Antibiotics (General - PRA)

There is debate about whether palindromic rheumatoid arthritis (PRA) is an early, seronegative form of rheumatoid arthritis (RA) or a distinct variant of rheumatic disease. Research that has focused on infections associated with PRA and its treatment with antibiotic therapy, for the most part, applies to both disease manifestations. For example, antibiotic therapies for the treatment of Lyme disease or mycoplasma can be found under those infection sections. However, in order to make it simpler to locate studies with a specific focus on antibiotic treatments for Tropheryma whipplei, a widely-accepted cause of PRA, these have been grouped together below.


Doxycycline, in combination with hydroxychloroquine, is described as being the typical treatment for the causative organism of Whipple’s disease, characterized by intermittent bouts of arthritis, often accompanied by weight loss and diarrhea.

[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.


Trimethoprim/sulfamethoxazole (TMP/SMX), also known as trimoxazole (brand name, Bactrim), is one part trimethoprim and 5 parts sulfamethoxazole. It is a broad spectrum, combination antibiotic that is used to treat urinary tract infections, methicillin-resistant staphylococcus aureus (MRSA) skin infections, travelers’ diarrhea, respiratory tract infections, cholera, and numerous other infections, including Tropheryma whipplei, a universally-acknowledged causative bacteria of palindromic rheumatoid arthritis (PRA).

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.


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