Novel Patterns in High-Resolution Computed Tomography in Whipple Pneumonia

With the use of metagenomic next-generation sequencing, patients diagnosed with Whipple pneumonia are being increasingly correctly diagnosed. We report a series of 3 cases in China that showed a novel pattern of movable infiltrates and upper lung micronodules. After treatment, the 3 patients recovered, and lung infiltrates resolved.

Whipple Disease Misdiagnosed as Lymphoma by 18 F-FDG PET/CT: A Case Study

ABSTRACT

Whipple disease is a rare disorder caused by infection with the gram-positive bacterium Tropheryma whipplei . It can invade various organs and systems of the whole body. This case report describes a patient with invasion of multiple lymph nodes throughout the body misdiagnosed as lymphoma by PET/CT.

Whipple's Disease with Long-term Endoscopic Follow-up

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.

Whipple's disease under the vision of capsule endoscopy

We read with great interest the paper by Martínez-Sánchez et al. entitled Diagnóstico atípico mediante cápsula endoscópica: enfermedad de Whipple and we support their conclusions.

Novel neuroimaging findings in a patient with cerebral Whipple's disease: a magnetic resonance imaging and positron emission tomography study

The authors report a 43-year-old patient with histopathologically proven cerebral Whipple's disease. Magnetic resonance imaging (MRI) revealed a multilayered left frontal lesion without mass effect, no perifocal brain edema, no contrast enhancement, and a thin shell of fluid signal that presented as an incomplete, open ring. An [11C]methionine positron emission tomography (PET) study showed low uptake below the threshold that is characteristic for brain tumors. In precise co-registration to the MR images, the PET data showed that increased uptake was mainly located in the direct adjacent part of the MRI lesion. The fluid signal on MRI corresponded to the extensive outflow of fluid from the lesion, which was observed during neurosurgical resection, and also to the neuropathological findings. The authors conclude that this cerebral manifestation of Whipple's disease made a unique and hitherto undescribed appearance on MRI; uptake pattern of PET amino acid tracer may help in the preoperative distinction of inflammatory from neoplastic lesions.

Whipple's disease with destructive arthritis, abdominal lymphadenopathy, and central nervous system involvement

We describe a patient with Whipple's disease who had an unusual erosive and destructive polyarthritis, massive abdominal lymphadenopathy, asymptomatic central nervous system involvement, and rare manifestations of orbital pseudotumor and orchitis with epididymitis. Taking oral therapy with trimethoprim-sulfamethoxazole he had recurrent flares of orbital pseudotumor, an episode of orchitis with epididymitis, and persistent polymerase chain reaction T. whipplei-positive cerebrospinal fluid. Resolution was achieved with a one month course of intravenous ceftriaxone and a 6 month course of azithromycin, and no relapse occurred during 24 months of followup.

Whipple's disease: a non-invasive approach for suspected diagnosis. Case report

A case is presented of Whipple's disease with mild gastrointestinal symptoms. Abdominal ultrasonography and breath test after lactose load were of great help in the diagnostic phase and follow-up. Ultrasonography showed dilated and thickened ansae and abdominal lymph nodes which were considerably increased in volume and markedly hyperechoic; this latter aspect would seem to be typical of lymph adenomegalia secondary to Whipple's disease and is linked to the accumulation of fats. The breath test showed two H2 peaks, the first being early (30 min after lactose intake) suggesting high seated bacterial colonization. Intestinal biopsy confirmed the diagnosis of Whipple's disease. After 40 days of antibiotic treatment the clinical and laboratory pictures were almost normal and the breath test showed complete disappearance of H2 production, thus confirming the effectiveness of the treatment in eradicating the intestinal bacteria.

[Mesenteric lipodystrophy]

This case report describes the clinic and pathologic findings of an inflammatory pseudotumor of the mesentery in a 43 years old male. Previous to the hospital admission he had several episodes of intestinal occlusion and an abdominal mass. Computed tomography and mesenteric angiography were very helpful. Laboratory tests were unspecific, and the final diagnosis was obtained after surgery and histologic study of the lesion. We review published literature on inflammatory pseudotumors.

[Mesenteric lymph node cavitations in Whipple's disease. Apropos of a case]

We report a computed tomographic and echographic description of lymphadenopathy during a Whipple's disease. The computed tomography find low density of involved lymph nodes because of the high fatty charge, ultrasound revealed diffusely echogenic aspect. This cavitation was highly suggestive of Whipple's disease. Moreover, the computed tomography allows the follow-up of the disease.

Sonographical findings in Whipple's disease. A case report with regard to the literature

We present a case report of a 60-year-old male patient and subsequently discuss sonographical findings in Whipple's disease. This particular patient showed an intraabdominal tumorous mass. Symptoms of a malabsorption disorder were absent. Computer-assisted tomography and radiological examination could not determine the origin of the tumor. Sonography demonstrated a polycyclic hyperechoic mass in the root of the mesentery. The small intestine was not distended and showed normal peristalsis. Its wall was hyperechoic concentrically thickened. Final diagnosis was established from a diagnostic laparotomy showing enlarged lymph nodes and distended lymphatic vessels. Based on the literature the described sonographical findings seem to be typical in cases of Whipple's disease.

