A 40-year-old male plasterer was assessed in the gastroenterology
outpatient clinic to investigate the cause of iron-deficiency anemia and raised
inflammatory markers (hemoglobin 7.7 g/dL, mean corpuscular volume
67 fl, iron level 2 µmol/L, erythrocyte sedimentation rate
106 mm/hour, C-reactive protein 91 mg/L). On direct questioning
he reported a 2-year history of lethargy, 6-kg weight loss despite a normal
appetite, and no bowel symptoms. On examination the patient was visibly
cachectic, and had gynecomastia and axillary lymphadenopathy. He was admitted
to hospital for further investigations.
A thoracoabdominal computed tomography scan showed abdominal
lymphadenopathy, which was thought to be reactive. A gastroscopy showed
significant candida esophagitis and ulcerative duodenitis. A capsule endoscopy
revealed that the ulcerations extended throughout the proximal small bowel and
were accompanied by nodules and hemorrhagic spots ([Fig. 1]; [Video 1]).
Fig. 1 Capsule endoscopy in
Whipple's disease.
Video
1 Capsule endoscopy in Whipple's disease.
Colonoscopy and terminal ileoscopy were normal. Biopsies taken from the second
part of the duodenum showed abundant foamy pink macrophages that contained
intense, periodic acid Schiff (PAS)-positive, diastase-resistant cytoplasmic
inclusions. These findings were consistent with Whipple's
disease.
Whipple’s disease is rare, and endoscopic changes tend to be
within the small bowel, which has meant there are very few reports of the
endoscopic appearance of the disease. A recent case series has reported edema
of the duodenum, brown discoloration of the mucosa, erythematous spots, and
subepithelial hemorrhages [1]. A previous report of
capsule endoscopy in a case of Whipple’s disease that was unresponsive to
antibiotics noted areas of bleeding throughout the jejunum [2]. We observed similar changes in the duodenum, which
extended throughout the proximal small bowel, prior to the start of antibiotic
treatment. Interestingly, although gross features were only observed in the
duodenum and jejunum, identical histologic features were found in the duodenum,
ileum, and colonic biopsies. With more evidence for the endoscopic appearances
of Whipple’s disease becoming available, capsule endoscopy promises to be
a useful diagnostic tool in this disease.
Endoscopy_UCTN_Code_CCL_1AC_2AD
