Snapshot A 56-year-old Caucasian man with a history of nonspecific arthritis complains of chronic GI upset. He has had diarrhea almost daily for several months now. He has lost 10 lbs unintentionally. His family has also noticed some loss of memory, such as forgetting where his keys are or forgetting someone’s birthday. Introduction Malabsorption syndrome with multisystem involvement Caused by infection with Tropheryma whipplei gram-positive bacillus Actinomyces spp family found in soil Epidemiology seen in older Caucasian men Risk factors previous exposure to soil or animals Presentation Symptoms CAN (though may not present all at once) plus diarrhea Cardiac symptoms endocarditis Arthralgias (very common and early in disease) Neurologic symptoms dementia seizures weight loss emaciation chronic diarrhea oligo-arthritis Physical exam fever mesenteric lymphadenopathy gray-brown pigmentation of skin malabsorption of vitamin D → hyperPTH → may lead to increased melanocyte stimulating hormone or adrenocorticotropic hormone Evaluation Endoscopic small bowel biopsy – most accurate test periodic acid-Schiff (PAS)-positive foamy macrophages intestinal lamina propria Differential Diagnosis Celiac disease Crohn's disease Lyme disease (arthralgias) Treatment Initial intravenous treatment with penicillin/ceftriaxone Maintenance with oral trimethoprim-sulfamethoxazole (TMP-SMX) Prevention, Prognosis, Complications Prognosis persistence after treatment common fatal if antibiotics not given Complications Jarisch-Herxheimer reaction to antibiotics fevers rigors hypotension