Fading Away: A Case Report on Whipple's Disease

Whipple's disease (WD) is a rare, multisystemic chronic disease caused by Gram-positive bacteria Tropheryma (T.) whipplei. Transmission usually occurs by the fecal-oral route, as the bacillus has been identified in stagnant water, human feces, and soil. This disorder not only causes malabsorption in the gastrointestinal tract but also has cardiovascular, neurological, ophthalmic, and musculoskeletal effects. Prolonged symptoms are the hallmark of this pathology. Definitive diagnosis requires histologic demonstration of Periodic Acid-Schiff (PAS) staining in macrophages from small bowel mucosa and/or polymerase chain reaction identification of T. whipplei. Treatment requires prolonged antibiotics for up to two years. We present the case of a 69-year-old man, admitted to the emergency department with complaints of worsening nocturnal diarrhea within the last seven months. Fatigue, weight loss, night sweats, and worsening lower limb edema were also present within the same timeframe. On physical examination, palpable lymph nodes were noted. Blood tests displayed hypochromic/microcytic anemia, hypoalbuminemia, and mildly elevated C-reactive protein. A thoracoabdominal computed tomography scan unveiled bilateral pleural effusion, as well as multiple abdominal lymphadenopathy. Upper digestive endoscopy revealed marked duodenal mucosa edema, congestion, and diffuse punctiform lymphangiectasia. Hematoxylin-eosin (HE) and PAS histologic staining of biopsied samples revealed spongy macrophages in lamina propria suggestive of WD. Antibiotic therapy was started with intravenous ceftriaxone for two weeks, followed by sulfamethoxazole/trimethoprim up to one year. After 12 months of antibiotic therapy, clinical improvement was remarkable and the patient fully recovered. Whipple's disease is a rare condition and its diagnosis is challenging. Prompt symptomatic recognition and diagnostic workup could avoid delaying appropriate therapy, therefore leading to better outcomes.