Whipple s Disease: the First Japanese Case Diagnosed by Electron Microscopy and Polymerase Chain Reaction

Size: px

Start display at page:

Download "Whipple s Disease: the First Japanese Case Diagnosed by Electron Microscopy and Polymerase Chain Reaction"

William Wheeler
5 years ago
Views:

1 CASE REPORT Whipple s Disease: the First Japanese Case Diagnosed by Electron Microscopy and Polymerase Chain Reaction Tatsuji YOGI, Akira HOKAMA, Fukunori KINJO*, Ryosaku TOMIYAMA, Michio KOIDE, Kazuto KISHIMOTO, Tomoko MAKISHI, Masaru OSHIRO, Satoru MIYAGI, Chiharu KOBASHIGAWA, Ryo TAKAKI, Takashi NAKAYAMA** and Atsushi SAITO Abstract A 52-year-old man presented with diarrhea and 20 kg weight loss in one year. Enteroscopy showed diffuse yellow-white shaggy mucosa in the duodenum and jejunum. Biopsies of the duodenal mucosa revealed massive infiltration within the lamina propria by foamy macrophages strongly positive for periodic acid-schiff stain. Electron microscopy demonstrated numerous bacilli within macrophages of the lamina propria. Tropheryma whipplei DNA was detected by polymerase chain reaction. The definitive diagnosis of Whipple s disease was made. Antibiotic therapy dramatically improved his clinical picture. This is the first Japanese case with Whipple s disease diagnosed by electron microscopy and polymerase chain reaction. (Internal Medicine 43: , 2004) Key words: Whipple s disease, Tropheryma whipplei, periodic acid-schiff stain, electron microscopy, polymerase chain reaction Introduction Whipple s disease, a rare systemic infection caused by Tropheryma whipplei, involves the small intestine, leading to severe malabsorption. Only a few cases have been reported in Asian populations (1). We herein describe the first Japanese case with Whipple s disease diagnosed by electron microscopy and polymerase chain reaction (PCR). Case Report watery diarrhea, weight loss, and low-grade intermittent fever of one-year duration. He lost 20-kg during this period. His past medical history was unremarkable. He denied arthralgia, or neurologic symptoms. On examination, he had hyperpigmentation of light-exposed skin. His pulmonary and cardiac sounds were normal. There was no tenderness of the abdomen with increased bowel sound. No neurological abnormalities and lymphadenopathy were present. Laboratory data on admission is summarized in Table 1, showing anemia and marked hypoalbuminemia. Colonoscopy showed normal findings. Enteroscopy showed diffuse yellow-white shaggy mucosa in the descending duodenum extending as far as the jejunum (Fig. 1A, B). Biopsies stained with hematoxylin and eosin showed clubbed epithelial villi and foamy macrophages (Fig. 2A). Periodic acid-schiff (PAS) staining revealed massive infiltration within the lamina propria by foamy macrophages (Fig. 2B). Electron micrograph of the duodenal mucosa disclosed numerous extracellular bacilli and phagosome-containing bacilli within a macrophage (Fig. 3A, B). PCR was performed to identify these bacilli according to the method using specific primers W3AF and W4AR established by Ramzan et al (2). DNA from duodenal mucosa showed a specific PCR-product of 160 base pairs demonstrating homology with the T. whipplei 16S ribosomal RNA gene (Fig. 4). Based on characteristic pathological and molecular findings, the definitive diagnosis of Whipple s disease was made. The patient was treated with a two-week course of ceftriaxone (2 g per day, intravenously), followed by trimethoprim-sulfamethoxazole (TMP-SMX, 4 g per day, orally). He responded dramatically with a rapid clinical remission. He has been free from symptoms and gained weight during the follow-up with the continuous administration of TMP-SMX. In July 2003, a 52-year-old Japanese man presented with From the First Department of Internal Medicine, *Department of Endoscopy, and **Department of Pathology, University of the Ryukyus, Okinawa Received for publication October 23, 2003; Accepted for publication; January 21, 2004 Reprint requests should be addressed to Dr. Akira Hokama, the First Department of Internal Medicine, University of the Ryukyus, 207 Uehara, Nishihara, Okinawa

Whipple s Disease Table 1. Laboratory Data on Admission Hematology WBC 7,700/l RBC 317 10 4 /l Hb 9.1 g/dl Ht 27.70% Plt 29.1 10 4 /l ESR 9 mm/h Serology CRP 2.

Parasite ( ) Occult blood ( ) Culture Normal flora Biochemistry TP Alb Glu BUN Cre Na K Cl Ca T-Bil AST ALT ALP LDH -GTP ChE CPK AMY TC TG Fe UIBC 4.5 g/dl 2.3 g/dl 76 mg/dl 11 mg/dl 0.

