RESUMEN
Introduction. Tropheryma whipplei is responsible for the classical Whipple's disease. Recently, a new Tropheryma species was described in a Belgian immunocompromised patient with pleuritis.Gap Statement. There is currently no specific molecular diagnostic test detecting other Tropheryma species than Tropheryma whipplei.Aim. To develop and validate two broad-range pan-Tropheryma genus PCRs detecting both T. whipplei and new Tropheryma species.Methodology. From shotgun sequencing data of the lung tissue biopsy of the Belgian subject, we designed two PCRs targeting the 23S rRNA and rnpB genes. Prospectively, requests for T. whipplei PCR were tested with T. whipplei-specific PCRs and the two Tropheryma broad-range PCRs from January 2019 to November 2022.Results. In total, 2605 samples were tested using both the pan-Tropheryma 23S rRNA PCR and the T. whipplei-specific PCR. In addition, 833 of the 2605 samples were also tested using the pan-Tropheryma rnpB PCRs. Sensitivity was 78.8% and 79.7% for 23S rRNA and rnpB PCRs, as compared with the species-specific T. whipplei PCR. Specificity was 99.9% and 99.7% for the 23S rRNA and the rnpB PCRs, respectively. We identified a patient whose bronchoalveolar lavage tested positive with the two broad-range PCRs with >105 copies ml-1. Specific T. whipplei PCRs were negative. Known for panuveitis, this 49-year-old male presented with an eye inflammation recurrence, and a CT scan showed multiple mediastino-hilar necrotic adenopathies. Doxycyclin (1 year), hydroxychloroquin (1 year) and co-trimoxazol (1 month) treatments led to a favourable outcome.Conclusion. Specific T. whipplei PCR exhibited better sensitivity than the pan-Tropheryma PCRs. However, both broad-range pan-Tropheryma PCRs demonstrated excellent specificity and were pivotal to identifying a new probable case of Tropheryma infection due to another species-level lineage.
Asunto(s)
Reacción en Cadena de la Polimerasa , ARN Ribosómico 23S , Sensibilidad y Especificidad , Tropheryma , Humanos , Tropheryma/genética , Tropheryma/aislamiento & purificación , Reacción en Cadena de la Polimerasa/métodos , ARN Ribosómico 23S/genética , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/microbiología , ADN Bacteriano/genética , Bélgica , Técnicas de Diagnóstico Molecular/métodos , Pulmón/microbiología , Pulmón/patología , MasculinoRESUMEN
Whipple disease is a rare systemic illness associated with weight loss, diarrhea, and arthralgia. Asymptomatic carriage is common, but the disease can be complicated by cardiac involvement and may result in culture-negative endocarditis. Cardiac manifestations of the disease can lead to death. This report presents the case of a 66-year-old man with Whipple disease and biventricular heart failure with cardiogenic shock. Medical therapy followed by successful replacement of the aortic and mitral valves resulted in substantial improvement.
Asunto(s)
Endocarditis Bacteriana , Insuficiencia Cardíaca , Implantación de Prótesis de Válvulas Cardíacas , Tropheryma , Enfermedad de Whipple , Humanos , Masculino , Anciano , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/complicaciones , Enfermedad de Whipple/tratamiento farmacológico , Enfermedad de Whipple/microbiología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/microbiología , Insuficiencia Cardíaca/terapia , Insuficiencia Cardíaca/etiología , Endocarditis Bacteriana/microbiología , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/complicaciones , Endocarditis Bacteriana/terapia , Tropheryma/aislamiento & purificación , Resultado del Tratamiento , Antibacterianos/uso terapéutico , Válvula Mitral/diagnóstico por imagen , Válvula Mitral/microbiología , Válvula Mitral/cirugía , Choque Cardiogénico/etiología , Choque Cardiogénico/terapia , Choque Cardiogénico/diagnóstico , Choque Cardiogénico/microbiología , Válvula Aórtica/microbiología , Válvula Aórtica/cirugía , Válvula Aórtica/diagnóstico por imagen , Enfermedades de las Válvulas Cardíacas/microbiología , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/complicacionesRESUMEN
Tropheryma whipplei is the causative agent of Whipple's disease, which is a rare multiorgan systemic disease. We report two cases of Tropheryma whipplei infection, all routine tests were negative and it was finally detected by mNGS. This may help clinicians increase awareness of the diagnosis and treatment of acute severe pneumonia and interstitial pneumonia caused by Tropheryma whipplei.
