, six patients were male. Median time to diagnosis was 5 years. All patients presented with polyarthritis with a predominantly symmetric pattern. Three had erosive arthritis. Affected joints were: wrists (5/7), metacarpophalangeal joints (MCPs) (5/7), knees (5/7), proximal interphalangeal joints (PIPs) (3/7), hips (2/7), elbow (2/7), shoulder (2/7). All patients had increased C-reactive-protein concentrations, while rheumatoid factor and anti-CCP-antibodies were absent, and were initially (mis)classified as RA-patients according to EULAR/ACR-criteria (median DAS28 4.3). Six patients received antirheumatic treatment consisting of prednisone with methotrexate and/or leflunomide, three were additionally treated with at least one biologic agent (abatacept, adalimumab, etanercept, rituximab, tocilizumab). Most patients showed insufficient treatment response. In all patients Tropheryma whipplei was detected in synovial fluid by polymerase-chain-reaction; in three patients the diagnosis of Whipple’s disease was further ascertained by periodic-acid-Schiff-staining. Gastrointestinal symptoms and other extra-articular manifestations were absent, mild or non-specific. Treatment was initiated with trimethoprin/sulfamethoxazole in five and doxycycline/hydroxychloroquine in two patients and had to be adapted in five patients. Finally, all patients had good treatment responses with improvement of arthritis and extra-articular manifestations. Conclusion Whipple’s disease is rare and can mimic rheumatoid arthritis. Especially patients with seronegative rheumatoid arthritis with a prolonged disease course and insufficient treatment response should be reevaluated for Whipple’s disease.
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Affiliation(s)
- Cornelia Glaser
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.
| | - Siegbert Rieg
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, Faculty of Medicine, University Hospital Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Thorsten Wiech
- Institute of Pathology, Nephropathology Section, University Hospital Hamburg, Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christine Scholz
- Private Practice for Rheumatology, Bertoldstraße 8, 79098, Freiburg, Germany
| | - Dominique Endres
- Section of Experimental Neuropsychiatry, Department of Psychiatry, Faculty of Medicine, University of Freiburg, Hauptstraße 5, 79104, Freiburg, Germany
| | - Oliver Stich
- Department of Neurology, Medical Center, University of Freiburg, Breisacher Straße 86, 79110, Freiburg, Germany
| | - Peter Hasselblatt
- Department of Medicine II, Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases, Faculty of Medicine, University Hospital Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Walter Geißdörfer
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3-5, 91054, Erlangen, Germany
| | - Christian Bogdan
- Mikrobiologisches Institut - Klinische Mikrobiologie, Immunologie und Hygiene, Universitätsklinikum Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Wasserturmstraße 3-5, 91054, Erlangen, Germany
| | - Annerose Serr
- Institute for Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Hermann-Herder-Str. 11, 79104, Freiburg, Germany
| | - Georg Häcker
- Institute for Microbiology and Hygiene, Faculty of Medicine, University of Freiburg, Hermann-Herder-Str. 11, 79104, Freiburg, Germany
| | - Reinhard E Voll
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Jens Thiel
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
| | - Nils Venhoff
- Department of Rheumatology and Clinical Immunology, Medical Center. Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany
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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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Whipple's disease without gastrointestinal symptoms: a challenging diagnosis. J Neurol 2016; 263:1657-8. [PMID: 27272955 DOI: 10.1007/s00415-016-8184-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 05/27/2016] [Accepted: 05/27/2016] [Indexed: 10/21/2022]
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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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Abstract
Bacteria, viruses, fungi, and parasites can all cause arthritis of either acute or chronic nature, which can be divided into infective/septic, reactive, or inflammatory. Considerable advances have occurred in diagnostic techniques in the recent decades resulting in better treatment outcomes in patients with infective arthritis. Detection of emerging arthritogenic viruses has changed the epidemiology of infection-related arthritis. The role of viruses in the pathogenesis of chronic inflammatory arthritides such as rheumatoid arthritis is increasingly being recognized. We discuss the various causative agents of infective arthritis and emphasize on the approach to each type of arthritis, highlighting the diagnostic tests, along with their statistical accuracy. Various investigations including newer methods such as nucleic acid amplification using polymerase chain reaction are discussed along with the pitfalls in interpreting the tests.
