title: [Fever and arthritis: rheumatic or Whipple's disease?].
abstract: METHODS
  Five years ago a 52-year-old patient presented with arthritis of the small and large joints. Further symptoms were relapsing fever, unspecific gastrointestinal complaints with meteorism but no diarrhea, fatigue and impaired concentration. Subsequently increasing lower back pain developed. A lumbar-disc lesion was already known.
  
  
  METHODS
  Inflammatory markers were elevated including leucocytosis. Gastroscopy with intestinal biopsies and colonoscopy remained without pathologic findings. Whipple's disease was excluded, but unspecific lymphozyte infiltration of the duodenal mucosa was described. Magnetic resconance imaging of the lumbar spine showed spondylodiscitis in L3/4 which was punctured, and polymerase chain reaction revealed Tropheryma whipplei DNA. Retrospectively, this was also found in the intestinal biopsies of three years ago.
  
  
  METHODS
  After initial exclusion of Whipple's disease an unspecific systemic inflammatory disease had been presumed, and the patient had been treated with immunomodulatory therapies in alternating combinations. Steroids improved the symptoms but an increasing dosage of steroids was required. After the detection of Tropheryma whipplei and diagnosis of Whipple's disease the patient received ceftriaxon for a period of two weeks, subsequently cotrimoxazol for one year. Inflammatory activity decreased but unspecific symptoms remained almost unaffected.
  
  
  CONCLUSIONS
  The differential diagnosis in patients with fever, elevated inflammatory markers and gastrointestinal symptoms must include Whipple's disease. A Tropheryma whipplei PCR from duodenal biopsies should be performed because of its higher sensitivity compared to histology alone.
authors.affiliation: Sektion Rheumatologie, Medizinische Klinik V, Universitätsklinikum Heidelberg. corinna.gerstenbergk@med.uni-heidelberg.de
authors.forename: C
authors.initials: C
authors.lastname: von Gerstenbergk
authors.forename: H-M
authors.initials: HM
authors.lastname: Lorenz
authors.forename: N
authors.initials: N
authors.lastname: Blank
mesh_terms: D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001707:Biopsy, Needle; D002443:Ceftriaxone / Q000627:therapeutic use; D004269:DNA, Bacterial / Q000302:isolation & purification; D003937:Diagnosis, Differential; D015299:Discitis / Q000175:diagnosis / Q000473:pathology; D004386:Duodenum / Q000382:microbiology / Q000473:pathology; D005335:Fever of Unknown Origin / Q000209:etiology* / Q000473:pathology; D006801:Humans; D007413:Intestinal Mucosa / Q000382:microbiology / Q000473:pathology; D008159:Lumbar Vertebrae / Q000382:microbiology / Q000473:pathology; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D016133:Polymerase Chain Reaction; D012216:Rheumatic Diseases / Q000175:diagnosis*; D014057:Tomography, X-Ray Computed; D054851:Tropheryma / Q000235:genetics; D008061:Whipple Disease / Q000175:diagnosis* / Q000473:pathology
chemical_list: D000900:Anti-Bacterial Agents; D004269:DNA, Bacterial; D002443:Ceftriaxone