Asunto(s)
Secuenciación de Nucleótidos de Alto Rendimiento , Metagenómica , Tropheryma , Enfermedad de Whipple , Humanos , Tropheryma/genética , Tropheryma/aislamiento & purificación , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/tratamiento farmacológico , Enfermedad de Whipple/microbiología , Masculino , Metagenómica/métodos , Persona de Mediana Edad , Anciano , Femenino , Neumonía Bacteriana/microbiología , Neumonía Bacteriana/diagnóstico , Neumonía Bacteriana/tratamiento farmacológico , Antibacterianos/uso terapéuticoRESUMEN
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.
Asunto(s)
Líquido del Lavado Bronquioalveolar , Secuenciación de Nucleótidos de Alto Rendimiento , Metagenómica , Tropheryma , Enfermedad de Whipple , Humanos , Masculino , Persona de Mediana Edad , Líquido del Lavado Bronquioalveolar/microbiología , Femenino , Tropheryma/genética , Tropheryma/aislamiento & purificación , Estudios Retrospectivos , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/microbiología , Metagenómica/métodos , Anciano , AdultoAsunto(s)
Linfadenopatía , Tropheryma , Enfermedad de Whipple , Humanos , Linfadenopatía/microbiología , Tropheryma/aislamiento & purificación , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/tratamiento farmacológico , Enfermedad de Whipple/microbiología , Enfermedad de Whipple/complicaciones , Masculino , Antibacterianos/uso terapéutico , Persona de Mediana EdadRESUMEN
Whipple disease (WD) is a rare infection in genetically susceptible people caused by the bacterium Tropheryma whipplei. An indirect immunofluorescence serological assay (IFA), detecting patient antibodies to the bacterium, was developed using T. whipplei as antigen. We hypothesised that this assay could be used to rule out WD in patients in whom the diagnosis was being considered, based on high immunoglobulin (Ig) G titres to T. whipplei. In this study, 16 confirmed WD patients and 156 age-matched controls from across Australia were compared serologically. WD patients mostly underproduced IgG antibody to T. whipplei, with titres of ≤1:32 being common. While at an antibody titre of <1:64 the assay sensitivity for WD was only 69% [95% confidence interval (CI) 41-89%], its specificity for excluding WD was 91% (95% CI 85-95%). This specificity increased to 95% (95% CI 90-98%) at an antibody titre of <1:16. Patients with antibody titres of >1:64 were unlikely to have WD. At this titre, the seroprevalence of T. whipplei IgG antibody was 92% (223/242) in Australian blood donors. Unlike other serological assays, which are used to confirm a specific infection, this novel assay is designed to rule out WD infection with a specificity in Australia of 91%. Further validation of this assay, by trialling in other countries, should now be undertaken, as its usefulness is dependent on there being a high background seropositivity to T. whipplei in the general population at the location in which the assay is being used.
Asunto(s)
Tropheryma , Enfermedad de Whipple , Humanos , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/microbiología , Estudios Seroepidemiológicos , Australia , Inmunoglobulina GRESUMEN
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.
