title: Whipple's disease diagnosed during anti-tumor necrosis factor alpha treatment: two case reports and review of the literature.
abstract: BACKGROUND
  Whipple's disease is a rare infectious disease caused by Tropheryma whipplei with protean clinical manifestations. This infection may mimic chronic inflammatory rheumatisms.
  
  
  METHODS
  We report two cases of Whipple's disease diagnosed in the context of an inflammatory disease with anti-tumor necrosis factor alpha failure. The first patient was a 58-year-old white man with psoriatic spondylarthritis, who was treated with adalimumab, etanercept, infliximab, tocilizumab and golimumab. The second was a 73-year-old white man with rheumatoid arthritis, who received treatment with infliximab, then etanercept and rituximab.
  
  
  CONCLUSIONS
  Whipple's disease should be suspected in all patients diagnosed with chronic inflammatory rheumatism, partially controlled or not controlled by treatment with tumor necrosis factor alpha blockers, whose condition worsens after treatment.
authors.affiliation: Department of Internal Medicine, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. jramosrincon@yahoo.es.|Department of Medicine, Miguel Hernández University of Elche, Sant Joan d'Alacant, 03550, Spain. jramosrincon@yahoo.es.|Servicio de Medicina Interna, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. jramosrincon@yahoo.es.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Ramos
authors.affiliation: Department of Internal Medicine, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain. pasquau_fra@gva.es.
authors.forename: Francisco
authors.initials: F
authors.lastname: Pasquau
authors.affiliation: Department of Internal Medicine, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain. norathais@hotmail.com.
authors.forename: Nora
authors.initials: N
authors.lastname: Galipienso
authors.affiliation: Department of Internal Medicine, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. beatrizvn@gmail.com.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Valero
authors.affiliation: Department of Internal Medicine, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain. angelanavarroc@hotmail.com.
authors.forename: Angela
authors.initials: A
authors.lastname: Navarro
authors.affiliation: Department of Rheumatology, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. martinez_agu@gva.es.
authors.forename: Agustín
authors.initials: A
authors.lastname: Martinez
authors.affiliation: Department of Rheumatology, Hospital Marina Baixa, Avenida Alcalde Jaume Botella Mayor, 7, Villajoyosa, 03570, Alicante, Spain. j.rosas.gs@gmail.com.
authors.forename: José
authors.initials: J
authors.lastname: Rosas
authors.affiliation: Department of Gastroenterology, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. gutierrez_ana@gva.es.
authors.forename: Ana
authors.initials: A
authors.lastname: Gutiérrez
authors.affiliation: Department of Internal Medicine, Hospital General Universitario de Alicante, c/ Pintor Baeza, 12, 03010, Alicante, Spain. sanchez_rosmar@gva.es.
authors.forename: Rosario
authors.initials: R
authors.lastname: Sanchez-Martínez
mesh_terms: D000068879:Adalimumab / Q000627:therapeutic use; D000368:Aged; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D061067:Antibodies, Monoclonal, Humanized / Q000627:therapeutic use; D018501:Antirheumatic Agents / Q000627:therapeutic use*; D003937:Diagnosis, Differential; D000068800:Etanercept / Q000627:therapeutic use; D006801:Humans; D000069285:Infliximab / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D012213:Rheumatic Fever / Q000150:complications* / Q000188:drug therapy*; D000069283:Rituximab / Q000627:therapeutic use; D014409:Tumor Necrosis Factor-alpha / Q000187:drug effects*; D008061:Whipple Disease / Q000150:complications* / Q000175:diagnosis*
chemical_list: D000911:Antibodies, Monoclonal; D061067:Antibodies, Monoclonal, Humanized; D018501:Antirheumatic Agents; D014409:Tumor Necrosis Factor-alpha; D000069283:Rituximab; C529000:golimumab; D000069285:Infliximab; D000068879:Adalimumab; C502936:tocilizumab; D000068800:Etanercept