2 Whipple s Disease Table 1. Laboratory Data on Admission Hematology WBC 7,700/l RBC /l Hb 9.1 g/dl Ht 27.70% Plt /l ESR 9 mm/h Serology CRP 2.43 mg/dl IgG 872 mg/dl IgA 194 mg/dl IgM 37 mg/dl IgE 35 IU/ml HBs Ag ( ) Anti HCV Ab ( ) Anti HTLV-1 Ab > 8,192 Anti HIV Ab ( ) Urialysis Glucose ( ) Protein ( ) Occult blood ( ) Stool analysis Parasite ( ) Occult blood ( ) Culture Normal flora Biochemistry TP Alb Glu BUN Cre Na K Cl Ca T-Bil AST ALT ALP LDH -GTP ChE CPK AMY TC TG Fe UIBC 4.5 g/dl 2.3 g/dl 76 mg/dl 11 mg/dl 0.35 mg/dl 129 meq/l 4.7 meq/l 96 meq/l 7.5 mg/dl 0.3 mg/dl 52 IU/l 28 IU/l 501 IU/l 269 IU/l 28 IU/l 153 IU/l 50 IU/l 282 IU/l 96 mg/dl 73 mg/dl 53 g/dl 88 g/dl Figure 1. (A) Enteroscopic image of the descending duodenum, showing diffuse yellow-white shaggy mucosa. (B) After spraying the area with a solution of indigo carmine dye, tortoise shell-like mucosa was identified, suggesting the presence of edematous or clubbed epithelial villi. 567

YOGI et al Figure 2. (A) Histological picture of a duodenal mucosa with clubbed epithelial villi and foamy macrophages (H&E stain, 40).

Note numerous rod shaped bacilli. Phagosomes containing numerous bacillary forms in various stages of degradation were within a macrophage. The bar represents 1 m.

Discussion Whipple s disease, formally known as intestinal lipodystrophy, was first described by George H. Whipple in 1907 (3).

Since the early 1990 s, PCR assay for 16S rrna genes has permitted the identification of the suspected causative bacteria (1, 4).

3 YOGI et al Figure 2. (A) Histological picture of a duodenal mucosa with clubbed epithelial villi and foamy macrophages (H&E stain, 40). (B) Photograph of a duodenal mucosa with diastase PAS-positive macrophages infiltrating the lamina propria (PAS stain, 40). Figure 3. (A) Electron micrograph of the duodenal mucosa. Note numerous rod shaped bacilli. Phagosomes containing numerous bacillary forms in various stages of degradation were within a macrophage. The bar represents 1 m. (B) On higher magnification, Whipple bacillus measured about m insize. The bar represents 0.5 m. Discussion Whipple s disease, formally known as intestinal lipodystrophy, was first described by George H. Whipple in 1907 (3). Its bacterial origins were identified by transmission electron microscopy in the early 1960 s, establishing the bacterial cause. Since the early 1990 s, PCR assay for 16S rrna genes has permitted the identification of the suspected causative bacteria (1, 4). Culture of the bacillus had been an elusive goal until Raoult and colleagues succeeded by using a human fibroblast cell line in 2000 (5). Surprisingly, the calculated doubling time of T. whipplei is 18 days, therefore, there is no wonder that culture of the bacteria is currently undertaken only in highly specialized laboratories (1). This disorder predominantly affects middle-aged Caucasian men; in fact, there has been only one case report in Japan according to the bibliographic search. The patient, whom Naramoto et al reported in 1976 (6), was suspected to have Whipple s disease by the demonstration of PAS-positive macrophages in the jejunal lamina propria. However, they failed to identify Whipple bacillus in the intestinal samples by electron microscopy. Due to the previous inability to culture the 568

Whipple s Disease Figure 4. PCR detection of T. whipplei. Lane 1 shows 1-kb DNA ladder as a size marker; lane 2, duodenal mucosa from the patient; and lane 3, reagent control.