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Affiliation(s)
- Ashish Jacob Mathew
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
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Tumoural form of Whipple's disease simulating carcinomatosis. Braz J Infect Dis 2014; 18:346-9. [PMID: 24690429 PMCID: PMC9427525 DOI: 10.1016/j.bjid.2014.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2013] [Accepted: 01/10/2014] [Indexed: 12/20/2022] Open
Abstract
Whipple's disease is a rare disease caused by the actinomycete bacteria Tropheryma whipplei, which cause intestinal infection. The most common symptoms are chronic diarrhoea, weight loss, abdominal pain, arthritis and neurological abnormalities, which can be fatal. This paper reports a case of a 57-year-old Brazilian woman with diarrhoea, vomiting, abdominal pain, appetite loss, intermittent fever, malaise, weight loss and malnutrition. Migratory polyarthralgia and recurrent visual scotomas preceded the symptoms. The retroperitoneal pseudotumour formation finding was associated with prolonged wasting syndrome, which did not respond to usual therapies, thus leading to the investigation of carcinomatosis disease. After laparotomy, biopsy and histochemical study of the lesions with negative results for malignancy, we proceeded to the investigation of Whipple's disease, which was then confirmed. The patient improved clinically and started gaining weight after using ceftriaxone (IV).
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Meunier M, Puechal X, Hoppé E, Soubrier M, Dieudé P, Berthelot JM, Caramaschi P, Gottenberg JE, Gossec L, Morel J, Maury E, Wipff J, Kahan A, Allanore Y. Rheumatic and musculoskeletal features of Whipple disease: a report of 29 cases. J Rheumatol 2013; 40:2061-6. [PMID: 24187107 DOI: 10.3899/jrheum.130328] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Whipple disease is a rare infection caused by Tropheryma whipplei. Although patients commonly complain of osteoarticular involvement, musculoskeletal manifestations have been poorly described. We report cases of Whipple disease with rheumatic symptoms and describe their clinical presentation, modes of diagnosis, and outcomes. METHODS This retrospective multicenter study included patients with Whipple disease diagnosed and referenced between 1977 and 2011 in 10 rheumatology centers in France and Italy. RESULTS Twenty-nine patients were included. The median age was 55 years. The median time to diagnosis from first symptoms was 5 years. Polyarthritis was the most frequent presentation (20/29), and was most often chronic, intermittent (19/29), seronegative (22/23), and nonerosive (22/29). In all cases, the symptoms had led to incorrect diagnosis of inflammatory rheumatic disease and immunosuppressants, including biotherapy, were prescribed in most cases (24/29) without success. The diagnosis of Whipple disease was made by histological analysis, molecular biology tests, or both in 21%, 36%, and 43% of the cases, respectively. Duodenal biopsies were performed in most cases (86%). Synovial biopsies were performed in 18% of cases, but all contributed to diagnosis. The clinical outcomes after antibiotic therapy were good for all patients. CONCLUSION Polyarthritis is the main feature observed in cases of Whipple disease; it is seronegative and associated with general and gastrointestinal symptoms. The molecular analysis of duodenal tissue and/or other tissues remains the method of choice to confirm the diagnosis. Reducing the time to diagnosis is important because severe late systemic and fatal forms of the disease may occur.