Asunto(s)
Linfoma , Enfermedad de Whipple , Humanos , Tomografía Computarizada por Tomografía de Emisión de Positrones , Fluorodesoxiglucosa F18 , Enfermedad de Whipple/diagnóstico por imagen , Enfermedad de Whipple/microbiología , Linfoma/diagnóstico por imagen , Errores DiagnósticosRESUMEN
Whipple's disease is a chronic and systemic disease caused by the Gram-positive bacterium Tropheryma whipplei that primarily affects the gastrointestinal tract. Data from the last two decades have substantially increased our knowledge of the spectrum and our understanding of T whipplei infections. Although T whipplei seems ubiquitously present in the environment, Whipple's disease itself is very rare. Remarkably, primary infections can be symptomatic, but most cases result in bacterial clearance and seroconversion. However, some individuals are unable to clear the bacterium leading to persistence and asymptomatic carriage. In very rare cases, which might be associated with a subtle immune defect, T whipplei replication is uncontrolled and manifests as classical Whipple's disease or T whipplei localised infections. In this review, we provide a comprehensive outline of T whipplei infection, including the epidemiology, clinical manifestations, diagnosis, and treatment. We also provide an up-to-date overview of our understanding of the host immune response and pathophysiology and discuss future research avenues to resolve the lacking pieces of the puzzle of T whipplei infections.
Asunto(s)
Tropheryma , Enfermedad de Whipple , Humanos , Tropheryma/fisiología , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/tratamiento farmacológico , Enfermedad de Whipple/microbiologíaRESUMEN
Whipple disease (WD) is a rare infectious systemic disease. Rheumatologists are at the frontline of WD diagnosis due to the early rheumatological manifestations. An early diagnosis is crucial, as usual anti-rheumatic drugs, especially TNF inhibitors, may worsen the disease course. We conducted a retrospective multicentre national study from January 2010 to April 2020 to better characterize the rheumatological features of WD. Classic WD (CWD) was defined by positive periodic acid-Schiff (PAS) staining of a small-bowel biopsy sample, and non-CWD (NCWD) was defined by negative PAS staining of a small-bowel biopsy sample but at least one positive Tropheryma whipplei (TW) polymerase chain reaction (PCR) for a digestive or extradigestive specimen. Sixty-eight patients were enrolled, including 11 CWD patients. Twenty patients (30%) received TNF inhibitors during the WD course, with inefficacy or symptom worsening. More digestive symptoms and systemic biological features were observed in CWD patients than in NCWD patients, but both patient groups had similar outcomes, especially concerning the response to antibiotics and relapse rate. Stool and saliva TW PCR sensitivity were both 100% for CWD and 75% for NCWD and 89% and 60% for small-bowel biopsy sample PCR, respectively. WD encountered in rheumatology units has many presentations, which might result from different pathophysiologies that are dependent on host immunity. Given the heterogeneous presentations and the presence of chronic carriage, multiple TW PCR tests on samples from specific rheumatological sites when possible should be performed, but samples from nonspecific digestive and extradigestive sites also have great value.
Asunto(s)
Enfermedad de Whipple/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Antibacterianos/uso terapéutico , Biomarcadores , Diagnóstico Diferencial , Diagnóstico por Imagen/métodos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Enfermedades Reumáticas/diagnóstico , Evaluación de Síntomas , Resultado del Tratamiento , Enfermedad de Whipple/tratamiento farmacológico , Enfermedad de Whipple/microbiologíaRESUMEN
Tropheryma whipplei, is an actinobacterium that causes different infections in humans, including Whipple's disease. The bacterium infects and replicates in macrophages, leading to a Th2-biased immune response. Previous studies have shown that T. whipplei harbors complex surface glycoproteins with evidence of sialylation. However, the exact contribution of these glycoproteins for infection and survival remains obscure. To address this, we characterized the bacterial glycoprofile and evaluated the involvement of human ß-galactoside-binding lectins, Galectin-1 (Gal-1) and Galectin-3 (Gal-3) which are highly expressed by macrophages as receptors for bacterial glycans. Tropheryma whipplei glycoproteins harbor different sugars including glucose, mannose, fucose, ß-galactose and sialic acid. Mass spectrometry identification revealed that these glycoproteins were membrane- and virulence-associated glycoproteins. Most of these glycoproteins are highly sialylated and N-glycosylated while some of them are rich in poly-N-acetyllactosamine (Poly-LAcNAc) and bind Gal-1 and Gal-3. In vitro, T. whipplei modulates the expression and cellular distribution of Gal-1 and Gal-3. Although both galectins promote T. whipplei infection by enhancing bacterial cell entry, only Gal-3 is required for optimal bacterial uptake. Finally, we found that serum levels of Gal-1 and Gal-3 were altered in patients with T. whipplei infections as compared to healthy individuals, suggesting that galectins are also involved in vivo. Among T. whipplei membrane-associated proteins, poly-LacNAc rich-glycoproteins promote infection through interaction with galectins. T. whipplei modulates the expression of Gal-1 and Gal-3 both in vitro and in vivo. Drugs interfering with galectin-glycan interactions may provide new avenues for the treatment and diagnosis of T. whipplei infections.
