All In The Farm: An Unusual Case of Endocarditis and Pericarditis | Patient Case Quiz
A 57-year-old Caucasian farmer presents with fatigue, weight gain, edema, progressive dyspnea, orthopnea and migratory arthralgias for 18 months. His past medical history included type II diabetes mellitus, hypertension, hyperlipidemia, remote Hodgkin's lymphoma s/p splenectomy and chest radiation, seronegative rheumatoid arthritis on immunosuppressive therapy (prednisone, methotrexate, and previously etanercept), and recent deep venous thrombosis on fondaparinux. Physical exam is notable for fever (temperature 39.1C), jugular venous distension and a positive Kussmaul's sign. Laboratory values were notable for leukocytosis (WBC 17.35), anemia (hgb 9.9) and elevated inflammatory markers (ESR 106, CRP 10.6). TEE showed mitral (Figure A; Video 1) and tricuspid valve vegetations. Cardiac MRI showed evidence of constrictive pericarditis with pericardial thickening and diastolic septal bounce (Figure B; Video 2); delayed pericardial enhancement (Figure C) and septal flattening (Video 3). Serum Whipple's PCR returned positive.
He was initiated on TMP/SMX and IV ceftriaxone and underwent pericardiectomy, MV replacement and TV vegetation removal with subsequent symptomatic improvement. Pathology showed foamy microphages on H&E staining (Figure D) and T.Whipplei-filled macrophages on PAS staining of MV tissue (Figure E), and fibrous pericarditis (Figure F) with PAS-positive organisms. Whipple's disease is an important consideration in patients with exposure risk (such as soil exposure) and the appropriate constellation of symptoms.
Which of the following statements concerning Whipple's disease is false?