A 52-year-old man presents to the clinic with a 3-month history of diarrhea, abdominal pain, and significant weight loss. He describes his stools as bulky, foul-smelling, and often associated with flatulence. He also reports joint pain and a persistent cough. Past medical history is negative, and he does not take any medications. Vital signs are within normal limits.On physical examination, there is generalized lymphadenopathy, hyperpigmentation of the skin, and a diastolic murmur at the right upper sternal border. Laboratory tests show the following:
Small bowel biopsy reveals villous atrophy and numerous periodic acid-Schiff (PAS)-positive macrophages in the lamina propria. Which of the following is the most appropriate initial treatment for this patient’s condition?
C) Penicillin
The patient's presentation of diarrhea, abdominal pain, weight loss, joint pain, cough, generalized lymphadenopathy, skin hyperpigmentation, and a diastolic murmur, along with small bowel biopsy findings of villous atrophy and numerous PAS-positive macrophages, is consistent with Whipple disease. Whipple disease is caused by the bacterium Tropheryma whipplei. The appropriate initial treatment involves antibiotics such as penicillin.
Answer choice A: Azathioprine, is incorrect. Azathioprine is an immunosuppressant used for autoimmune conditions but is not indicated for treating Whipple disease.
Answer choice B: Metronidazole, is incorrect. Metronidazole is an antibiotic but is not the first-line treatment for Whipple disease.
Answer choice D: Prednisone, is incorrect. Prednisone is a corticosteroid used for various inflammatory conditions but is not appropriate for treating Whipple disease.
Answer choice E: Sulfasalazine, is incorrect. Sulfasalazine is used for treating inflammatory bowel disease but is not effective for treating Whipple disease.
Key Learning Point
Whipple disease presents with symptoms such as diarrhea, weight loss, joint pain, cough, generalized lymphadenopathy, and small bowel biopsy shows villous atrophy with PAS-positive macrophages. The appropriate initial treatment is ceftriaxone or penicillin which are known to penetrate the blood-brain barrier, followed by maintenance therapy with oral trimethoprim-sulfamethoxazole (TMP-SMX) for 12 months.