Whipple's disease complicated by a retinal Jarisch-Herxheimer reaction: a case report

A 36 year old white man was diagnosed as having Whipple's disease after a prolonged illness of lethargy, night sweats, and weight loss associated with lymphadenopathy and splenomegaly. Biopsy specimen of an inguinal lymph node confirmed the presence of periodic acid Schiff positive macrophages and culture gave a pure growth of Corynebacterium jeikeium. Twelve hours after the introduction of oral co-trimoxazole and streptomycin the patient's condition deteriorated. He became confused, feverish, and developed florid retinal vasculitis with associated visual impairment. Both the systemic symptoms and the retinal vasculitis responded to treatment with corticosteroids and his vision returned to normal. We think this was a Jarisch-Herxheimer reaction not previously described in Whipple's disease and advise inspection of the fundi of such patients before starting treatment.

[Scintigraphy using 99m-TC HM-PAO labeled autologous granulocytes in the diagnosis of Whipple's disease]

Whipple's disease is a systemic disease, mainly localized in the small intestine, that even today shows some difficulties about its etiopathogenesis and diagnosis. The surveys usually used in the diagnosis, among which the biopsy is an indispensable test, have some limits particularly in follow-up. The 99mTc-HM-PAO labelled granulocytes scintigraphy may be a useful alternative method in the evaluation of location and extension of the Whipple's disease. Furthermore, as it is not an invasive method, 99mTc granulocyte scintigraphy may be an important means in establishing the term of the therapy mainly when other methods are not able to exactly confirm the remission of the disease.

Whipple's disease with axial and peripheral joint destruction

A seropositive white man had follow-up for 16 years with a diagnosis of palindromic rheumatism. Treatment had included parenteral gold, methotrexate, prednisone, hydroxychloroquine sulfate, and penicillamine before diarrhea led to a biopsy-proven diagnosis of Whipple's disease. Clinical and radiographic criteria for ankylosing spondylitis were met. In addition to classic Whipple's arthropathy, he had the combined but singular findings of pancarpal destruction and cervical apophyseal fusion. HLA typing revealed the B7 antigen. This case illustrates the pitfalls in diagnosis of a chronic polyarthritis that has, as a typical feature, a long latency before manifesting its more specific signs and symptoms (ie, diarrhea, malabsorption, and hyperpigmentation). Care should be taken during evaluation of any disease with atypical and nonspecific features (eg, positive rheumatoid factor in a patient with polyarthritis) and one should continue to reevaluate the original impression while confirmatory evidence is lacking. Moreover, the roentgenographic findings of pancarpal narrowing, apophyseal fusion, and advanced iliofemoral joint disease, in addition to sacroiliitis and syndesmophyte formation, challenge the generally held notion that Whipple's arthropathy is a nondestructive joint disease.

[Cerebral involvement in Whipple's disease]

Whipple's disease is a rare protean disease. Cerebral involvement occurs in ten percent of the cases. CCT findings in two patients with cerebral symptoms are presented. There was an unspecific atrophy in one patient. Patient two had hydrocephalus occlusus and a temporal lesion enhanced by contrast agent. A specific diagnosis on the sole basis of the CCT without additional clinical data does not seem possible.

HLA antigens in Whipple's disease

The prevalence of HLA-A and B antigen loci in patients with Whipple's disease was determined from data obtained in a review of the literature and from personal communications. Data on the HLA-A and B locus typing of 30 patients were available (with the exception that 1 of the patients was not typed for the HLA-B locus), and for an additional 18 patients, HLA-B27 data were available. Of the 47 patients typed for B27, 13 (28%) were B27 positive. Twelve of the 48 patients had sacroiliitis, and 2 (17%) of them were B27 positive. These data suggest that Whipple's disease may be associated with HLA-B27, even in the absence of concomitant sacroiliitis.

[Malignant-appearing retroperitoneal lymphography findings in Whipple's disease--a source of possible misdiagnosis]

Whipple's disease may mimic clinically primary intestinal lymphoma. In addition, lymphographic findings in the paraaortic lymph nodes in Whipple's disease simulate malignant lymphoma. These severe tumor-like lymphographic changes are described in three cases of Whipple's disease. The data highlight the risk of misinterpreting of Whipple's disease as malignant lymphoma on the basis of clinical data and lymphographic findings.

Computed tomography in Whipple disease

A case of Whipple disease demonstrated on computed tomography (CT) a large mesenteric mass of low density and thickened folds in the jejunum, which was confirmed by barium studies. Retroperitoneal manifestations were absent. The importance of CT in demonstrating the extraintestinal manifestations of Whipple disease is emphasized.

[Experience with double-contrast examination of the small intestine]

Experiences and results of 600 small bowel examinations in double-contrast technique are reported. Pathologic lesions were found in 40%. The double-contrast technique has proved to be an efficient method in detecting small bowel pathology. Its specific value lies in precise delineation of pattern, extent and intensity of disease.

