Case history
Case history #1
A 55-year-old man presents with a 2-year history of polyarthralgia, intermittent fever, weight loss, and diarrhoea. The seronegative polyarthritis has been treated with immunosuppressive drugs without improvement. Lymphadenopathy was reported for the mesenteric and retriperitoneal lymph nodes. Gastroscopy shows mucosal abnormalities in the duodenum. Histological examination of duodenal biopsies reveals numerous foamy macrophages in the lamina propria that contain large amounts of diastase-resistant periodic acid-Schiff (PAS)-positive particles in the cytoplasm.
Case history #2
A 61-year-old man presents with memory impairment, decreasing level of consciousness, and progressive supranuclear ophthalmoplegia in conjunction with oculomasticatory myorhythmia (pendular vergence oscillations of the eyes and synchronous 1 Hz to 3 Hz contractions of the masticatory, but not palatal, muscles). The patient reports occasional headache and occasional articular pain. Laboratory investigation of the spinal fluid shows slightly elevated cell numbers and inflammatory parameters. Microbiological analysis of the spinal fluid is negative. Gastroscopy shows a normal mucosal macroscopy, but a histological examination of duodenal biopsies reveals diastase-resistant PAS-positive macrophages in the lamina propria.
Other presentations
Uncommon presentations include infections without gastrointestinal evidence of the agent. These include isolated Tropheryma whipplei-induced infective endocarditis,[15] isolated joint manifestations,[16] and isolated neurological manifestations.[17] A particular problem during treatment is an inflammatory immune reconstitution syndrome that may occur in previously immunosuppressed patients.[11][18]
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