Palindromic Rheumatoid Arthritis-An Unorthodox Presentation of Whipple’s Disease
Science Journal of Clinical Medicine
Volume 5, Issue 2, March 2016, Pages: 20-23
Received: Feb. 28, 2016;
Accepted: Mar. 6, 2016;
Published: Mar. 21, 2016
Views 3771 Downloads 127
Stephanie Santucci, Department of Surgery, Mater Dei Hospital, Msida, Malta
Ernest Ellul, Department of Surgery, Mater Dei Hospital, Msida, Malta
Noel Gatt, Department of Pathology, Mater Dei Hospital, Msida, Malta
Jonathan Cutajar, Department of Surgery, Mater Dei Hospital, Msida, Malta
Leigh Joseph Calleja, Department of Surgery, Mater Dei Hospital, Msida, Malta
Follow on us
Whipple's disease is a rare infection of the gastrointestinal tract caused by the actinomycete Tropheryma whippelii. It most commonly presents with arthralgia, abdominal pain, diarrhoea and weight loss. Invasion of the bacterium through the gastrointestinal mucosa leads to small intestinal villus blunting and malabsorption. Diagnosis is made by histological examination of small bowel biopsies. We report the case of a 78 year old gentleman who had a two year history of fleeting joint pain and multiple hospital admissions for varying symptoms. He was treated with antibiotics for a chest infection with improvement only to present again after 1 year with anorexia, fatigue, blackish loose stools and epigastric pain. Microscopic examination of duodenal biopsies showed a stunted villous architecture and expansion of the lamina propria by foamy macrophages. These expressed CD68 and cytoplasmic contents were strongly PAS positive, consistent with a diagnosis of Whipple’s disease. He was started on intravenous ceftriaxone and a prolonged course of oral co-trimoxazole (at least 1 year) with marked clinical improvement. In retrospect, the previous year’s admissions might have also been due to Whipple’s disease but since he did not have the full course of the appropriate treatment he relapsed. Whipple's disease is a difficult diagnosis to make because of the variety of clinical symptoms and the long time span between the initial unspecific symptoms (the prodromal stage) and the full-blown clinical picture of the illness (the steady-state stage). It may be misdiagnosed with a non-infectious rheumatic illness and may be fatal if untreated.
Arthritis, Endoscopy, Histopathology, Infection, Tropheryma whippelii, Whipple’s Disease
To cite this article
Leigh Joseph Calleja,
Palindromic Rheumatoid Arthritis-An Unorthodox Presentation of Whipple’s Disease, Science Journal of Clinical Medicine.
Vol. 5, No. 2,
2016, pp. 20-23.
Copyright © 2016 Authors retain the copyright of this article.
This article is an open access article distributed under the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/
) which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Klochan C, Anderson TA, Rose D et al. Nearly Fatal Case of Whipple’s Disease in a Patient Mistakenly on Anti-TNF Therapy. ACG Case Reports Journal. 2013; 1(1): 25-28.
Magira EE, Gounaris T, Sioula E. Whipple’s Disease: Multiple Hospital Admissions of a Man with Diarrhoea, Fever and Arthralgia. J Infect. 2005 Aug; 51(2): E35-7.
Schijf LJ, Becx MC, de Bruin PC et al. Whipple’s Disease: Easily Diagnosed if Considered. Neth J Med. 2008; 66 (9): 392-5.
Ratnaike RL. Whipple’s Disease. Postgrad Med J. 2000; 76: 760–766.
Relman DA, Schmidt TM, MacDermott RP, et al. Identification of the uncultured bacillus of Whipple’s disease. N Engl J Med. 1992; 327: 293–301.
Marth T. New Insights into Whipple’s Disease – A Rare Intestinal Inflammatory Disorder. J Dig Dis. 2009; 27(4): 494-501.
Günther U1, Moos V, Offenmüller G et al. Gastrointestinal diagnosis of Whipple disease: clinical, endoscopic and histopathologic features in 191 patients. Medicine. 2015 Apr; 94(15): e714.
Yee A, Paget S. Expert guide to rheumatology. Philadelphia, Pa.: American College of Physicians; 2005.
Jan Bureš, Marcela Kopáčová, Tomáš Douda, et al. Whipple’s Disease: Our Own Experience and Review of the Literature. Gastroenterology Research and Practice, vol. 2013, Article ID 478349, 10 pages, 2013.
Fenollar F, Puéchal X, Raoult D. Medical progress: Whipple’s disease. N Engl J Med. 2007; 356: 5566.
Feurle GE, Junga N, Marth T. Efficacy of ceftriaxone or meropenem as initial therapies in Whipple's disease. Gastroenterology 2010; 138: 478-86.
Fenollar F, Rolain JM, Alric L, et al. Resistance to trimethoprim-sulfamethoxazole and Tropheryma whippelii. Int J Antimicrob Agents 2009; 34: 255-9.
Fenollar F, Raoult D. How should classic Whipple's disease be managed? Nat Rev Gastroenterol Hepatol 2010; 7: 246-8.
Lagier JC, Fenollar F, Lepidi H, Raoult D. Failure and relapse after treatment with trimethoprim/sulfamethoxazole in classic Whipple’s disease. J Antimicrob Chemother 2010 Sep; 65(9): 2005-12.
Krol CG, de Meijer PHEM. Palindromic Rheumatism: consider Whipple’s Disease. Int J Rheum Dis 2013; 16: 475-476.