Whipple's endocarditis: a case report of a blood culture-negative endocarditis

Abstract

Background: Whipple's disease is caused by Tropheryma whipplei and causes a self-limiting gastrointestinal infection. The majority of the population is an asymptomatic carrier, however, in some patients, it causes an invasive infection with for example arthritis, endocarditis, or involvement of the eyes.

Case summary: This case describes a man with long-lasting complaints of progressive dyspnoea caused by heart failure due to total destruction of the aortic and mitral valve as a result of T. whipplei endocarditis, diagnosed with serum polymerase chain reaction. The patient was treated with ceftriaxone and prolonged co-trimoxazole therapy and surgical replacement of the aortic and mitral valve. He was discharged to a rehabilitation centre.

Discussion: Tropheryma whipplei is one of the possible microorganisms classified as causing blood culture-negative endocarditis, with predominantly afebrile patients that do not fulfil the Dukes criteria, which makes it difficult to diagnose. Polymerase chain reaction is the cornerstone of the diagnosis. It requires long-term antibiotic treatment up to 12 months. It is recommended by the European Society of Cardiology to discuss treatment in an Endocarditis Team because Whipple's endocarditis has only rarely been described in the literature previously. Whipple's endocarditis has high mortality and relapse rates.

Keywords: Blood culture-negative endocarditis; Case report; Endocarditis; Tropheryma whipplei; Whipple’s endocarditis.

Figure 1

Transoesophageal aortic long-axis view with (A) abscess of the non-coronary cusp and large vegetation (arrowhead) and (B) severe aortic valve regurgitation with wide jet reaching the apex of the left ventricle. AO, aorta; LA, left atrium; LV, left ventricle.

Figure 2

Transoesophageal aortic short-axis view (multiplanner review) with (A) abscess of the non-coronary cusp. (B) Transoesophageal aortic long-axis view to demonstrate the cross section.

Figure 3

Transoesophageal echocardiography dual chamber with a vegetation of the mitral valve (arrowhead). LA, left atrium; LV, left ventricle.

Figure 4

Illustrative image of PAS-positive Tropheryma whipplei bacteria in human macrophages. (Copyright Gabriele Schoedon, Department of Internal Medicine, University Hospital of Zurich).

Figure 5

Flow chart of suspected infectious endocarditis with the recommended diagnostics of blood culture-negative infectious endocarditis. (Copyright 2015 ESC guidelines for the management of infective endocarditis).