Diagnosis and treatment of Tropheryma whipplei infection in patients with inflammatory rheumatic disease: Data from the French Tw-IRD registry

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.

Clinical and laboratory predictors and prevalence of immune reconstitution inflammatory syndrome in patients with Whipple's disease

OBJECTIVES

Whipple's disease (WD) is a rare and potentially fatal infectious disease caused by Tropheryma whipplei. It is characterized by a long prodromal phase that mimics a rheumatological disease, often leading to immunosuppressant treatment. Immune reconstitution inflammatory syndrome (IRIS) is currently the most important complication of WD, requiring prompt recognition and treatment as it can be fatal. However, epidemiological data on IRIS are scarce. We aimed to identify the clinical and laboratory predictors of IRIS at WD diagnosis and to evaluate whether the prevalence of IRIS has changed over time.

METHODS

Forty-five patients with WD (mean age 52 ± 11 years; 10 females) were followed up between January 2000 and December 2021. Clinical and laboratory data at WD diagnosis were retrospectively collected and compared among patients who developed IRIS and those who did not.

RESULTS

Erythrocyte sedimentation rate (ESR; 33.4 ± 11.8 mm/h vs 67.1 ± 26.3 mm/h, P < 0.01), platelet (PLT; 234 × 109 /L vs 363 × 109 /L, P < 0.01), and body mass index (22.0 ± 2.0 kg/m2 vs 19.8 ± 3.0 kg/m2 , P = 0.04) differed significantly between patients who subsequently developed IRIS and those who did not. ROC analysis identified ESR ≤46 mm/h (AUROC 0.88, 95% CI 0.72-1.00) and PLT ≤ 327 × 109 /L (AUROC 0.85, 95% CI 0.70-1.00) as optimal cut-off values to discriminate WD patients at a high risk of developing IRIS. Prevalence of IRIS remained stable (22.2%) over time.

CONCLUSIONS

Low ESR and PLT count at diagnosis help identify WD patients at high risk of developing IRIS. Instead, a greater inflammatory response suggests a lower risk of IRIS. Prevalence of IRIS did not change over two decades.

Patients with Whipple's disease have a high prevalence of Helicobacter pylori infection

INTRODUCTION

Whipple's disease is a rare systemic infection due to an impaired immunological response against T. whipplei in genetically predisposed individuals. Since we previously noted development of H. pylori related complications in some patients with Whipple's disease, our aim was to study the prevalence of H. pylori infection and H. pylori related disorders in Whipple's disease.

METHODS

Whipple's disease patients diagnosed from Jan-2002 to Dec-2021 and two controls per patient, matched for age, gender, ethnicity and year of H. pylori testing were enrolled.

RESULTS

34 patients with Whipple's disease and 68 controls were enrolled. H. pylori infection (13/34 vs 8/68, p<0.01), H. pylori-related gastritis (p<0.01) and gastric atrophy (p = 0.01) were significantly more common in patients with Whipple's disease than controls. H. pylori infection and Whipple's disease were diagnosed synchronously in 6/13 patients, and during follow-up in the remaining 7. Interestingly, these last 7 patients were all on trimethoprim-sulfamethoxazole long-term therapy. Two patients developed H. pylori-related gastric malignancies during follow-up. No patients on doxycycline developed H. pylori infection.

CONCLUSIONS

H. pylori infection and related disorders are common in patients with Whipple's disease and should always be excluded both at time of diagnosis and during follow-up. These findings should be taken into account when selecting antibiotics for Whipple's disease long-term prophylaxis.

Whipple's disease review, prevalence, mortality, and characteristics in the United States: A cross-sectional national inpatient study

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.

Tropheryma whipplei Intestinal Colonization in Migrant Children, Greece

We obtained fecal samples from migrant children <12 years of age throughout hotspots in Greece and tested them for Tropheryma whipplei by using a quantitative PCR assay. We identified 6 genotypes of T. whipplei, 4 of which are newly described. Our findings suggest a high prevalence of T. whipplei in these regions.

Tropheryma whipplei as a Cause of Epidemic Fever, Senegal, 2010-2012

Findings suggest that the bacterium has role in febrile episodes, is contagious, and has an epidemic character.