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Affiliation(s)
- Marine Meunier
- From the Paris Descartes University, Rheumatology A Department and Rheumatology B Department, Cochin Hospital, AP-HP, Paris; Rheumatology Department, Le Mans Hospital; Rheumatology Department, CHU Angers; Rheumatology Department, CHU Clermont-Ferrand; Rheumatology Department, Bichat Hospital, AP-HP, Paris; Rheumatology Department, CHU Nantes; Unità di Reumatologia, Azienda Ospedaliera Universitaria Integrata, Verona, Italy; Rheumatology Department, CHU Strasbourg; and the Rheumatology Department, Teaching Hospital of Lapeyronie and University of Montpellier, France
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Maresi E, Argo A, Portelli F, Busardò FP, Raoult D, Lepidi H. Rare occurrence of Whipple Disease in a young female patient with a fatal outcome. EGYPTIAN JOURNAL OF FORENSIC SCIENCES 2013. [DOI: 10.1016/j.ejfs.2013.04.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Vayssade M, Tatar Z, Soubrier M. Rhumatisme palindromique. Rev Med Interne 2013; 34:47-52. [DOI: 10.1016/j.revmed.2012.07.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Revised: 05/06/2012] [Accepted: 07/30/2012] [Indexed: 01/06/2023]
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Makol A, Maleszewski JJ, Warrington KJ. A case of refractory rheumatoid pericarditis. Arthritis Care Res (Hoboken) 2012; 64:935-40. [PMID: 22337605 DOI: 10.1002/acr.21645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Ashima Makol
- Division of Rheumatology, Department of Internal Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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Uryu K, Sakai T, Yamamoto T, Mae T, Willard YI, Sugita H, Asano K, Yamashita K, Harada H, Fukuda K. Central nervous system relapse of Whipple's disease. Intern Med 2012; 51:2045-50. [PMID: 22864135 DOI: 10.2169/internalmedicine.51.7304] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 50-year-old man presented with a 12 kg weight loss in 8 months. Upper gastrointestinal endoscopy findings showed strong erosion and diffuse bleeding in the duodenum. Histopathological findings showed PAS staining-positive macrophages consistent with Whipple's disease. He was treated with trimethoprim-sulfamethoxazole. His condition initially improved. However, during his 6-year course of treatment he developed a central nervous system relapse. Tropheryma whipplei DNA was detected by a polymerase chain reaction in his cerebrospinal fluid. This relapse was successfully treated with ceftriaxone sodium (CTRX). We considered that as initial therapy for Whipple's disease, it would be important to administer CTRX for at least a few months, due to its high translatability to CSF.
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Affiliation(s)
- Kiyoaki Uryu
- Department of Respiratory Medicine, Yao Tokushukai General Hospital, Japan.
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Samarasena JB, Hu KQ. Hepatobiliary manifestations of gastrointestinal and nutritional disorders. Clin Liver Dis 2011; 15:89-110. [PMID: 21111995 DOI: 10.1016/j.cld.2010.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Hepatobiliary manifestations of gastrointestinal and nutritional disorders can occur as part of the clinical spectrum of the underlying disease or as a consequence of the treatment of the disease. This article reviews aspects of pathogenesis, diagnosis, and management of hepatobiliary manifestations associated with a selection of gastrointestinal and nutritional disorders including inflammatory bowel disease, celiac disease, Whipple's disease, and parenteral nutrition associated disorders.
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Affiliation(s)
- Jason B Samarasena
- Division of Gastroenterology, University of California Irvine Medical Center, 101 The City Drive, City Tower, Suite 400, Zot 4092, Orange, CA 92868, USA
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New insights into Whipple’s disease and Tropheryma whipplei infections. Microbes Infect 2010; 12:1102-10. [DOI: 10.1016/j.micinf.2010.08.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 08/02/2010] [Indexed: 12/17/2022]
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Lagier JC, Lepidi H, Raoult D, Fenollar F. Systemic Tropheryma whipplei: clinical presentation of 142 patients with infections diagnosed or confirmed in a reference center. Medicine (Baltimore) 2010; 89:337-345. [PMID: 20827111 DOI: 10.1097/md.0b013e3181f204a8] [Citation(s) in RCA: 149] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Culture of Tropheryma whipplei, the agent of Whipple disease (WD), was achieved in our laboratory in 2000, allowing new perspectives for the diagnosis of this disease and for the description of other potential clinical manifestations caused by this microorganism. Since 2000, we have developed new tools in our center in Marseille, France, to optimize the diagnosis of T whipplei infections. Classic WD was characterized by positive periodic acid-Schiff performed on duodenal biopsy. In the absence of duodenal histologic involvement, localized infections were defined by specific positive T whipplei polymerase chain reaction (PCR) results obtained using samples of other tissues and body fluids. The physicians in charge of patients were asked to complete a questionnaire. A total of 215 diagnoses were performed or confirmed and, among these, 142 patients with sufficient clinical data were included.Herein, we report epidemiologic data, clinical manifestations, and diagnostic tools of T whipplei infections. In the 113 patients with classic WD, the main symptom was arthralgia (88/113, 78%), which explains the many cases misdiagnosed as inflammatory rheumatoid disease (56/113, 50%). Frequently immunosuppressive treatments, more recently including tumor necrosis factor inhibitor, had been previously prescribed (50%) and were often responsible for more rapid clinical progression (43%). Sometimes a short course of antibiotics improved the clinical status.Endocarditis was the second most frequent manifestation of T whipplei, with 16 cases. The clinical picture of this entity corresponds to cardiovascular involvement with acute heart failure (50%) occurring without fever (75%) or previous valvular disease (69%). Neurologic symptoms were the third major manifestation. Other localized infections such as adenopathy, uveitis, pulmonary involvement, or joint involvement were sporadic. Infection with T whipplei resulted in multifaceted conditions. Some localized infections due to this agent have recently been reported and may correspond to emerging entities. Patients with inflammatory rheumatoid disease must be systematically interviewed to determine the efficacy of previous immunosuppressive and antibiotic therapies.
