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FROM PALLIATIVE CARE TO A DEFINITE CURE: A SEVERE PRESENTATION OF WHIPPLE'S DISEASE

Margarida Rajão Saraiva 1, Daniel Conceição 2, Joana Lemos Garcia 1, Sara da Mata 1, João Pedro Caldeira 1, Pedro Currais 1, Carolina Simões 3, Isabel Claro 1

Affiliations

1 Instituto Português de Oncologia de Lisboa Francisco Gentil, Lisbon, Portugal

2 Portuguese Oncology Institute, Lisboa, Portugal

3 Hospital de Santa Maria, CHULN, Lisboa, Portugal

Summary

AI Generated

A 51-year-old woman with chronic diarrhoea and weight loss initially diagnosed with metastatic ovarian cancer was ultimately diagnosed with Whipple's disease after re-assessment of imaging and enteroscopy with PAS-D positive foamy macrophages on biopsy.

Initial abdomen-pelvic CT and MRI suggested cystadenocarcinoma of the right ovary with widespread adenopathy, leading to palliative care referral.
Re-assessment of imaging showed adenopathy morphology, mesenteric lymph node conglomerate, and jejunal thickening suggestive of Whipple's disease rather than malignancy.
Enteroscopy revealed hyperaemic, oedematous, and friable mucosa in duodenum and proximal jejunum; biopsies demonstrated foamy macrophages with positive PAS-D cytoplasmic granules, confirming Whipple's disease.
The ovarian lesion was re-classified as a benign cystadenofibroma after further evaluation with ultrasound.
Treatment with intravenous ceftriaxone resulted in clinical improvement with resolution of symptoms and nutritional recovery, maintained at eight months with ongoing antibiotic therapy and no recurrence.

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This summary was generated by an AI large language model based on the content transcript. It is for informational purposes only and should not be considered a substitute for clinical judgment. Always rely on your professional expertise and the full clinical context when making clinical decisions.

Abstract

Clinical Case Summary

Woman, 51 years old, farmer, past history of pelviperitonitis when 46 years old and family history of gastric and breast neoplasm.
She was admitted to the Emergency Department for abdominal pain for 2 years and 4 months of diarrhoea (without blood or mucus), anorexia, weight loss (12%), arthralgias and asthenia.
Analysis results: Hb 8.2mg/dL, leukocytosis 11200x10³/µL, thrombocytosis 63131x10³/µL, abnormal liver tests, CRP 6mg/dL, iron deficiency and hypoalbuminemia (2.5g/dL).
Abdomen-pelvic CT and MRI revealed cystadenocarcinoma of the right ovary with bilateral supraclavicular, axillary and inguinal adenopathy.
After observation by Gynaecology, she was referred to Palliative Care and for evaluation in a tertiary hospital. There, after a multidisciplinary discussion, an etiological study of diarrhoea was carried out, and laboratory evaluation was negative.
The imaging exams were then re-assessed: the presence and morphology of the adenopathy, the mesenteric lymph nodes conglomerate and jejunal thickening suggested the diagnosis of Whipple's disease.
An enteroscopy was also performed: duodenum and proximal jejunum’s mucosa was hyperaemic, oedematous and friable. Biopsies showed expansion of the lamina propria by lymphangiectasias, fat droplets and dense and multifocal aggregates of foamy macrophages with positive PAS-D (periodic acid-schiff with diastase) cytoplasmic granules, Ziehl-Neelsen negative.
A malignant ovarian tumour was excluded: the multiloculated cystic tumour of the right ovary was actually a cystadenofibroma – a diagnosis additionally confirmed by suprapubic and transvaginal ultrasound.
After treatment with intravenous ceftriaxone, the patient showed clinical improvement with resolution of pain, normal intestinal transit and recovery of nutritional status. Eight months after, she maintains antibiotic therapy, with no evidence of recurrence.
This case highlights the need for a low suspicion threshold for diagnosing this rare and benign disease.

References

Boumaza A, Ben Azzouz E, Arrindell J, Lepidi H, Mezouar S, Desnues B. Whipple's disease and Tropheryma whipplei infections: from bench to bedside. Lancet Infect Dis. 2022 Oct;22(10):e280-e291. doi: 10.1016/S1473-3099(22)00128-1. Epub 2022 Apr 12. PMID: 35427488.

Conference

UEG Week Copenhagen 2023

Topics

Small Intestine & Nutrition

Submission format

Clinical Case

Session

PP 12 Clinical Cases (Posters)

Published

2023

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Cracking the code: How primary care can conquer malabsorption

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