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Whipple Disease

  • Author: Ingram M Roberts, MD, MBA; Chief Editor: Julian Katz, MD  more...
 
Updated: Dec 29, 2015
 

Background

Whipple disease is a systemic disease most likely caused by a gram-positive bacterium, Tropheryma whippelii.[1, 2] Although the first descriptions of the disorder described a malabsorption syndrome with small intestine involvement, the disease also affects the joints, central nervous system, and cardiovascular system. T whipplei infection is recognized to be a major cause of culture-negative endocarditis.[3] Because fewer than 1000 reported cases have been described, clinical experience with this disorder is sparse.[4]

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Pathophysiology

The clinical manifestations of the disease are believed to be caused by infiltration of the various body tissues by T whippelii. The patient's immune system reacts by incorporating the organisms into tissue macrophages.

These macrophages can be easily observed infiltrating the tissues using conventional light microscopy. The macrophages are easily observed when periodic acid-Schiff stain is used for the histologic sections. However, positive periodic acid-Schiff–stained macrophages infiltrating body tissues are not pathognomonic for Whipple disease. These microphages also can be detected in infection due to Mycobacterium avium intracellulare, cryptococcosis, or other parasitic organisms (usually observed in patients who are immunosuppressed with HIV disease).[5, 6] Stains for fungal organisms and acid-fast bacilli are helpful in ruling out Whipple disease.

Diagnostic electron microscopy reveals coccobacillary bodies that represent the T whippelii organism. This is diagnostic because a positive polymerase chain reaction (PCR) for T whippelii will be present in the affected tissue.[7, 8, 9]

The malabsorption observed in the small bowel that is associated with this condition is believed to be secondary to the disruption of normal villous function due to infiltration of the lamina propria of the small bowel. Patients with arthralgias have been found to have the organism in the synovial tissues.[10] The organisms have been detected in the heart valves of patients with cardiac Whipple disease[11, 12] and in the CNS of patients with neurologic disease.[13] Rarely, the organism can be detected in the lungs of affected patients.[14] In short, although Whipple disease represents a systemic condition, only a few organ systems of the body are affected overtly.

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Etiology

The disease is believed to be due to a disordered host response to the bacterium T whippelii.[15] Of note, patients with human immunodeficiency virus (HIV) infection do not acquire the disease.

Data that suggest that T whippelii DNA may be found in patients who are asymptomatic.[16, 15]  One study revealed its presence in saliva in 35% of a sample of 40 healthy patients.[17]  This suggests that Whipple disease is a manifestation of an abnormal host response to a microorganism that may occur frequently in humans (perhaps in a similar manner to that observed with Helicobacter pylori).

To date, Koch's postulates have not been fulfilled completely (infection of an animal model and isolation of the organism from the animal). However, T whippelii bacteria have been grown successfully in HEL (a human fibroblast line) cells.[2]  The production of immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies has been shown. The organism has been cultured from affected cerebrospinal fluid (CSF) and vitreous humor of patients with Whipple disease.

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Epidemiology

International statistics

Whipple disease is extremely rare worldwide; only several hundred clinical cases have been reported, mostly from North America and western Europe. The disease appears to be associated with the human leukocyte antigen B27 (HLA-B27) haplotype.[18] The incidence has been estimated to be less than 1 per 1,000,000.[19]

Race-, sex-, and age-related demographics

Whipple disease is most common in white males[15] and rarely is described in females (male-to-female ratio: approximately 8-9:1).

Whipple disease is usually observed in middle-aged[15] and elderly persons (older than 40 y).

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Prognosis

If Whipple disease is untreated, the prognosis is poor, and mortality approaches 100% after 1 year in patients who do not receive the correct diagnosis and therapy.[20, 21, 22]

If this condition is treated for a full year, the prognosis usually is good. Clinical remission occurs in approximately 70% of patients.

Complications

Up to 30-40% of patients may relapse, and relapse appears to be more common in patients with central nervous system (CNS)–related Whipple disease.

A potential complication is a reaction or allergy to antibiotics that could require changing the antibiotic agent.

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Contributor Information and Disclosures
Author

Ingram M Roberts, MD, MBA Clinical Professor of Medicine (Adjunct), Temple University School of Medicine

Ingram M Roberts, MD, MBA is a member of the following medical societies: American College of Gastroenterology, American Association for Physician Leadership, American Gastroenterological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Noel Williams, MD, FRCPC FACP, MACG, Professor Emeritus, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Professor, Department of Internal Medicine, Division of Gastroenterology, University of Alberta, Edmonton, Alberta, Canada

Noel Williams, MD, FRCPC is a member of the following medical societies: Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

Marco G Patti, MD Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American Surgical Association, American College of Surgeons, American Gastroenterological Association, American Medical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, Western Surgical Association

Disclosure: Nothing to disclose.

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