Whipple's disease demonstrated by double contrast small bowel enema with barium and methylcellulose

The radiologic findings on small bowel enema examination using barium and methylcellulose (SBE + Ba + MC) in a patient with Whipple's disease before and after treatment are described. The changes on SBE + Ba + MC corresponded well to the clinical and morphologic picture. The advantages of this double contrast technique compared to the enteroclysis with barium alone are demonstrated. The SBE + Ba + MC is a good method to demonstrate the manifestations of Whipple's disease involving the small bowel and the mesentery.

Whipple's disease presenting as a small-bowel obstruction

A 51-year-old white man with chronic diarrhea, generalized weakness, and a 70-lb. weight loss in 6 months developed small-bowel obstruction while undergoing investigation in the hospital. At laparotomy, an edematous, thickened mid-portion of small bowel matted between large lymph nodes, involved by characteristics of Whipple's disease, seemed to be responsible for the small-bowel obstruction.

Whipple disease of the nervous system

A 58-year-old man with dizziness and unsteady gait had a 10-year history of behavioral change, impotence, and a progressive peripheral neuropathy. CT revealed low-density, contrast-enhancing lesions in the right pontine tegmentum and the right medial temporal lobe. Temporal lobe biopsy contained a collection of mature histiocytes, with PAS-positive rod-shaped inclusions. These inclusions, when studied by electronmicroscopy, were seen to be membrane-bound bacilliform bodies. Peroral jejunal biopsy contained no such inclusions. Despite treatment with antibiotics, the patient's neurologic illness progressed, and he succumbed to intercurrent sepsis. We believe this to be the first instance in which a lesion of Whipple disease has been identified within the CNS by CT scan, and the diagnosis made antemortem, in the absence of demonstrable systemic disease.

Whipple's disease confined to the nervous system

Whipple's disease confined to the nervous system occurred in a 36-year old woman who presented with grand mal seizures and dementia. There was no evidence of extracerebral involvement and the jejunal biopsy was negative before treatment. Multiple enhancing lesions on CT scan progressed despite therapy with minocycline and prednisone, but resolved on treatment with tetracycline. The dementia did not progress while she was on antibiotic therapy. Whipple's disease should be considered as a treatable cause of progressive dementia even in the absence of an abnormal jejunal biopsy.

Central nervous system involvement in Whipple's disease

A case of Whipple's disease is presented manifesting itself predominantly with neurological and mental symptoms but without gastrointestinal complaints. Although the first cranial CT in the fourth year of the disease was normal, the second, 1.5 years later, revealed intensive hypodensity of the white matter and cortical enhancement. CT findings are compared with autopsy results and a review of the pertinent literature is given.

Abdominal computed tomography in Whipple's disease

The computed tomographic findings in a patient with Whipple's disease are described. Particular emphasis is placed on the extraintestinal manifestations of lymphadenopathy, which are not as familiar to radiologists and have been difficult to demonstrate with conventional radiographic techniques.

Cranial computed tomography in Whipple's disease

Cranial computed tomography (CT) in a 58-year-old man disclosed enhancing lesions in the medial right temporal lobe and the right pons. Biopsy of the sural nerve was positive for Whipple's disease, and one of the temporal lobe lesions showed unprecedented histological findings. This case, to our knowledge, is unique in its demonstration of cranial CT findings in association with Whipple's disease. It is suggested that a cranial CT scan with the use of intravenous contrast material should be performed in patients presenting with the signs or symptoms of Whipple's disease.

Scintigraphic evidence of transient unilateral sacroiliitis in a case of Whipple's disease

Investigation of low back pain by quantitative sacroiliac joint scintigraphy (QSS) can detect the presence of sacroiliitis not apparent by roentgenography. Transient unilateral sacroiliitis was documented by QSS in a patient with Whipple's disease during tetracycline treatment, when the peripheral arthropathy was in remission. Thus, the pattern of inflammatory spinal disease, if associated with the intestinal disease, differs from that of the peripheral arthritis.

Abnormal fat collections in the omentum and mesocolon of children

Two cases of abnormal collection of fat in the abdomen are reported. One involved the omentum, the other involved the mesocolon. Both patients had few symptoms with strikingly similar radiological findings of increased radiolucency due to fat surrounding the small bowel.

[Mesenteric panniculitis]

A 4-year-old girl was studied at the Pediatrics Unit at the Hospital General de México, S.S.A., with a diagnosis of abdominal tumor, probably malignant. After several laboratory tests (blood count, blood chemistry, catecholamines and the following X-ray studies: chest, skull, long bones, Cava's phlebography and excretory urography), she was submitted to surgery without a diagnosis. After this, the final diagnosis was established: mesenteric panniculitis (mesenteric lipodystrophy. This case is published because of its rare occurrence at this age and because it is important to be kept in mind in the differential diagnosis of abdominal tumors in pediatric practice.