Asunto(s)
Proteínas Sanguíneas/metabolismo , Galectina 1/metabolismo , Galectinas/metabolismo , Tropheryma/patogenicidad , Enfermedad de Whipple/metabolismo , Proteínas Bacterianas/metabolismo , Galactosa/metabolismo , Galectina 1/sangre , Galectinas/sangre , Glicoproteínas/metabolismo , Glicosilación , Humanos , Macrófagos/metabolismo , Macrófagos/microbiología , Polisacáridos Bacterianos/metabolismo , Tropheryma/metabolismo , Virulencia , Enfermedad de Whipple/microbiologíaRESUMEN
Our institution has performed microbiological diagnosis of Tropheryma whipplei since 2001, initially with a PCR targeting 16S rRNA before the development of a quantitative PCR in 2012. Here we report the clinical characteristics of a cohort of patients suffering from Whipple disease (WD) and evaluate the impact of these molecular techniques. Patients with a positive PCR for T. whipplei between 2001 and 2016 were retrospectively collected from microbiological databases. Two infectious diseases specialists reviewed their medical records and classified them as definite WD, probable WD or carriage of T. whipplei without disease. A total of 1153 samples were tested for T. whipplei; 76 samples taken from 36 patients were positive. Fifteen were considered as presenting a definite WD, seven as a probable WD and 14 as carriers. Median age was 56.4 years (extremes, 6.6-76.1). Median time from symptoms to diagnosis was 3 years (2.5 months to 13.3 years). About 60% were immunosuppressed. The most frequent clinical presentations were joint pain (16/22), weight loss (15/22) and/or digestive tract disorder (15/22); 41% had neurological manifestations, 32% pulmonary involvement and 32% lymphadenopathies. Bacterial load in faeces or saliva were 88 425 copies/mL (IQR 6175-292 725) in definite and probable WD and 311 copies/mL (IQR 253-2090) in carriers, respectively. We observed a 90% PPV above 32 200 copies/mL in faeces. WD is a chronic multisystemic disease with frequent pulmonary involvement. Underlying immunodeficiency is commonly observed leading to more complex clinical presentation. Positive T. whipplei PCR in both stool and saliva has a high positive predictive value. Moreover, patients with WD present higher bacterial load in faeces with a threshold of >32 200 copies/mL predicting ongoing infection.