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Affiliation(s)
- Jean-Christophe Lagier
- From Université de la Méditerranée, Unité des Rickettsies, URMITE CNRS-IRD 198 UMR 6236, Marseille, France
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Lagier JC, Fenollar F, Raoult D. De la maladie de Whipple aux infections à Tropheryma whipplei. Med Mal Infect 2010; 40:371-82. [DOI: 10.1016/j.medmal.2009.10.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2009] [Accepted: 10/28/2009] [Indexed: 12/17/2022]
Affiliation(s)
- J-C Lagier
- Urmite CNRS-IRD UMR 6236, unité des Rickettsies, faculté de médecine, université de la Méditerranée, 27, boulevard Jean-Moulin, 13385 Marseille cedex 05, France
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Lauwers G, Mino-Kenudson M, Kradin RL. Infections of the Gastrointestinal Tract. DIAGNOSTIC PATHOLOGY OF INFECTIOUS DISEASE 2010. [PMCID: PMC7152102 DOI: 10.1016/b978-1-4160-3429-2.00009-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Kneitz C, Suerbaum S, Beer M, Müller J, Jahns R, Tony HP. Exacerbation of Whipple's disease associated with infliximab treatment. Scand J Rheumatol 2009; 34:148-51. [PMID: 16095013 DOI: 10.1080/03009740510015230] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
A 34-year-old man with chronic inflammatory joint disease and recurrent fever over 6 years was diagnosed as having Still's disease. Treatment with corticosteroids and azathioprine was ineffective. Therefore, infliximab/ methotrexate was started. The patient subsequently developed a wasting disease with rapid weight loss, erythema nodosum, diarrhoea, progressive lymph node enlargement, and a sigmoido-vesical fistula. Histological analysis of several enlarged lymph nodes, the margins of the fistula, and the small bowel established the diagnosis of Whipple's disease (WD). The presence of Tropheryma whipplei (Tw) DNA in the tissues was confirmed by polymerase chain reaction (PCR). Careful re-evaluation of biopsies taken from the ileum and the liver 2 years earlier, which at that time was not judged to be diagnostic for WD, retrospectively showed subtle histological signs of WD and were positive for Tw DNA. In summary, infliximab treatment seems to increase the risk of exacerbation of WD. WD should be carefully ruled out prior to application of tumour necrosis factor-alpha (TNF-alpha) blockade.
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Affiliation(s)
- C Kneitz
- Department of Clinical Immunology and Rheumatology, Medizinische Poliklinik, University of Würzburg, Germany.
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Orlando A, Renna S, Perricone G, Cottone M. Gastrointestinal lesions associated with spondyloarthropathies. World J Gastroenterol 2009; 15:2443-8. [PMID: 19468992 PMCID: PMC2686900 DOI: 10.3748/wjg.15.2443] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Subclinical gut inflammation has been described in up to two-thirds of patients with spondyloarthropathies (SpA). Arthritis represents an extra-intestinal manifestation of several gastrointestinal diseases, including inflammatory bowel disease (IBD), Whipple’s disease, Behcet’s disease, celiac disease, intestinal bypass surgery, parasitic infections of the gut and pseudomembranous colitis. Moreover about two-thirds of nonsteroidal anti-inflammatory drug users demonstrate intestinal inflammation. Arthritis may manifest as a peripheral or axial arthritis. The spondyloarthropathy family consists of the following entities: ankylosing spondylitis, undifferentiated spondyloarthritis, reactive arthritis, psoriatic arthritis, spondyloarthritis associated with IBD, juvenile onset spondyloarthritis. This topic reviews the major gastrointestinal manifestations that can occur in patients with SpA and in nonsteroidal anti-inflammatory drugs users.
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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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