title: Central nervous system Whipple's disease: relapse during therapy with trimethoprim-sulfamethoxazole and remission with cefixime.
abstract: The central nervous system (CNS) is frequently involved in patients with Whipple's disease and is the most common site of disease relapse. Antibiotics such as trimethoprim-sulfamethoxazole (TMP-SMX) that have reliable CNS penetration, are therefore recommended as first-line therapy. We report a patient with Whipple's disease who was treated with TMP-SMX and presented 14 months after initiation of therapy with visual decline and severe headaches. The patient was also treated concurrently with low-dose weekly methotrexate for severe psoriasis. Evaluation by magnetic resonance imaging revealed bilateral posterior white matter abnormalities that pathologically were consistent with Whipple's disease. He was ultimately treated with cefixime, an orally administered third-generation cephalosporin. Visual function improved on this regimen and follow-up magnetic resonance imaging showed regression of the lesions. This case represents the first report of both CNS relapse during therapy with TMP-SMX and successful treatment with cefixime. We also speculate that methotrexate, which impairs cell-mediated immunity, may have contributed to the relapse.
authors.affiliation: Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University School of Medicine, Ohio.
authors.forename: G S
authors.initials: GS
authors.lastname: Cooper
authors.forename: E W
authors.initials: EW
authors.lastname: Blades
authors.forename: B F
authors.initials: BF
authors.lastname: Remler
authors.forename: R A
authors.initials: RA
authors.lastname: Salata
authors.forename: K W
authors.initials: KW
authors.lastname: Bennert
authors.forename: G H
authors.initials: GH
authors.lastname: Jacobs
mesh_terms: D020682:Cefixime; D002439:Cefotaxime / Q000031:analogs & derivatives* / Q000627:therapeutic use; D002493:Central Nervous System Diseases / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D012008:Recurrence; D012074:Remission Induction; D015662:Trimethoprim, Sulfamethoxazole Drug Combination / Q000627:therapeutic use*; D014786:Vision Disorders / Q000209:etiology; D008061:Whipple Disease / Q000175:diagnosis / Q000188:drug therapy* / Q000473:pathology
chemical_list: D015662:Trimethoprim, Sulfamethoxazole Drug Combination; D020682:Cefixime; D002439:Cefotaxime