Asunto(s)
Reacción en Cadena de la Polimerasa , Tropheryma/aislamiento & purificación , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/microbiología , Adolescente , Adulto , Anciano , Antibacterianos/uso terapéutico , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Sensibilidad y Especificidad , Enfermedad de Whipple/tratamiento farmacológico , Adulto JovenAsunto(s)
Antibacterianos/uso terapéutico , Pruebas Respiratorias , Duodeno/efectos de los fármacos , Fiebre/tratamiento farmacológico , Ureasa/análisis , Pérdida de Peso , Enfermedad de Whipple/tratamiento farmacológico , Amoxicilina/uso terapéutico , Biopsia , Cefuroxima/uso terapéutico , Claritromicina/uso terapéutico , Doxiciclina/uso terapéutico , Quimioterapia Combinada , Duodeno/microbiología , Duodeno/patología , Fiebre/diagnóstico , Fiebre/microbiología , Gastroscopía , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Tomografía Computarizada por Rayos X , Resultado del Tratamiento , Enfermedad de Whipple/complicaciones , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/microbiologíaRESUMEN
SIGNIFICANCE: Whipple disease is a rare chronic, systemic bacterial infection that predominantly affects the small intestine but also other organs of the body. When left untreated, it can be not only vision threatening but also life threatening because of its central nervous system involvement. Therefore, early detection and treatment are important. PURPOSE: We report a rare case of unilateral optic disc edema as a critical identifying sign of Whipple disease. CASE REPORT: An asymptomatic 49-year-old African American man presented for an eye examination and was found to have optic nerve edema of the right eye. His best-corrected visual acuity was 20/20 in the right and left eye. He denied symptoms of diplopia, amaurosis fugax, or eye pain. His medical history was significant for HIV with no recent detectable viral load at the time of his eye examination. The patient denied any other infectious risk factors or changes in medical status. Extensive ophthalmic, neuroimaging, and laboratory investigations were completed as a comprehensive approach to rule out more common etiologies for unilateral optic disc edema. This initial workup yielded no identifying etiology, and the patient was monitored closely with frequent examinations with a retina specialist. Soon after his diagnosis of optic nerve edema, the patient developed new symptoms of chronic diarrhea, weight loss, and fatigue requiring hospitalization. Evaluations by internal medicine and gastroenterology, including serological testing, stool analysis, histological and microbiological analysis, esophagogastroduodenoscopy, and gastrointestinal biopsy, confirmed a diagnosis of Whipple disease that was successfully treated with oral antibiotics. CONCLUSIONS: Whipple disease is a rare cause of infectious optic nerve edema that may present with other rheumatoid and gastrointestinal symptoms. A comprehensive medical approach for investigating unilateral optic nerve edema is paramount in diagnosing and treating Whipple disease.
Asunto(s)
Infecciones Bacterianas del Ojo/microbiología , Papiledema/microbiología , Tropheryma/aislamiento & purificación , Enfermedad de Whipple/microbiología , Administración Oral , Antibacterianos/uso terapéutico , Infecciones Bacterianas del Ojo/diagnóstico , Infecciones Bacterianas del Ojo/tratamiento farmacológico , Angiografía con Fluoresceína , Humanos , Masculino , Persona de Mediana Edad , Fibras Nerviosas/patología , Papiledema/diagnóstico , Papiledema/tratamiento farmacológico , Células Ganglionares de la Retina/patología , Tomografía de Coherencia Óptica , Combinación Trimetoprim y Sulfametoxazol/uso terapéutico , Agudeza Visual/fisiología , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/tratamiento farmacológicoAsunto(s)
Diarrea/microbiología , Fiebre/microbiología , Intestino Delgado/microbiología , Enfermedad de Whipple/microbiología , Anciano , Biopsia , Enfermedad Crónica , Enteroscopía de Doble Balón , Femenino , Humanos , Intestino Delgado/patología , Tomografía Computarizada por Rayos X , Enfermedad de Whipple/complicaciones , Enfermedad de Whipple/diagnósticoRESUMEN
BACKGROUND: Whipple's disease is a clinically relevant multi-system disorder that is often undiagnosed given its elusive nature. We present an atypical case of Whipple's disease involving pan-valvular endocarditis and constrictive pericarditis, requiring cardiac intervention. A literature review was also performed assessing the prevalence of atypical cases of Whipple's disease. CASE PRESENTATION: A previously healthy 56-year-old male presented with a four-year history of congestive heart failure with weight loss and fatigue. Notably, he had absent gastrointestinal symptoms. He went on to develop pan-valvular endocarditis and constrictive pericarditis requiring urgent cardiac surgery. A clinical diagnosis of Whipple's disease was suspected, prompting duodenal biopsy sampling which was unremarkable, Subsequently, Tropheryma whipplei was identified by 16S rDNA PCR on the cardiac valvular tissue. He underwent prolonged antibiotic therapy with recovery of symptoms. CONCLUSIONS: Our study reports the first known case of Whipple's disease involving pan-valvular endocarditis and constrictive pericarditis. A literature review also highlights this presentation of atypical Whipple's with limited gastrointestinal manifestations. Duodenal involvement was limited and the gold standard of biopsy was not contributory. We also highlight the Canadian epidemiology of the disease from 2012 to 2016 with an approximate 4% prevalence rate amongst submitted samples. Routine investigations for Whipple's disease, including duodenal biopsy, in this case may have missed the diagnosis. A high degree of suspicion was critical for diagnosis of unusual manifestations of Whipple's disease.
