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Whipple disease — ESEGH MCQ

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HardLuminal GIWhipple diseaseESEGH

A 57-year-old man presents with chronic diarrhoea, weight loss, migratory arthralgia and progressive cognitive slowing. Duodenal biopsies contain foamy periodic acid–Schiff-positive macrophages in the lamina propria, and tissue PCR confirms Tropheryma whipplei. Which is the most appropriate established antimicrobial regimen?

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Correct answer: B — Intravenous ceftriaxone for 14 days, followed by oral co-trimoxazole for 12 months

This is classic Whipple disease with neurological involvement. The established trial-supported regimen is an initial CNS-penetrating parenteral agent—ceftriaxone for 14 days—followed by prolonged oral co-trimoxazole, conventionally for 12 months. Ceftriaxone induction alone is insufficient because relapse, particularly within the CNS, is an important concern. Oral co-trimoxazole without parenteral induction was not the regimen evaluated in the pivotal prospective trial. Doxycycline is used in specialist-directed regimens, often with hydroxychloroquine, but doxycycline monotherapy is not an equivalent option. A short azithromycin course cannot eradicate this chronic systemic infection. Because optimal therapy remains incompletely standardised and neurological disease is present, treatment and follow-up should involve infection specialists.

Reference: Feurle GE, Junga NS, Marth T. Efficacy of ceftriaxone or meropenem as initial therapies in Whipple's disease. Gastroenterology. 2010;138:478–486. https://pubmed.ncbi.nlm.nih.gov/19879276/