The bacterium Tropheryma whipplei, which causes Whipple disease in humans, is commonly detected in the feces of persons in Africa. It is also associated with acute infections. We investigated the role of T. whipplei in febrile patients from 2 rural villages in Senegal. During June 2010–March 2012, we collected whole-blood finger-prick samples from 786 febrile and 385 healthy villagers. T. whipplei was detected in blood specimens from 36 (4.6%) of the 786 febrile patients and in 1 (0.25%) of the 385 apparently healthy persons. Of the 37 T. whipplei cases, 26 (70.2%) were detected in August 2010. Familial cases and a potential new genotype were observed. The patients’ symptoms were mainly headache (68.9%) and cough (36.1%). Our findings suggest that T. whipplei is a cause of epidemic fever in Senegal.

High prevalence of asymptomatic carriers of Tropheryma whipplei in different populations from the North of Spain

INTRODUCTION

Tropheryma whipplei is the causative agent of Whipple disease. T. whipplei has also been detected in asymptomatic carriers with a very different prevalence. To date, in Spain, there are no data regarding the prevalence of T. whipplei in a healthy population or in HIV-positive patients, or in chronic fatigue syndrome (CFS). Therefore, the aim of this work was to assess the prevalence of T. whipplei in stools in those populations.

METHODS

Stools from 21 HIV-negative subjects, 65 HIV-infected, and 12 CFS patients were analysed using real time-PCR. HIV-negative and positive subjects were divided into two groups, depending on the presence/absence of metabolic syndrome (MS). Positive samples were sequenced.

RESULTS

The prevalence of T. whipplei was 25.51% in 98 stool samples analysed. Prevalence in HIV-positive patients was significantly higher than in HIV-negative (33.8% vs. 9.09%, p=0.008). Prevalence in the control group with no associated diseases was 20%, whereas no positive samples were observed in HIV-negative patients with MS, or in those diagnosed with CFS. The prevalence observed in HIV-positive patients without MS was 30.35%, and with MS it was 55.5%. The number of positive samples varies depending on the primers used, although no statistically significant differences were observed.

CONCLUSIONS

There is a high prevalence of asymptomatic carriers of T. whipplei among healthy and in HIV-infected people from Spain. The role of T. whipplei in HIV patients with MS is unclear, but the prevalence is higher than in other populations.

High prevalence of Tropheryma whipplei in Lao kindergarten children

Background

Tropheryma whipplei is a bacterium commonly found in feces of young children in Africa, but with no data from Asia. We estimated the prevalence of T. whipplei carriage in feces of children in Lao PDR (Laos).

Methods/Principal Findings

Using specific quantitative real-time PCR, followed by genotyping for each positive specimen, we estimated the prevalence of T. whipplei in 113 feces from 106 children in Vientiane, the Lao PDR (Laos). T. whipplei was detected in 48% (51/106) of children. Those aged ≤4 years were significantly less frequently positive (17/52, 33%) than older children (34/54, 63%; p< 0.001). Positive samples were genotyped. Eight genotypes were detected including 7 specific to Laos. Genotype 2, previously detected in Europe, was circulating (21% of positive children) in 2 kindergartens (Chompet and Akad). Genotypes 136 and 138 were specific to Chompet (21% and 15.8%, respectively) whereas genotype 139 was specific to Akad (10.55%).

Conclusions/Significance

T. whipplei is a widely distributed bacterium, highly prevalent in feces of healthy children in Laos. Further research is needed to identify the public health significance of this finding.

Tropheryma whipplei is a common bacterium carried in feces of young children. Here, using specific PCR, we estimated the prevalence of T. whipplei in 113 feces from 106 children in Vientiane, the Lao PDR (Laos). T. whipplei was detected in 48% (51/106) of children. Eight genotypes were detected, including 7 specific to Laos. Genotype 2, previously detected in Europe, was circulating (21% of positive children) in 2 kindergartens (Chompet and Akad). Genotypes 136 and 138 were specific to Chompet (21% and 15.8%, respectively), whereas genotype 139 was specific to Akad (10.55%). Long regarded as a rare bacterium, now we can affirm that T. whipplei is a widely distributed bacterium, highly prevalent in feces including those from children in Vientiane.

Tropheryma whipplei endocarditis

Tropheryma whipplei endocarditis differs from classic Whipple disease, which primarily affects the gastrointestinal system. We diagnosed 28 cases of T. whipplei endocarditis in Marseille, France, and compared them with cases reported in the literature. Specimens were analyzed mostly by molecular and histologic techniques. Duke criteria were ineffective for diagnosis before heart valve analysis. The disease occurred in men 40-80 years of age, of whom 21 (75%) had arthralgia (75%); 9 (32%) had valvular disease and 11 (39%) had fever. Clinical manifestations were predominantly cardiologic. Treatment with doxycycline and hydroxychloroquine for at least 12 months was successful. The cases we diagnosed differed from those reported from Germany, in which arthralgias were less common and previous valve lesions more common. A strong geographic specificity for this disease is found mainly in eastern-central France, Switzerland, and Germany. T. whipplei endocarditis is an emerging clinical entity observed in middle-aged and older men with arthralgia.

