Letter to the Editor
Chronic bilateral panuveitis as first manifestation of Whipple's disease
Panuveítis crónica bilateral como primera manifestación de la enfermedad de Whipple
Pedro Arriola-Villalobosa,b, Jorge Ruiz-Medranoa,
, David Diaz-Valleb,c, Jose M. Benitez del Castillob,c
Corresponding author
a Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
b Cooperative Research Network on Age-Related Ocular Pathology, Visual and Life Quality, Instituto de Salud Carlos III, Madrid, Spain
c Servicio de Oftalmología, Departamento de Oftalmología y Otorrinolaringología, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Benitez del Castillo" "autores" => array:4 [ 0 => array:3 [ "nombre" => "Pedro" "apellidos" => "Arriola-Villalobos" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "Jorge" "apellidos" => "Ruiz-Medrano" "email" => array:1 [ 0 => "jorge.ruizmedrano@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "David" "apellidos" => "Diaz-Valle" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Jose M." "apellidos" => "Benitez del Castillo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Oftalmología, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cooperative Research Network on Age-Related Ocular Pathology, Visual and Life Quality, Instituto de Salud Carlos III, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Oftalmología, Departamento de Oftalmología y Otorrinolaringología, Hospital Clínico San Carlos, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Panuveítis crónica bilateral como primera manifestación de la enfermedad de Whipple" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Ocular involvement in Whipple's disease is rare (2–5% of patients, depending on the series),<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> and it mainly manifests as uveitis, optic neuropathy and macular oedema.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">2–4</span></a> Ocular problems can also be secondary to a central nervous system (CNS) impairment, and may manifest as oculomotor palsy, nystagmus and ophthalmoplegia.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">4</span></a> Ocular involvement usually occurs late in the disease and it is associated with gastrointestinal<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">5</span></a> and/or neurological manifestations. Ocular involvement non-secondary to CNS disorder in the absence of intestinal manifestations is very rare, with few cases described in literature.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–9</span></a> Despite being very unusual, it may be the first manifestation of Whipple's disease, making the already complex diagnosis of this entity even more difficult.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 59-year-old male without systemic symptoms and an 18-month history of anterior uveitis, peripheral retinal vasculitis and bilateral macular oedema with poor response to multiple anti-inflammatory and immunosuppressive treatments at local and systemic level. A complete etiologic study was conducted, including serology, autoimmunity tests and imaging tests, but it was not sufficient to establish a causal diagnosis. After a month of mild gastrointestinal symptoms, the patient was referred to internal medicine due to severe diarrhoea as well as fatigue and weight loss of 3<span class="elsevierStyleHsp" style=""></span>kg. An endoscopic capsule was performed, reported as lymphangiectasis, affecting the entire small intestine. Days later, by scheduled jejunoscopy, 3 samples of jejunal mucosa were taken. The histopathologic study was suggestive of Whipple’ disease, as there were numerous macrophages with negative PAS+ and Ziehl–Neelsen staining in the small intestine mucosa layer. The combination of compatible clinical and pathological anatomy confirmed the diagnosis of Whipple's disease, so antibiotic therapy was started with intramuscular ceftriaxone (2<span class="elsevierStyleHsp" style=""></span>g daily for 2 weeks) and cefixime (400<span class="elsevierStyleHsp" style=""></span>mg/day, orally, for one year). During the subsequent months, there was an overall improvement, with weight gain and gradual disappearance of gastrointestinal and joint symptoms. A new capsule endoscopy was performed, showing a significant improvement, with almost complete disappearance of the intestinal lymphangiectasis. The retinal vasculitis also improved; that wasn’t the case of the macular oedema, which persisted due to the development of an epiretinal membrane.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The pathogenesis of ocular manifestations in Whipple's disease remains unclear.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3,5</span></a> Some authors uphold an immune mechanism, which assumes that the ocular manifestations are due to a hypersensitivity phenomenon. Another plausible theory is that there is a bacterial invasion in the eye, as the presence of the bacterium was detected by PCR in vitreous samples.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6–9</span></a> Even then, the presence of bacterial products, as determined by PCR, does not demonstrate that the bacteria are responsible for the ocular signs and symptoms.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Late diagnosis is very common in Whipple's disease due to the large number of non-specific signs and symptoms with which it manifests itself. And it is even more delayed in patients with an unusual presentation of the disease. Ocular involvement is not usually the first manifestation of Whipple's disease.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">6,7</span></a> Nevertheless, in the case we are reporting, the first symptoms of Whipple's disease were ocular manifestations. The diagnosis of the disease was done almost 2 years after the onset of ocular symptoms.