Klinische Verlaufsformen der Tropheryma whipplei Infektion und des Morbus Whipple – Bedeutung für die Rheumatologie

Zusammenfassung

Da sich der Morbus Whipple (MW) sehr häufig als Erstes durch Gelenkbeschwerden manifestiert, ist die differenzialdiagnostische Berücksichtigung der Erkrankung für den rheumatologisch tätigen Arzt von Bedeutung, denn es vergehen bis zur gesicherten Diagnose des MW oft viele Jahre. Der seltene, klassische MW, bei dem neben Arthralgien auch häufig Diarrhoen, Gewichtsverlust und andere generalisierte Beschwerden vorkommen, ist weithin bekannt und wurde in der Literatur ausführlich beschrieben. Kaum bekannt jedoch sind bislang die anderen Manifestationen der Tropheryma whipplei Infektion. So wurden kürzlich bei Kindern transiente und selbstlimitierende Infektionen mit akuter Gastroenteritis, Lungensymptomen und Fieber durch T. whipplei beschrieben. Daneben findet sich der Erreger in etwa 4% der asymptomatischen Bevölkerung, was nicht überrascht, da T. whipplei weit verbreitet in der Umwelt, z. B. in Abwässern, vorkommt. Auch lokalisierte Formen der T. whipplei Infektion, das heißt ohne intestinale Beteiligung, etwa an Herzklappen oder im Zentralnervensystem (ZNS), werden aufgrund neuer Diagnosemöglichkeiten häufiger beschrieben. Schließlich finden sich in der Literatur vermehrt Berichte über den Zusammenhang eines kompliziert verlaufenden MW mit Organkomplikationen wie einer Endokarditis nach einer medikamentösen Immunsuppression.
Die Kenntnis der möglichen Krankheitsverläufe der Infektion mit T. whipplei und des MW hat für den Rheumatologen nochmals erheblich an Relevanz gewonnen, da mittels verbesserter Diagnosemöglichkeiten auch Frühformen der Erkrankung von rheumatologischen Krankheitsbildern abgrenzbar sind, und da es Hinweise auf ein gefährliches Fortschreiten der T. whipplei Infektion gibt, sofern wegen seronegativer Arthritiden Immunusuppressiva oder Biologika eingesetzt werden.

Abstract

As Whipple’s disease (WD) presents frequently with arthralgia which may precede the diagnosis by many years, it is important for the rheumatologist to include this disorder in the differential diagnosis of unclear arthritis. The main symptoms of classical WD, i. e., arthropathy, diarrhea, weight loss and other systemic symptoms, have been described in the literature extensively.
However, other manifestations of Tropheryma whipplei infection are currently not widely recognised. Just recently, transient and self-limiting infections caused by T. whipplei presenting with diarrhea, fever and cough have been described in children. Additionally, T. whipplei is found in around 4% of healthy individuals. This is not surprising because T. whipplei is ubiquitously present in water and soil. Localised, i. e., isolated, forms of T. whipplei infection may become manifest on cardiac valves or affection of the central nervous system (CNS). Lastly, there are an increasing number of publications reporting on complicated courses of WD such as endocarditis following medical immunosuppression.
For the clinician and rheumatologist it is important to consider not only the classical form of WD but also the other different manifestations of T. whipplei infection. They can be diagnosed or excluded early by modern diagnostic tools such as polymerase chain reaction (PCR). This is relevant for patients with seronegative arthritis, as treatment with immunosuppressives or biologicals could lead to a complicated course of T. whipplei infection.

Schlüsselwörter

PCR - Immunsuppression - Biologika - Endokarditis - Therapie

Key words

PCR - immunosuppression - biological - endocarditis - therapy

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