LETTERS TO THE EDITOR

 

Whipple's disease under the vision of capsule endoscopy

 

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Key words: Capsule endoscopy. Small bowel. Whipple disease.

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Dear Editor,

We read with great interest the paper by Martínez-Sánchez et al. entitled Atypical diagnosis by endoscopic capsule: Whipple's disease and we support their Conclusions.

 

Case Report

A 54-year-old man, on treatment with esteroidal anti-inflammatory drugs, presented a two-year period of migratory arthritis due to suspected sarcoidosis. Over the last six months, he had developed diarrhoea and weight loss. No diagnosis was obtained from stool cultures or blood tests, and only iron-deficiency anemia and hypoalbuminemia were identified. Computed tomography revealed small bowel and colon inflammation. Therefore, conventional endoscopy with biopsy specimens and video capsule endoscopy (VCE) were performed (Fig. 1 A and B). A diffuse affection of the whole mucosa with preservation of distal ileum was identified. Histopathological examination was compatible with Whipple's disease (Fig. 1C), confirming definitive diagnosis by polymerase chain reaction. Fourteen-day intravenous ceftriaxone treatment followed by one-year oral trimethoprim-sulfamethoxazole was indicated. Patient's improvement was observed in 2-3 weeks, leading to steroidal anti-inflammatory drugs discontinuation.

 

 

Discussion

Whipple's disease is a rare chronic systemic infection produced by the actinomycete Tropherima wipplei. Small bowel and other extra-intestinal locations may be affected. Migratory arthritis may precede gastrointestinal symptoms in years (1). Diarrhoea and weigh loss accompanied by abdominal pain are typical gastrointestinal symptoms. Both duodenal PAS-positive staining on small bowel biopsy specimens and polymerase chain reaction are needed for a definitive diagnosis (2). However, up to 30% of patients may present with normal endoscopy and duodenal biopsies. In these cases, VCE may be useful, as it is a complementary tool that can identify lesions throughout the small bowel (3), allowing push enteroscopy to localize and take biopsies to analyze (4). Therefore, VCE may be a useful tool in the diagnosis of Whipple's disease when duodenal biopsies are negative and distal affection is suspected or when other pathologies must be rule out.

 

José Francisco Juanmartiñena-Fernández^1,2, Daniel Oyón-Lara², Socorro Rázquin-Lizarraga³ and Ignacio Fernández-Urien^1,2
Departments of ¹Endoscopy, ²Digestive Diseases and
³Pathology. Complejo Hospitalario de Navarra. Pamplona, Navarra, Spain

 

References

1. Günther U, Moos V, Offenmüller G, et al. Gastrointestinal diagnosis of classical Whipple disease: Clinical, endoscopic and histopathologic features in 191 patients. Medicine (Baltimore) 2015;94:e714. DOI: 10.1097/MD.0000000000000714.         [ Links ]

2. Ojeda E, Cosme A, Lapaza J, et al. Whipple's disease in Spain: A clinical review of 91 patients diagnosed between 1947 and 2001. Rev Esp Enferm Dig 2010;102:108-23. DOI: 10.4321/S1130-01082010000200006.         [ Links ]

3. Martínez-Sánchez A, Sánchez-Ceballos FL, Fernández-Diéz S, et al. Atypical diagnosis by endoscopic capsule: Whipple's disease. Rev Esp Enferm Dig 2016;108(3):158-62. DOI: 10.17235/reed.2015.3718/2015.         [ Links ]

4. Pérez-Cuadrado E, Más P, Hallal H, et al. Enteroscopia de doble balón: estudio descriptivo de 50 exploraciones. Rev Esp Enferm Dig 2006; 98:73-81. DOI: 10.4321/S1130-01082006000200002.         [ Links ]