Should we systematically perform central nervous system imaging in patients with Whipple's endocarditis?

Area of Science:

• Infectious Diseases
• Neurology
• Cardiology

Background:

• Whipple's endocarditis is a rare condition, typically lacking extracardiac signs.
• Previous case series indicated a low incidence of extra-cardiac manifestations.

Observation:

• This study reports four male patients (56-72 years) with Whipple's endocarditis and associated brain lesions.
• Patients presented with varied endocarditis (mitral, aortic, tricuspid) and neurological symptoms like cognitive decline or ataxia.
• Brain MRI revealed contrast-enhancing lesions, and one patient had meningitis.

Findings:

• Whipple's disease was confirmed via PCR on excised valves or duodenal biopsy.
• All patients received a treatment regimen including ceftriaxone, gentamicin, and trimethoprim-sulfamethoxazole, resulting in favorable outcomes.
• Despite negative CSF PCR, neurological involvement was evident through imaging and symptoms.

Implications:

• Central nervous system involvement in Whipple's endocarditis may be more prevalent than previously thought.
• Distinguishing neurological Whipple's disease is critical as treatment differs significantly (trimethoprim-sulfamethoxazole vs. doxycycline/hydroxychloroquine).
• Recommend brain imaging for patients diagnosed with Whipple's endocarditis to detect potential CNS disease.