Whipple's Disease with Colonic Involvement: A Rare Endoscopic Documentation.

A 78-year-old woman presented with watery diarrhea and weight loss – 20 kg, 33% of body weight – in the previous 5 months. She denied fever or relevant epidemiological context. Her previous history was unremarkable. Blood analysis showed anemia (hemoglobin 8.4 g/dL), leukocytosis with neutrophilia and high C-reactive protein (73.8 mg/L). Fecal analysis was negative for microbiological, parasitological and Giardia presence; fecal calprotectin was unchanged. Magnetic resonance enterography described normal small bowel and colon appearance, mesenteric fat densification and prominent mesenteric ganglia. Upper endoscopy revealed enlarged duodenal folds, lymphangiectasias, focal hyperemia and friability of the duodenal mucosa (Fig. 1a, b). Ileocolonoscopy revealed continuous edema, hyperemia and friability of the distal ascending colon, associated with erosions and superficial ulcers, as well as a reduced distensibility (Fig. 2b, c). There were no endoscopic alterations in the remaining segments, including the terminal ileum (Fig. 2a). Histological examination of duodenal (Fig. 1c–e), ileal and ascending colonic samples (Fig. 2d–f) identified the presence of foamy macrophages, with periodic acid-Schiff (PAS)positive intracytoplasmic granules, which were Ziehl-Neelsennegative. Despite having no clinical neurological involvement, Tropheryma whipplei DNA was detected in the cerebrospinal fluid (CSF). The patient completed a 14-day course of once daily 2 g intravenous ceftriaxone, followed by a 12-month course of twice daily 800 + 160 mg oral trimethoprim-sulfamethoxazole, which is currently under way. Diarrhea resolved in the first weeks of antibiotic therapy, and full weight recovery occurred after 4 months.