Review Question - QID 217719

This elderly patient who presents with arthritis (joint pain), diarrhea, weight loss, and forgetfulness likely has Whipple disease. Whipple disease is treated with an initial dose of ceftriaxone or penicillin followed by a long-term course of trimethoprim/sulfamethoxazole.

Whipple disease is a malabsorption syndrome that has multisystem involvement. The disease is caused by infection with Tropheryma whipplei and typically affects Caucasian men aged 30-60. Risk factors include exposure to soil or animals, as T. whipplei is found in soil. The symptoms of Whipple disease include a triad of cardiac symptoms (e.g., endocarditis), arthralgias, and neurologic symptoms (dementia or seizures). Other systemic manifestations include weight loss, chronic diarrhea, and fevers. Endoscopic small bowel biopsy is the most accurate test used to diagnose Whipple disease, and the presence of periodic acid-Schiff (PAS)-positive foamy macrophages confirms the diagnosis. The treatment for Whipple disease involves an initial dose of ceftriaxone or penicillin followed by a long-term course of trimethoprim/sulfamethoxazole.

Bureš et al. discuss the diagnosis of Whipple disease and state that anemia, lymphopenia, and increased erythrocyte sedimentation rate (ESR) are common laboratory findings in patients with Whipple disease.

Incorrect Answers:
Answer 2: Donepezil is an acetylcholinesterase inhibitor that may be used to treat Alzheimer disease. Studies have shown that it may increase mental and physical functioning; however, it does not slow the progression of Alzheimer disease. This patient's forgetfulness is more likely associated with Whipple disease.

Answer 3: Ibuprofen may be trialed in patients with osteoarthritis. Osteoarthritis presents with joint pain and stiffness that is worsened with activity. Though this patient experiences arthritis of the back and knees, his other symptoms point toward a systemic illness.

Answer 4: Loperamide is a mu-opioid agonist that works to reduce the frequency of diarrhea. It may be used for mild traveler's diarrhea, irritable bowel syndrome, and in cases of high-output ileostomies. Loperamide is not indicated for the treatment of diarrhea secondary to Whipple disease, which is better treated with antibiotics.

Answer 5: Pancreatic enzyme supplementation may be required in patients with cystic fibrosis, patients with chronic pancreatitis, or patients who have had a pancreatectomy. These patients no longer have functional pancreases that produce enzymes required to digest fats, leading to steatorrhea.

Bullet Summary:
Whipple disease presents with cardiac symptoms, arthralgias, and neurologic symptoms and is treated with antibiotic therapy.