4 Whipple s Disease Figure 4. PCR detection of T. whipplei. Lane 1 shows 1-kb DNA ladder as a size marker; lane 2, duodenal mucosa from the patient; and lane 3, reagent control. Lane 2 shows a PCRproduct of 160 base pairs specific to T. whipplei 16S ribosomal RNA. Whipple bacillus, PAS staining was considered the main tool for diagnosing Whipple s disease (7). However, because detection of PAS-positive macrophages is also seen in other diseases including infection with Mycobacterium aviumintracellulare, Bacillus cereus, or corynebacterium (1), nowadays confirmation by electron microscopy and PCR assay are mandatory for definitive diagnosis (1, 3). Thus, the present case is the first Japanese patient with Whipple s disease diagnosed by electron microscopy and PCR. The infectious route of T. whipplei remains unclear. Detection of the bacterium by PCR in sewage water and human feces in Europe has led to speculation of its existence in the environment (1). Other research has demonstrated that 35% of 40 healthy people showed evidence of T. whipplei DNA in their saliva, suggesting this bacterium can be an oral commensal (8). The detection rate may vary geographically; therefore, we should further study PCR detection of the bacterium in the saliva of patient s family members and the surrounding environment. Moreover, genomic studies have been in progress to clarify the link between genotype and symptom pattern (9). The pathogenesis of Whipple s disease by T. whipplei is not fully understood. Marth and colleagues (1, 10) showed that a defective cellular immune response in a large series of Whipple s disease patients and an important pathogenic role of impaired T-helper cells of type 1 (Th1) responses with reduced production of interleukin (IL)-12 and interferon (IFN)- and subsequent decreased activation of macrophages. The present patient was infected with both T. whipplei and human T-cell lymphotropic virus type I (HTLV-I). The patient was born and has lived in Okinawa, a well-studied endemic region of HTLV-I. Most individuals chronically infected with HTLV-I remain asymptomatic; however, some of them may have a significant form of chronic immune suppression and, as a consequence, this affects the risk of other infectious diseases including strongyloidiasis and tuberculosis (11). Increasing evidence has indicated the immune deviation toward Th1 with a high production of IL-2, IL-12, and IFN-in the asymptomatic state and early immunopathogenesis of HTLV-I infection (12, 13). Therefore, the hypothesis of Th1/Th2 balance fails to explain solely this complicated pathogenesis whether or not coinfection with HTLV-I involves the onset of Whipple s disease in our case. Other unknown mechanisms of immune suppression may be associated with the development of the disease. Further immunological studies are necessary to clarify this immunopathogenesis. Because Whipple s disease is uncommon, prospective evaluations of therapeutic regimens have not been established. We therefore followed the currently recommended regimens described in a review article (1). Although most patients respond well, some patients with relapse have a poor outlook (1). In addition, regression of histopathological findings seems slower and PAS-positive structures may persist for years (3). We therefore should follow-up the patient with electron microscopy and PCR. In conclusion, although extremely rare in Asia, Whipple s disease should be included in a differential diagnosis for the management of chronic diarrhea. Acknowledgements: We thank Dr. Fuse (PCL Japan) for his excellent electron microscopic examination. References 1) Marth T, Raoult D. Whipple s disease. Lancet 361: , ) Ramzan NN, Loftus E Jr, Burgart LJ, et al. Diagnosis and monitoring of Whipple disease by polymerase chain reaction. Ann Intern Med 126: , ) Dutly F, Altwegg M. Whipple s disease and Tropheryma whippelii. Clin Microbiol Rev 14: , ) Relman DA, Schmidt TM, MacDermott RP, Falkow S. Identification of the uncultured bacillus of Whipple s disease. N Engl J Med 327: , ) Raoult D, Birg ML, La Scola B, et al. Cultivation of the bacillus of Whipple s disease. N Engl J Med 342: , 2000 (Erratum in: N Engl J Med 342: 1538, 2000). 6) Naramoto J, Tamechika Y, Niizeki H, Mitsui H, Okabe H, Ishida H. Whipple s disease accompanied by nonspecific multiple ulcers of the small intestine: report of a case. I to Cho (Stomach and Intestine) 11: , 1976 (in Japanese, Abstract in English). 7) Lepidi H, Fenollar F, Gerolami R, et al. Whipple s disease: immunospecific and quantitative immunohistochemical study of intestinal biopsy specimens. Hum Pathol 34: ,

5 YOGI et al 8) Street S, Donoghue HD, Neild GH. Tropheryma whippelii DNA in saliva of healthy people. Lancet 354: , ) Hinrikson HP, Dutly F, Altwegg M. Evaluation of a specific nested PCR targeting domain III of the 23S rrna gene of Tropheryma whippelii and proposal of a classification system for its molecular variants. J Clin Microbiol 38: , ) Marth T, Kleen N, Stallmach A, et al. Dysregulated peripheral and mucosal Th1/Th2 response in Whipple s disease. Gastroenterology 123: , ) Marsh BJ. Infectious complications of human T cell leukemia/lymphoma virus type I infection. Clin Infect Dis 23: , ) Nakamura T, Furuya T, Nishiura Y, Ichinose K, Shirabe S, Eguchi K. Importance of immune deviation toward Th1 in the early immunopathogenesis of human T-lymphotropic virus type I-associated myelopathy. Med Hypotheses 54: , ) Carvalho EM, Bacellar O, Porto AF, Braga S, Galvao-Castro B, Neva F. Cytokine profile and immunomodulation in asymptomatic human T- lymphotropic virus type 1-infected blood donors. J Acquir Immune Defic Syndr 27: 1 6,

Whipple s Disease: A Case Report with Long-term Endoscopic Follow-up

doi: 10.2169/internalmedicine.9631-17 Intern Med Advance Publication http://internmed.jp CASE REPORT Whipple s Disease: A Case Report with Long-term Endoscopic Follow-up Hiroaki Saito 1,2, Junji Shiode