[Whipple's disease]

Whipple's disease (WD) is a rare, chronic, systemic infection caused by the bacterium Tropheryma whipplei. New molecular techniques and epidemiological data over the latest decade have contributed to better understanding of this infection. The classical form of WD is characterized by arthritis followed years after by diarrhoea, weight loss and malabsorption but other clinical forms without intestinal involvement have been described. Prompt recognition and treatment of the infection is important, as the disease can be fatal if untreated. New studies are required to establish the optimal therapy regimen.

Central nervous system involvement in Whipple disease: clinical study of 18 patients and long-term follow-up

Whipple disease (WD) is a rare multisystemic infection with a protean clinical presentation. The central nervous system (CNS) is involved in 3 situations: CNS involvement in classic WD, CNS relapse in previously treated WD, and isolated CNS infection. We retrospectively analyzed clinical features, diagnostic workup, brain imaging, cerebrospinal fluid (CSF) study, treatment, and follow-up data in 18 patients with WD and CNS infection. Ten men and 8 women were included with a median age at diagnosis of 47 years (range, 30-56 yr). The median follow-up duration was 6 years (range, 1-19 yr). As categorized in the 3 subgroups, 11 patients had classic WD with CNS involvement, 4 had an isolated CNS infection, and 3 had a neurologic relapse of previously treated WD. CNS involvement occurred during prolonged trimethoprim-sulfamethoxazole (TMP-SMX) treatment in 1 patient with classic WD. The neurologic symptoms were various and always intermingled, as follows: confusion or coma (17%) related to meningo-encephalitis or status epilepticus; delirium (17%); cognitive impairment (61%) including memory loss and attention defects or typical frontal lobe syndrome; hypersomnia (17%); abnormal movements (myoclonus, choreiform movements, oculomasticatory myorhythmia) (39%); cerebellar ataxia (11%); upper motor neuron (44%) or extrapyramidal symptoms (33%); and ophthalmoplegia (17%) in conjunction or not with progressive supranuclear palsy. No specific pattern was correlated with any subgroup. Brain magnetic resonance imaging (MRI) revealed a unique focal lesion (35%), mostly as a tumorlike brain lesion, or multifocal lesions (23%) involving the medial temporal lobe, midbrain, hypothalamus, and thalamus. Periventricular diffuse leukopathy (6%), diffuse cortical atrophy (18%), and pachymeningitis (12%) were observed. The spinal cord was involved in 2 cases. MRI showed ischemic sequelae at diagnosis or during follow-up in 4 patients. Brain MRI was normal despite neurologic symptoms in 3 cases. CSF cytology was normal in 62% of patients, whereas Tropheryma whipplei polymerase chain reaction (PCR) analysis was positive in 92% of cases with tested CSF. Periodic acid-Schiff (PAS)-positive cells were identified in cerebral biopsies of 4 patients. All patients were treated with antimicrobial therapy for a mean duration of 2 years (range, 1-7 yr) with either oral monotherapy (TMP-SMX, doxycycline, third-generation cephalosporins) or a combination of antibiotics that sometimes followed parenteral treatment with beta-lactams and aminoglycosides. Eight patients also received hydroxychloroquine. At the end of follow-up, the clinical outcome was favorable in 14 patients (78%), with mild to moderate sequelae in 9. Thirteen patients (72%) had stopped treatment for an average time of 4 years (range, 0.7-14 yr). Four patients had clinical worsening despite antimicrobial therapy; 2 of those died following diffuse encephalitis (n = 1) and lung infection (n = 1). In conclusion, the neurologic manifestations of WD are diverse and may mimic almost any neurologic condition. Brain involvement may occur during or after TMP-SMX treatment. CSF T. whipplei PCR analysis is a major tool for diagnosis and may be positive in the absence of meningitis. Immune reconstitution syndrome may occur in the early months of treatment. Late prognosis may be better than previously reported, as a consequence of earlier diagnosis and a better use of antimicrobial therapy, including hydroxychloroquine and doxycycline combination.

