A 74-year-old male with a history of weight loss of 10 kg in the last 10 months, as well as shoulder and knee arthralgias.
He had presented sprouts of episodic diarrhea without pathological products with asthenia, anorexia and febricula.
The examination revealed hyperpigmentation of the skin and significant malnutrition.
Basic laboratory tests revealed microcytic anemia in the stool, blood count, erythrocyte sedimentation rate (GSR) 57 sec, albumin 2.46 g/dl, cholesterol 82 mg/dl, ferritin 12 mcg/dl
Computed tomography (CT) showed a large number of retroperitoneal lymph nodes and mesentery of significant size.
Oral endoscopy showed an image compatible with chronic gastritis and a white bulging in the second duodenal portion.
Duodenal biopsy showed positive macrophages to Schiff periodic acid (PAS) and negative Ziehl staining, compatible with Whipple's disease.
The patient began to be treated with penicillin and streptomycin 15 days later and then trimethoprim-prim-sulfamethoxazole (TM-SF) but developed a urticarial reaction, for which the latter had to be discontinued.
There was clinical improvement and weight gain, but macrophages PAS positive in the biopsy were repeated for up to two cycles more than 15 days of penicillin and streptomycin.
During the evolution, the patient developed gait instability and dizziness secondary to labyrinthine toxicity due to streptomycin, which initially raised a differential diagnosis with neurological involvement of the disease.
Then, removal of the adrenal gland was performed because it was associated with a higher number of relapses, and cefixima was used.
The patient completed two years of antibiotic treatment and is currently asymptomatic.
