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Case Reports
. 2024 Aug 22;16(8):e67472.
doi: 10.7759/cureus.67472. eCollection 2024 Aug.

Whipple's Disease Endocarditis Following Immunomodulatory Treatment for Arthritis: A Case Report and Screening Recommendation

Warren Back  1 , James Meade  2 , Salman Arif  3 , Hend Elsaghir  2 , Basmah Khalil  2 , Claudiu Georgescu  3
Affiliations
Case Reports

Whipple's Disease Endocarditis Following Immunomodulatory Treatment for Arthritis: A Case Report and Screening Recommendation

Warren Back et al. Cureus. .

Abstract

Whipple's disease (WD) is a rare systemic disorder affecting various organ systems, including the gastrointestinal, cardiovascular, and joint systems. This report discusses a case of WD endocarditis likely associated with tocilizumab (TCZ), an immunomodulator used to treat refractory seronegative arthritis, in a patient with coronary artery disease and rheumatoid arthritis. The diagnosis was confirmed through laboratory studies, imaging, and esophagogastroduodenoscopy with biopsies. WD is increasingly recognized as a potential etiology of seronegative arthritis, with joint pain often preceding gastrointestinal symptoms. Immunomodulatory agents such as TCZ, while effective for rheumatoid arthritis, may exacerbate underlying WD, potentially leading to severe complications such as endocarditis. This case reveals the importance of considering WD in patients with refractory arthritis and the necessity of thorough diagnostic evaluation before initiating immunomodulatory therapy. Epidemiological studies indicate a higher prevalence of WD in certain demographics, highlighting the need for targeted screening with noninvasive screening methodologies, such as stool and saliva polymerase chain reaction testing.

Keywords: blood culture-negative endocarditis; endocarditis tropheryma whipplei; infective endocarditis; seronegative arthritis; tocilizumab; tropheryma whipplei; whipple’s disease.

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Conflict of interest statement

Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. H&E stain of duodenal tissue biopsy showing foamy pink macrophages (red arrows) associated with lymphangiectasia. Increasing magnification of the same sample in each panel from A-E. Panel F demonstrates normal duodenal histology.
H&E = hematoxylin and eosin
Figure 2
Figure 2. PAS with diastase stain of duodenal biopsy showing PAS-positive, diastase-resistant rod- and sickle-shaped bacterial inclusions (red arrows). Panel B is magnified.
PAS = periodic acid-Schiff
Figure 3
Figure 3. AFB stain of duodenal biopsy, negative for mycobacterial organisms.
AFB = acid-fast bacilli
Figure 4
Figure 4. Repeat TTE redemonstrating aortic valve vegetation (red arrows) with measurements.
TTE = transthoracic echocardiogram
See this image and copyright information in PMC

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