Asunto(s)
Endocarditis Bacteriana/microbiología , Enfermedades de las Válvulas Cardíacas/microbiología , Miocarditis/microbiología , Pericarditis Constrictiva/microbiología , Tropheryma/aislamiento & purificación , Enfermedad de Whipple/microbiología , Antibacterianos/uso terapéutico , Endocarditis Bacteriana/diagnóstico , Endocarditis Bacteriana/tratamiento farmacológico , Endocarditis Bacteriana/cirugía , Insuficiencia Cardíaca/microbiología , Enfermedades de las Válvulas Cardíacas/diagnóstico , Enfermedades de las Válvulas Cardíacas/tratamiento farmacológico , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Masculino , Persona de Mediana Edad , Anuloplastia de la Válvula Mitral , Miocarditis/diagnóstico , Miocarditis/tratamiento farmacológico , Pericardiectomía , Pericarditis Constrictiva/diagnóstico , Pericarditis Constrictiva/tratamiento farmacológico , Pericarditis Constrictiva/cirugía , Ribotipificación , Resultado del Tratamiento , Tropheryma/genética , Enfermedad de Whipple/diagnóstico , Enfermedad de Whipple/tratamiento farmacológicoRESUMEN
AIM: To obtain the first molecular epidemiological survey of Tropheryma whipplei intestinal colonization in Italy. Materials & methods: Retrospective, observational study to assess the prevalence of T. whipplei, the causative agent of Whipple's disease, in stool samples (real-time PCR) of patients attending the Center for Tropical Diseases (Italy) and risk factors associated. RESULTS: Overall prevalence was 6.9% (85/1240). The younger age group showed a significantly higher rate than older age group (12.7 vs 5.9%, p = 0.002). The prevalence was 4.9% for Italians and 9.3% for migrants (p = 0.003). Among the latter, children less than 10 years had higher prevalence than older ones (17.3 vs 7.3%, p = 0.003). The young age, male gender and Giardia duodenalis and Entamoeba histolytica coinfection were risk factors. CONCLUSION: Our study confirms an increased risk of acquiring T. whipplei infection during childhood, under poor sanitary conditions.
Asunto(s)
Intestinos/microbiología , Tropheryma/crecimiento & desarrollo , Enfermedad de Whipple/microbiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Heces/microbiología , Femenino , Humanos , Lactante , Italia , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Migrantes/estadística & datos numéricos , Tropheryma/genética , Tropheryma/aislamiento & purificación , Adulto JovenRESUMEN
Introduction: Malabsorptive bariatric techniques are associated with nutritional deficiencies. However, when patients do not respond to supplemental intensive treatments they should be closely followed because they can hide other pathological conditions. We present the case of a 47-year-old man with morbid obesity (body mass index [BMI]: 48 kg/m2) who underwent bariatric surgery. In 2016, he presented severe pneumonia and hospitalization at the Intensive Unit Care was required. After this episode, his nutritional state impaired, presenting 6-7 diarrhea/steatorrhea events per-day and requiring several hospitalizations due to the persistence of severe hypoproteinemia. He was given parenteral high-protein associated with low-fat oral diet. He presented a temporary biochemical improvement, but the hypoproteinemia recurred. Finally, tests revealed the presence of Tropheryma whipplei as protein-losing enteropathy. Whipple's disease (WD) is a rare cause of diarrhea and malnutrition, and these symptoms can be confused with the postoperative status of malabsorptive bariatric techniques. WD requires early diagnosis with prolonged antibiotic treatment to avoid severe complications.
