Lyme disease: musculoskeletal manifestations. Rheum Dis Clin North Am. 1989 Nov;15(4):649-56.
The authors of this commentary at University of Minnesota School of Medicine, in Minneapolis, Minnesota, describe the observed musculoskeletal syndrome experienced by some patients with Lyme disease and several distinct patterns with which it presents when untreated. In early Lyme, widespread, diffuse muscle achiness and stiffness is experienced. If left untreated, this early stage is followed by recurrent, episodic bouts of arthritis. In late stage Lyme disease, a chronic form of oligoarticular arthritis can be experienced, often large joints like the knees. These authors describe Lyme as closely resembling reactive arthropies and that it can also mimic connective tissue diseases, like juvenile rheumatoid arthritis, rheumatoid arthritis, myositis, and scleroderma.
Studies on Whipple’s Disease, primarily affecting middle-aged, Caucasian males, have been included in this section, as this infection, originating in the gut, typically presents with migrating, episodic attacks of arthritis, very similar to palindromic rheumatism (PRA), but can be misdiagnosed and have severe consequences if it is inappropriately treated.
Whipple’s arthritis. Joint Bone Spine. 2016 Dec;83(6):631-635.
Whipple’s disease is a chronic systemic infection that is due to the bacterial agent Tropheryma whipplei and it classically presents with diarrhea, weight loss and episodic bouts of arthritis, which if left undiagnosed can progress to chronic septic, destructive polyarthritis. PCR testing of joint fluid, feces or saliva may prove positive for the infection, but study authors state that rheumatologists should suspect Whipple’s disease (especially in middle-aged, Caucasian men) if a patient presents with unexplained, seronegative, intermittent oligoarthritis and other symptoms indicative of this gut infection, which can be cured by antibiotic therapy, but may be fatal if misdiagnosed and inappropriately treated.
Arthralgia and blood culture-negative endocarditis in middle Age Men suggest tropheryma whipplei infection: report of two cases and review of the literature. BMC Infect Dis. 2015 Aug 18;15:339. doi: 10.1186/s12879-015-1078-6.
Study authors conclude the importance of assessing patients for the infection, Tropheryma whipplei, the causative pathogen of Whipple’s disease, in patients with a history of transient arthralgia and culture-negative pericarditis, prior to treatment with immune-suppressants, to ensure appropriate treatment with combination antibiotic protocols. In the cases described, trimetoprim-sulfamethoxazol (Bactrim), was administered long-term.
[Whipple’s disease and Tropheryma whipplei infections in internal medicine. When to think about it? How to treat?]. Rev Med Interne. 2014 Dec;35(12):801-7.
Although new diagnostic tools that include genomic sequencing testing can identify the causative pathogen of Whipple’s disease that leads to weight loss, diarrhea, and intermittent bouts of arthritis, the diagnosis can be easily missed. Treatment with disease-modifying anti-rheumatic drugs (DMARDs) and other immune-suppressive medications will result in treatment failure with clinical worsening of symptoms. Clues to diagnosis may come in the shape of patients who note improvements when treated with antibiotics for an unrelated acute infection. Whipple’s disease is typically treated with doxycycline (200mg/day) and hydroxychloroquine (600 mg/day) for a length of 12 months, followed by a lifetime treatment by doxycycline (200 mg/day) to avoid reinfection. Less severe, localized infections may be treated with doxycycline (200mg/day) and hydroxychloroquine (600 mg/day) for 12 to 18 months, but close follow-up for life is recommended.
Palindromic rheumatism: Consider Whipple’s disease. Int J Rheum Dis. 2013 Aug;16(4):475-6.
Tropheryma whipplei, the causative micro-organism of Whipple’s disease, classified as a form of Actinobacteria, may present with migrating, episodic attacks of arthritis, similar to palindromic rheumatism (PRA). The authors of this review state that up to 50% of Whipple’s disease patients are “misdiagnosed” as having PRA and “wrongly treated,” sometimes with fatal consequences, with disease-modifying anti-rheumatic drugs, corticosteroids and anti-TNF agents and specific testing methods to identify this pathogen are outlined to ensure appropriate treatment with antimicrobial agents.
Whipple’s disease with axial and peripheral joint destruction. South Med J. 1990 Jun;83(6):684-7.
Inappropriate immune-suppressant treatment of a man with a 16-year history of palindromic rheumatism (PRA) with biopsy-proven infection with Tropheryma whipplei, the causative organism of Whipple’s disease. PRA then progressed to joint destructive disease with HLA genetic-typing revealing the B7 antigen, typical of ankylosing spondylitis. The authors “… challenge the generally held notion that Whipple’s arthropathy is a nondestructive joint disease.”