Systemic Tropheryma whipplei: clinical presentation of 142 patients with infections diagnosed or confirmed in a reference center

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.

[Whipple's disease: current problems]

Whipple's disease is a rare multisystemic infectious disease of bacterial origin characterized by variable clinical manifestations, and an insidious and chronic relapsing course. Untreated disease can be even fatal. The presence of the characteristic (though not specific) triad of weight loss, chronic diarrhea and arthralgias may raise its suspicion. When chronic intermittent fever and lymphadenopathy are associated, the suspicion is substantial. Recognition of the causative agent, Tropheryma whippelii with unique characteristics was essential. Despite the presumed ubiquitous presence of the bacteria the disease probably occurs only in cases of immunological host susceptibility. Presence of the bacteria living and multiplying especially in macrophages has suggested alterations of the mononuclear-phagocytic system. (Whipple's disease is commonly mentioned as a macrophage disorder.) Clinical manifestations are quite diverse. While it has traditionally been regarded as a gastrointestinal disease, currently is considered to be a systemic disorder. In cases of suspected infection the approach of first choice is upper gastrointestinal endoscopy. Small, whitish-yellow diffusely distributed plaques alternating with an erythematous, erosive, friable mucosa in the postbulbar region of the duodenum or in the jejunum can appear. Histological samples indicate tissue infiltration of macrophages with intracellular bacterial invasion. The hallmark of Whipple's disease is the presence of PAS positive macrophages in the lamina propria of duodenal biopsy specimens, still the diagnosis needs to be confirmed with the detection of bacteria by PCR. The selection of antibiotics and duration of treatment still remains largely empiric.

Cerebellar Ataxia and Central Nervous System Whipple Disease

BACKGROUND

Whipple disease (WD) is an infectious disease, which may affect the central nervous system. Central nervous system symptoms are eventually present in as many as 43% of the cases. To our knowledge, cerebellar ataxia in WD has never been formally studied in any large series.

OBJECTIVE

To determine the prevalence of cerebellar ataxia in central nervous system WD.

RESULTS

Between January 1974 and December 2003, we identified 11 patients who met criteria for definite central nervous system WD, the second largest series to date. Surprisingly, while oculomasticatory myorrhythmia was recorded in only 1 patient (9%), cerebellar ataxia had been documented in 5 cases (45%).

CONCLUSION

Our data suggest that cerebellar ataxia should be considered a more common feature of central nervous system WD.

Whipple's disease

Whipple's disease is a rare multisystemic infectious disorder affecting predominantly middle-aged men. Clinical manifestations are very variable with a very long, insidious, prediagnostic course. Weight loss, chronic diarrhea, arthralgias, and low-grade fever are characteristic features in most patients. Although gastrointestinal compromise is very common, atypical clinical forms are being increasingly recognized. Although a bacterial cause was strongly suggested for many years, the infectious agent was elusive until recently. The bacillus that was classified as an actinomycete was named Tropheryma whipplei and has singular characteristics. It presents affinity for the periodic acid-Schiff stain, but it is negative for Ziehl-Neelsen staining and has a characteristic trilamellar cell wall. Its genetic material has been recently sequenced, and culture was finally performed on a human fibroblast cell line. Pathological specimens show macrophage infiltration with mostly intracellular invasion of live bacteria. Immunologic factors, such as a subtle defect of cellular immunity possibly specific for the Whipple's bacterium, are believed to play a role in pathogenesis. The diagnosis requires the histologic assessment of diseased tissue, showing the characteristic infiltration, as a first approach, and confirmatory tests such as electron microscopy and/or polymerase chain reaction. Antibiotic treatment is mandatory and leads to a rapid clinical improvement and remission in most patients. Although the rationale for treatment is largely empiric, current recommendations include a 2-week parenteral therapy (third generation cephalosporin) followed by a long-term therapy with trimethoprim-sulphamethoxazole. This approach has been shown to reduce the number of relapses and was effective for prevention and/or treatment of the neurologic compromise.

Whipple disease

Whipple disease is a rare disease caused by infection with the bacterium Tropheryma whippelii. Humans are the only known host for the infection. The signs of systemic infection include gastrointestinal problems, weight loss, and arthritis. Signs of central nervous system infection include cognitive changes, supranuclear gaze palsy, altered level of consciousness, and movement disorders. The diagnosis is based on clinical findings as well as microscopic examination of biopsy specimens and, more recently, polymerase chain reaction (PCR) analysis, which has high sensitivity and specificity. Although the organism historically has been difficult to culture, several recent attempts have been successful. Antibiotic treatment is recommended for 1 year while monitoring the clinical signs and cerebrospinal fluid PCR results.