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In short, this case illustrates, on one hand, the need to include Whipple's disease in the differential diagnosis of chronic bilateral panuveitis, given its harmful progression (it is life threatening) and good response to antibiotic treatment of systemic and ocular manifestations. This consideration is even more important in long term cases which are refractory to immunosuppressive treatment. In these cases, an infectious cause should always be ruled out. On the other hand, this case also shows that Whipple's disease can start with unusual symptoms, far from the typical insidious pattern of joint pain, diarrhoea and weight loss.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Arriola-Villalobos P, Ruiz-Medrano J, Diaz-Valle D, Benitez del Castillo JM. Panuveítis crónica bilateral como primera manifestación de la enfermedad de Whipple. Med Clin (Barc). 2016;146:467–468.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0050" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Whipple's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "T. Marth" 1 => "D. Raoult" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(03)12274-X" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2003" "volumen" => "361" "paginaInicial" => "239" "paginaFinal" => "246" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12547551" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0055" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Manifestations of Whipple's disease in the posterior segment of the eye" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M.P. Avila" 1 => "A.E. Jalkh" 2 => "E. Feldman" 3 => "C.L. Trempe" 4 => "C.L. Schepens" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Arch Ophthalmol" "fecha" => "1984" "volumen" => "102" "paginaInicial" => "384" "paginaFinal" => "390" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/6200096" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0060" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ocular manifestations of Whipple disease. An atypical presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "J.G. Williams" 1 => "D.P. Edward" 2 => "H.H. Tessler" 3 => "D.H. Persing" 4 => "P.S. Mitchell" 5 => "D.A. Goldstein" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:7 [ "tituloSerie" => "Arch Ophthalmol" "fecha" => "1998" "volumen" => "116" "paginaInicial" => "1232" "paginaFinal" => "1234" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9747687" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673615600277" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0065" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ocular Whipple's disease: therapeutic strategy and long-term follow-up" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "V. Touitou" 1 => "F. Fenollar" 2 => "N. Cassoux" 3 => "H. Merle-Beral" 4 => "P. LeHoang" 5 => "Z. Amoura" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ophtha.2012.01.024" "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2012" "volumen" => "119" "paginaInicial" => "1465" "paginaFinal" => "1469" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22420960" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0070" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Chemosis asociated with Whipple's disease" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P. Disdier" 1 => "J.R. Harle" 2 => "D. Vidal-Morris" 3 => "J. Sahel" 4 => "P.J. Weiller" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "1991" "volumen" => "112" "paginaInicial" => "217" "paginaFinal" => "219" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1714240" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0075" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Brief report: uveitis caused by <span class="elsevierStyleItalic">Tropheryma whippelii</span> (Whipple's bacillus)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L.S. Rickman" 1 => "W.R. Freeman" 2 => "W.R. Green" 3 => "S.T. Felman" 4 => "J. Sullivan" 5 => "V. Russack" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJM199502093320604" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "1995" "volumen" => "332" "paginaInicial" => "363" "paginaFinal" => "366" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7529892" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S1470204515004659" "estado" => "S300" "issn" => "14702045" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0080" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Whipple disease presenting as a posterior uveitis without prominent gastrointestinal symptoms" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "J.K. Nishimura" 1 => "B.E. Cook" 2 => "J.M. Pach" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Am J Ophthalmol" "fecha" => "1998" "volumen" => "126" "paginaInicial" => "130" "paginaFinal" => "132" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9683160" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0085" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ocular Whipple's disease. Earlier definitive diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "R.Y. Chan" 1 => "L.A. Yannuzzi" 2 => "C.S. Foster" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Ophthalmology" "fecha" => "2001" "volumen" => "108" "paginaInicial" => "2225" "paginaFinal" => "2231" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11733263" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0090" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Whipple's syndrome (uveitis, B-27-negative spondylarthropathy, meningitis, and lymphadenopathy) associated with <span class="elsevierStyleItalic">Arthrobacter</span> sp. infection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Bodaghi" 1 => "C. Dauga" 2 => "N. Cassoux" 3 => "B. Wechsler" 4 => "H. Merle-Beral" 5 => "J.D. 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