Endoscopic diagnosis of Whipple disease in a patient without gastrointestinal symptoms: A case report

Abstract

Whipple's disease is a systemic chronic bacterial infection caused by Tropheryma whipplei, a gram-positive bacillus. T. whipplei infection in the small intestine often causes malabsorption and is often accompanied by gastrointestinal symptoms such as diarrhea and abdominal pain. In this report, we describe our experience with a case of Whipple's disease in which the affected patient did not have the typical gastrointestinal symptoms. The patient was an 80-year-old male who presented with complaints of weight loss and lower leg edema due to malabsorption and shortness of breath during exertion. A blood test revealed a decreased albumin level and an elevated C-reactive protein level. Endoscopic images revealed diffuse white villi, the presence of which extended from the duodenum to the upper jejunum. We made a diagnosis of Whipple's disease based on pathological findings associated with the duodenum, electron microscopic findings, and findings of polymerase chain reaction (PCR) tests (performed using mucosal tissue). Clinical symptoms and endoscopic findings improved with antibiotics. Real-time PCR tests were performed for a quantitative evaluation of the effect of treatment. Endoscopy is useful for diagnosing Whipple's disease when there is an absence of gastrointestinal symptoms, and hypoalbuminemia of unknown etiology is observed.

Keywords: electrons; endoscopy; microscopy; real‐time polymerase chain reaction; tropheryma; whipple disease.

FIGURE 1

Clinical course of the patient after first admission. Through treatment with antibiotics, the patient's condition improved with respect to the inflammatory markers, and his nutritional status gradually recovered Abbreviations CTRX, ceftriaxone; TMP/SMX, trimethoprim‐sulfamethoxazole.

FIGURE 2

Endoscopic findings associated with the duodenum that were obtained at the time of admission (a), 3 months after the start of treatment (b), 9 months after the start of treatment (c), and 2 years after the start of treatment (d). Capsule endoscopy findings obtained at admission (e), 2 weeks after the start of treatment (f), and 1 year after the start of treatment (g)

FIGURE 3

Histopathological findings. (a–e) Histological features of the specimens derived through a duodenum biopsy that was performed at the time of admission; (a and b) Hematoxylin and eosin staining; (c and d) periodic acid‐Schiff (PAS) staining; (e) Ziehl–Neelsen staining. (f–h) Histological features of the duodenum (associated with PAS staining) observed through endoscopic examinations performed during the follow‐up period; (f) 3 months after the start of treatment, (g) 9 months after the start of treatment, (h) 2 years after treatment. Original magnification; (a) × 200, (b) × 400, (c) × 200, (d) × 400, (e) × 200, (f–h) × 200.

FIGURE 4

(a–c) Electron microscopic findings through which Tropheryma whipplei was detected. Original magnification; (a) × 5000, (b) × 20000, (c) × 50000. (d–f) Detection of T. whipplei through a polymerase chain reaction (PCR) test. (d) DNA amplification was observed in the tissue samples from the duodenum and ileum obtained through a biopsy performed at the time of admission. (e) Detection of T. whipplei DNA using a real‐time PCR test performed with 16s rDNA‐derived primers using biopsy specimens obtained at the time of admission. (f) A real‐time PCR test using biopsy specimens obtained at the time of 2 years after treatment Abbreviations: DU, duodenum; IL, ileum; NTC, no template control; ST, stomach.