Whipple disease associated with giardiasis

We tested 53 fixed duodenal biopsy samples from 25 patients with Whipple disease for the presence Giardia and 6 fresh duodenal biopsy samples for Giardia duodenalis DNA by polymerase chain reaction (PCR). We also used histological examination and PCR assay to determine the prevalence of G. duodenalis in duodenal biopsy samples from 150 control patients without Whipple disease. Three of 25 patients with Whipple disease had histological evidence of giardiasis, whereas only 1 of 150 control patients was affected (P<.001). By PCR, we found Giardia in 2 of 6 patients with Whipple disease whom we tested, but in only 2 of 150 control patients (P<.001). In a literature review, we identified 15 other cases of coinfection. The occurrence of these diseases may be promoted by a common immune defect or a common source of infection, or infection with one may predispose to infection with the other.

Prevalence of Tropheryma whipplei DNA in patients with various gastrointestinal diseases and in healthy controls

BACKGROUND

Little is known about the epidemiology of Tropheryma whipplei and its prevalence in people without clinical signs of Whipple's disease.

PATIENTS AND METHODS

We screened 239 patients with various gastrointestinal diseases for T. whipplei DNA and compared them with 215 healthy controls in order to check whether T. whipplei might be a risk factor for common gastrointestinal problems or diseases. We detected the 16S rDNA of T. whipplei in salivary and stool samples using a specific seminested PCR.

RESULTS

The prevalence of T. whipplei DNA in patients and in controls was 4.2% (95% CI 2.0-7.6% ) and 7.0% (95% CI 4.0-11.3%), respectively. None of the different gastrointestinal diseases was associated with a higher rate of PCR-positive tests, except for the group of patients with reflux syndrome. Five out of 43 patients with reflux were found to be positive, with all five being positive in the salivary sample. This is in contrast to our findings in carriers without reflux with mainly positive stool samples (p < 0.01).

CONCLUSION

We conclude that the asymptomatic carrier state of T. whipplei indeed exists and that it is much more frequent than the rare Whipple's disease. The higher prevalence of T. whipplei DNA in the saliva of patients with reflux syndrome suggests that the stomach might be the habitat of the organism.

Whipple's disease and "Tropheryma whippelii"

Whipple's disease is a rare bacterial infection that may involve any organ system in the body. It occurs primarily in Caucasian males older than 40 years. The gastrointestinal tract is the most frequently involved organ, with manifestations such as abdominal pain, malabsorption syndrome with diarrhea, and weight loss. Other signs include low-grade fever, lymphadenopathy, skin hyperpigmentation, endocarditis, pleuritis, seronegative arthritis, uveitis, spondylodiscitis, and neurological manifestations, and these signs may occur in the absence of gastrointestinal manifestations. Due to the wide variability of manifestations, clinical diagnosis is very difficult and is often made only years or even decades after the initial symptoms have appeared. Trimethoprim-sulfamethoxazole for at least 1 year is usually considered adequate to eradicate the infection. The microbiological diagnosis of this insidious disease is rendered difficult by the virtual lack of culture and serodiagnostic methods. It is usually based on the demonstration of periodic acid-Schiff-positive particles in infected tissues and/or the presence of bacteria with an unusual trilaminar cell wall ultrastructure by electron microscopy. Recently, the Whipple bacteria have been characterized at the molecular level by amplification of their 16S rRNA gene(s). Phylogenetic analysis of these sequences revealed a new bacterial species related to the actinomycete branch which was named "Tropheryma whippelli." Based on its unique 16S ribosomal DNA (rDNA) sequence, species-specific primers were selected for the detection of the organism in clinical specimens by PCR. This technique is currently used as one of the standard methods for establishing the diagnosis of Whipple's disease. Specific and broad-spectrum PCR amplifications mainly but not exclusively from extraintestinal specimens have significantly improved diagnosis, being more sensitive than histopathologic analysis. However, "T. whippelii" DNA has also been found in persons without clinical and histological evidence of Whipple's disease. It is unclear whether these patients are true asymptomatic carriers or whether differences in virulence exist among strains of "T. whippelii" that might account for the variable clinical manifestations. So far, six different "T. whippelii" subtypes have been found by analysis of their 16S-23S rDNA spacer region. Further studies of the pathogen "T. whippelii" as well as the host immune response are needed to fully understand this fascinating disease. The recent cultivation of the organisms is a promising major step in this direction.

