Transmission electron microscopy helpfulness in Whipple's disease masked by immunosuppressant therapy for arthritis

Abstract

A 61-year-old woman received a diagnosis of undifferentiated non-erosive arthritis in 2010 and assumed methotrexate and steroids in 2014. After 1 year, she experienced watery diarrhea, vomiting, fever, weight loss, and severe hypoalbuminemia, thus being admitted into our Unit. Esophagogastroduodenoscopy showed duodenal lymphangiectasia and duodenal biopsy samples several foamy PAS-positive macrophages and villous subtotal atrophy. Transmission electron microscope demonstrated several extracellular and intracellular rod-shaped bacteria (Tropheryma whipplei). Therefore, we diagnosed Whipple's disease. Our patient assumed doxycycline/hydroxychloroquine with prompt remission of gastrointestinal symptoms. At 1 year of follow-up, she was symptom-free, histological reassessment showed almost complete mucosal healing and transmission electron microscope demonstrated bacteria breaking/disappearance. The present report demonstrates that: (i) rheumatological manifestations are common onset symptoms of Whipple's disease; (ii) immunosuppressive therapy may delay the diagnosis and worsen clinical presentation; (iii) transmission electron microscopy for specific bacteria detection/disappearance is an helpful diagnostic tool, when available.

Whipple’s disease: 5-year clinical follow-up

“…Проведенная 27.02.18 ВЭГДС позволила визуализировать атрофию ворсин и лимфангиэктазии двенадцатиперстной и тощей кишки, морфологически-PAS-позитивные макрофаги. Для верификации возбудителя в ДПК и оценки эффективности АБТ мы использовали ЭМ, т. к. данный метод применялся рядом авторов при наличии суставного синдрома при БУ [20]. Наличие электронно-микроскопических скоплений палочковидных бактерий, расположенных внеклеточно и в фрагментах цитоплазмы разрушенных клеток, массивной инфильтрации мононуклеарами с макрофагами, содержащими в цитоплазме мешотчатые образования в слизистой оболочке ДПК позволило поставить диагноз болезни Уиппла через 6 лет от начала клинических проявлений.…”

Tropheryma whipplei in the stool samples of children with acute diarrhea: a study from Tehran, Iran

“…In contrast, PCR can be preferred to identify T. whipplei in various specimens (e.g., stool, mucosa, and fluids), and it is a fast, specific, sensitive, and cost-effective method [2]. In addition, transmission electron microscopy is a helpful diagnostic tool for identifying both living and dead bacteria after therapy, when available [8]. Early diagnosis can help to treatment and eradication of T. whipplei in patients.…”