Introducción: Las técnicas bariátricas malabsortivas suelen asociarse a deficiencias nutricionales. Sin embargo, cuando los pacientes no responden a tratamientos intensivos suplementarios, deben valorarse otras condiciones patológicas. Presentamos el caso de un hombre de 47 años, obeso mórbido (índice de masa corporal [IMC]: 48 kg/m2) sometido a cirugía bariátrica, que dos años más tarde presentó neumonía severa, por lo que requirió ingreso en la Unidad de Cuidados Intensivos. Posteriormente, el estado nutricional se deterioró, presentando 6-7 episodios de diarrea-esteatorrea/día y requiriendo varias hospitalizaciones por hipoproteinemia severa. Recibió infusión parenteral rica en proteínas asociada con una dieta baja en grasas y presentó mejoría analítica temporal. Finalmente, las pruebas revelaron la presencia de Tropheryma whipplei, una bacteria que genera enteropatía pierde-proteínas. La enfermedad de Whipple (EW) es una causa poco común de diarrea y malnutrición. Estos síntomas pueden confundirse con el posoperatorio de técnicas bariátricas malabsortivas. La EW requiere un diagnóstico precoz con un tratamiento antibiótico prolongado para evitar complicaciones graves.
Asunto(s)
Cirugía Bariátrica , Síndromes de Malabsorción/complicaciones , Desnutrición/complicaciones , Complicaciones Posoperatorias/fisiopatología , Enfermedad de Whipple/etiología , Antibacterianos/uso terapéutico , Dieta con Restricción de Grasas , Proteínas en la Dieta/uso terapéutico , Femenino , Humanos , Síndromes de Malabsorción/etiología , Desnutrición/etiología , Persona de Mediana Edad , Estado Nutricional , Obesidad Mórbida/cirugía , Complicaciones Posoperatorias/etiología , Tropheryma , Enfermedad de Whipple/dietoterapia , Enfermedad de Whipple/microbiologíaRESUMEN
OBJECTIVE: To look for abnormalities in circulating B-cell subsets in patients with rheumatic symptoms of Whipple's disease (WD). METHOD: Consecutive patients seen between 2010 and 2016 for suspected inflammatory joint disease were identified retrospectively. Results of standardized immunological and serological tests and of peripheral-blood B-cell and T-cell subset analysis by flow cytometry were collected. Patients with criteria suggesting WD underwent PCR testing for Tropheryma whipplei, and those with diagnosis of WD (cases) were compared to those without diagnosis (controls). We used ROC curve analysis to evaluate the diagnostic value of flow cytometry findings for WD. RESULTS: Among 2917 patients seen for suspected inflammatory joint disease, 121 had suspected WD, including 9 (9/121, 7.4%) confirmed WD. Proportions of T cells and NK cells were similar between suspected and confirmed WD, whereas cases had a lower proportion of circulating memory B cells (IgD-CD38low, 18.0%±9.7% vs. 26.0%±14.2%, P = 0.041) and higher ratio of activated B cells over memory B cells (4.4±2.0 vs. 2.9±2.2, P = 0.023). Among peripheral-blood B-cells, the proportion of IgD+CD27- naive B cells was higher (66.2%±18.2% vs. 54.6%±18.4%, P = 0.047) and that of IgD-CD27+ switched memory B cells lower (13.3%±5.7% vs. 21.4%±11.9%, P = 0.023), in cases vs. controls. The criterion with the best diagnostic performance was a proportion of IgD+CD27- naive B cells above 70.5%, which had 73% sensitivity and 80% specificity. CONCLUSION: Our study provides data on peripheral-blood B-cell disturbances that may have implications for the diagnosis and pathogenetic understanding of WD.