Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Clinical Medicine Journal

  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Clinical Medicine Journal

clinmedicine Logo
  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

One in a million

Alexandra Cox-Smith, Angad Singh, Manuel Jasper and Nada El-Hag
Download PDF
DOI: https://doi.org/10.7861/clinmedicine.19-2-s19
Clin Med March 2019
Alexandra Cox-Smith
AGastroenterology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Angad Singh
AGastroenterology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Manuel Jasper
AGastroenterology
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Nada El-Hag
BMicrobiology; Basildon Unviersity Hospital Trust, Essex, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
Loading

Aims

Whipple's disease is a rare, multi-systemic chronic infectious disease caused by the organism Tropheryma whipplei. It can manifest with a variety of symptoms including gastrointestinal (eg weight loss, diarrhoea and abdominal pain), arthritis, neurological involvement, pyrexia, lymphadenopathy, anaemia/hypoalbuminaemia amongst other multi-system symptoms. We present a case of small bowel malabsorption due to Whipple's disease.

Methods

A 51-year-old gentleman presented to hospital with a 6-month history of diarrhoea, fatigue, asymmetrical arthritis and 11 stone weight loss, but preserved appetite clinical examination demonstrated only abdominal fullness. There were no other symptoms on further history including no history of foreign travel or any other symptoms suggestive of inflamatory bowel disease.

He had a past medical history of hypertension and hypothyrodisim, for which he was on ramipril and levothyroxine.

Blood results showed a microcytic anaemia, lymphopenia, hypoalbuminaemia and low IgM levels. Urgent upper and lower gastrointestinal endoscopy were performed with duodenal, caecal and rectal biopsies taken alongside tissue for polymerase chain reaction (PCR). Computed tomography (CT) of chest/abdomen/pelvis revealed multiple enlarged lymph nodes and subsequently a diagnostic laparoscopy was arranged.

Duodenal and lymph node biopsies were consistent with Whipple's disease. Following diagnosis, microbiology advised a lumbar puncture and transthoracic echocardiogram, to rule out central nervous system involvement and endocarditis respectively. These were normal.

Results

The patient was treated with 2 weeks of intravenous ceftriaxone followed by maintenance therapy of doxycycline and hydroxychloroquine. He has since reported improvements in appetite and weight and is currently being reviewed in outpatient clinic.

The pathogenesis is currently unknown with T whipplei being identified in healthy subjects although there is evidence to suggest a genetic predisposition, most commonly occurring in caucasian, European males. In addition, some studies have suggested a higher incidence with increased sewage exposure.

Diagnosis of Whipple's disease is challenging through varied presentations and its rarity with an annual incidence <1:1,000,000.

Maintenance treatment is continued for at least 1 year, monitored by D2 biopsies and PCR tests, and may be stopped after PCR tests become negative.

Conclusion

This case highlights that where small bowel malabsorption is suspected, due to symptoms such as diarrhoea or unexplained weight loss, rarer causes such as Whipple's disease, amyloidosis and small bowel lymphoma do need to be considered and upper gastrointestinal endoscopy with duodenal biopsies can be a crucial investigation in determining a diagnosis, especially if initial lower gastrointestinal endoscopy has not revealed a diagnosis.

  • © Royal College of Physicians 2019. All rights reserved.
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
One in a million
Alexandra Cox-Smith, Angad Singh, Manuel Jasper, Nada El-Hag
Clinical Medicine Mar 2019, 19 (Suppl 2) s19; DOI: 10.7861/clinmedicine.19-2-s19

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
One in a million
Alexandra Cox-Smith, Angad Singh, Manuel Jasper, Nada El-Hag
Clinical Medicine Mar 2019, 19 (Suppl 2) s19; DOI: 10.7861/clinmedicine.19-2-s19
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Aims
    • Methods
    • Results
    • Conclusion
  • Info & Metrics

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • A clinical observation of the effects of hypothyroidism on the cardiovascular system
  • A case of painless jaundice
  • What are the risk factors for TIA and stroke in Newport?
Show more Clinical

Similar Articles

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home
clinmedicine Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2020 by the Royal College of Physicians