[Whipple's disease. Histologic diagnosis after the discovery of Tropheryma whippelii]

Since the microbiological discovery of Tropheryma whippelii, Whipple's disease has attracted to new attention in clinical medicine. As small intestinal biopsy is the diagnostic procedure, the impact of knowledge about the histopathological features of Whipple's disease and its differential diagnosis has increased. PAS-positive macrophages in the intestinal mucosa are the diagnostic hallmark, but further subtyping of cells is important. In Whipple's disease macrophages with intensely PAS-positive granular particles in the cytoplasm (type 1) should be distinguished from cells with faintly PAS-positive cytoplasm without granular particles (type 3). The latter type of macrophages may persist even for many years but does not affect a diagnosis of intestinal remission. However, as systemic infection with T. whippelii is common, but intestinal biopsy specimens are not representative for other organs, additional investigations are performed. These include analysis of the cerebrospinal fluid by means of cytology and polymerase chain reaction, even in patients without neurological symptoms. For ascertaining eradication of T. whippelii in the cerebrospinal fluid, polymerase chain reaction is more reliable than cytology.

Whipple's disease - current status of diagnostics and therapy

Whipple's disease is a multisystemic infectious disease whose pathogen, a gram-unstable actinomycete, has been characterized in the meantime by molecular-biological techniques (polymerase chain reaction). This infectious disease which was firstly described in 1907 by G.H. Whipple as intestinal lipodystrophy appears rarely and sporadically and can affect nearly every organ, in the course of which the small intestine is also concerned in the majority of patients. The symptoms and signs are polymorphous and depend on organic involvement and stage. This leads to significant difficulties concerning differential diagnosis and to a delay in diagnosis. Misjudging the syndromes provokes invalidism and death whereas correct therapy leads to a cure in most of the cases.

Epidemiology of Whipple's disease in Germany. Analysis of 110 patients diagnosed in 1965-95

BACKGROUND

The epidemiology of Whipple's disease (WD) is obscure. To obtain basic data, we performed an evaluation of WD patients in Germany.

METHODS

Information was collected from 110 WD patients diagnosed during 1965-95 at 5 institutions in different regions of Germany. Four items were evaluated: 1) year in which the diagnosis was made; 2) residence and 3) age at the time of diagnosis; and 4) sex.

RESULTS

WD patients originated from all parts of Germany. The incidence of new cases was relatively stable, with a mean of one to two cases per year per collecting centre. In 1995, a maximum of 13 new WD patients was diagnosed. There was a significant increase in the mean age of patients (1965-75, 48.7 years; confidence interval, +/- 3.98 years; 1976-85, 50.7 years, +/- 3.69 years; 1986-95, 57.0 years, +/- 2.80 years; P < 0.01) and an increasing proportion of women (1965-85, 4%; 1986-1995, 22%).

CONCLUSIONS

Whipple's disease is not quite as rare as commonly assumed. There is no obvious geographic predominance. During the past three decades, the demography of WD patients has changed.

[Epidemiologic aspects of seronegative spondylarthritis]

In accordance with the prevailing trends of the development of science in rheumatology Wright, Moll and Haslock inaugurated the integrative conception of the seronegative spondarthritides in the middle of the seventies. The diseases which belong to the seronegative spondarthritides are the ankylosing spondylitis, the psoriasis-arthritis, the Reiter syndrome, the Behçet syndrome, the ulcerous colitis, Crohn's disease and Whipple's disease. Object of the representation is the determination of the notion of seronegative spondarthritis and its presence among the dwelling population. Furthermore, the authors deal more in detail with the distribution according to the demographic and ethnographic characteristics, the frequency of the presence of HLA B 27 as well as with the results of familial investigations (familial aggregation and association). The heuristic value of the classification scheme of the seronegative spondarthritides developed by clinics appears worth of discussion, since from the epidemiological point of view aggravating critical objections concerning the method must be raised. Clinico-epidemiological statements of investigation, prospective and multicentric longitudinal investigations concerning the more profound study of the "natural history" of the seronegative spondarthritides are hopeful and necessary within the future research strategy.

Whipple's disease in neighbors

Two patients new newly diagnosed Whipple's disease lived 2000 ft apart over a 20-year period in the southern Connecticut, Long Island Sound Community of Bridgeport. The scant literature concerning the epidemiology of this possibly infectious multisystem disease is reviewed.