Whipple’s disease concomitant with candida esophagitis and subsequent Giardia lamblia coinfection

Abstract

Whipple's disease is a rare systemic condition resulting from a chronic infection by Tropheryma whipplei. Clinical presentation can be widely heterogeneous, often leading to delayed diagnosis and treatment. Furthermore, little is known about the underlying pathogenic mechanisms, although several abnormalities in immune cell function have been observed. We describe the case of a 51-year-old woman presenting with dysphagia, odynophagia, long-lasting low-grade fever, and malabsorption syndrome who underwent an upper gastrointestinal endoscopy showing esophageal candidiasis. On the same occasion, duodenal biopsies were also performed, with evidence of mucosal infiltration of periodic acid-Schiff-positive and CD68+ foamy macrophages at microscopic examination. Such findings were suggestive of Whipple's disease, as also confirmed by molecular analysis by PCR for T. whipplei. No specific risk factors were identified in our patient that could explain the occurrence of an opportunistic infection such as candida esophagitis, thus leading to the hypothesis of a direct correlation with Whipple's disease. Interestingly, a Giardia lamblia coinfection was subsequently identified, which is consistent with an underlying immune deficit although still undefined.

Fungal-Bacterial Interactions in Health and Disease

“…Bacteria that are often co-isolated with Candida spp. from infection sites are staphylococci [10,316], but also less frequent bacteria such as S. marcescens , Tropheryma whipplei or other fungi, for example, C. neoformans [317,318,319].…”

Severe pneumonia in adults caused by Tropheryma whipplei and Candida sp. infection: a 2019 case series

“…Sulis et al [17] have reported a case of TW in which no specific risk factors for opportunistic infections were identified in patients with candidal esophagitis except TW infection; therefore, they hypothesized that the candidal infection was directly related to WD. Moussawi et al [18] have proved using a mouse model that TW alone cannot invade tissues but can smolder in cells, including macrophages, by inhibiting the xenogenic phagocytosis process, a selective autophagy that targets pathogens.…”

Advances in understanding Giardia: determinants and mechanisms of chronic sequelae

“…In some populations, up to 75% of Giardia infections include co-enteropathogens, most commonly with Vibrio cholerae and rotavirus [ 151 ] and elsewhere with norovirus and enteropathogenic E. coli [ 46 ]. Cases of co-infections with Tropheryma whipplei have also been reported [ 152 ]. In rural Ecuador, the OR for diarrhea with rotavirus infection was 6-14.8, but G. lamblia with rotavirus increased the OR to 11-24.13.…”