A 70-year-old male who reported pain and swelling of the hands and right ankle for 12 years, lasting 2 to 3 days, with a frequency of 3 to 4 times a month.
Pain in the cervical and dorsal spine was subsequently diagnosed.
It was accompanied by elevated ESR.
Diagnosed as a rheumatism, it was treated with gold salts, NSAI and methotrexate.
Since then she has had moderate anemia and was treated with oral iron with no clear improvement.
For about 20 years she complains of neurotic depression and chronic delusional celotypic disorder that has required therapy on several occasions (risperidone, venla ̄).
She was admitted to the hospital in June 2003 for melena and dizziness.
Hemoglobin 9.3 g/dl. Gastroscopy could not be performed due to lack of cooperation.
A gastroduodenal series and opaque enema were normal.
Three months later, she was readmitted for diffuse sporadic abdominal pain, associated with high number of liquid diarrheal stools, asthenia, anorexia and weight loss for 15 days.
On physical examination she presented with a mild cough, cachectic with skin hyperpigmentation.
The patient had vesicular emphysema, left submandibular adenopathy of 2 cm, wheel, painless and elastic, and two left axillary lymph nodes of 1.5-2 cm. Cardiopulmonary auscultation revealed a decrease in the vesicular murmur.
The abdomen was blade with 3 right inguinal lymphadenopathies of 1 cm and 2 left inguinal lymph nodes of 1.5 cm, non-adherent and painless.
Laboratory data included: hemoglobin 8.9 g/dl (13-17), hemoglobin 26.4%, normal serum levels of folic acid (CML) 77.2 g, platelets (BUN), hemoglobin 25 pg/dl glycoprotein transfer test, iron 13 ng/dl
The serologies (hepatitis A, B and C, cytomegalovirus, human immunodeficiency virus, Toxoplasma, Salmonella and Trepon sputum smear negative or authentic) were normal and normal.
Mantoux: 28 mm.
The chest X-ray showed a left pleural effusion.
Epidermal pleural fluid was analysed in 372,000 μ/l, leukocytes 1,970 μ/l (41% polymorphonuclear and 59% lymphocytes), proteins 3,2 g/dl, ADA 21 U/l (0-43),
Malignant cells were not seen.
The gastroduodenal series, opaque enema, abdominal ultrasound and even blind revealed no lesions.
Abdominal CT showed bilateral pleural effusion, lymphadenopathies of pathological size, retroperitoneal, left paraaortic, interaortic-caval, retrocavas, paracardiac and peritoneal fluid in a small amount of douglas.
Biopsy of the left inguinal ganglion was performed.
Microgranulomas without necrosis were identified in the histological study.
A laparoscopy was then performed for biopsy of retroperitoneal adenopathy.
Histopathological examination revealed a lipophagic pseudogranulomatous, partially effaceted architecture lymphadenopathy with abundant PAS + diastase, globular and/or elongated cytoplasmic material.
The 16S ribosomal RNA sequence of T. whippleii was positive in the lymph node.
Intravenous ceftriaxone (2 g/day) was started for 2 weeks, followed by oral cotrimoxazole (800/160 mg) every 12 hours for 3 years.
In a few weeks digestive symptoms and constitutional syndrome disappeared.
At three and a half years of follow-up he made an attempt of self-lysis, so he entered the Psychiatry Service.
A confusional state, tremor and gait disorder were observed.
A brain CT scan showed a right temporoparietal mass suggestive of a high-grade glial tumor.
Brain MRI was compatible with a high-grade glial tumor located in the right posterior temporal region and white matter lesions in bilateral parietofrontal region, grade I-II of the ARWMC classification.
The family was given surgical treatment that is not accepted and the patient was sent to a long-term care center.
