AN EVALUATION OF ANTIMICROBIAL TREATMENT FOR WHIPPLES-DISEASE - TETRACYCLINE VERSUS TRIMETHOPRIM-SULFAMETHOXAZOLE

Whipple's disease is a multisystemic disorder in which almost all orga n systems can be invaded by rod-shaped bacteria. Without extended anti microbial therapy, its course is lethal. Empirically, treatment consis ts of tetracyclines given for one to two years. Trimethoprim-sulfameth oxazole, a compound that crosses the blood-brain barrier, has been sug gested as an alternative when patients were observed with progressive cerebral involvement. There has never been a formal evaluation of the selection of antibiotics for the treatment of Whipple's disease. In th e present nonrandomized, partially retrospective study, we compared th e result of two treatment regimens in 30 patients, all examined person ally. Twenty-two patients were treated with tetracycline and eight pat ients with trimethoprim-sulfamethoxazole. In five patients, therapy wi th tetracycline was changed to another antimicrobial agent because of treatment failure or drug intolerance. The main treatment measure was disappearance of the clinical symptoms such as weight loss, arthritis, malabsorption, fever, edema, central nervous system manifestations, l ymphadenopathy, and congestive heart failure. Drug intolerance requiri ng a change of medication was also considered a treatment failure. We found that trimethoprim-sulfamethoxazole induced complete clinical rem ission in 12 of 13 treatment cycles, tetracycline in 13 of 22 treatmen t cycles (P < 0.05; mean difference 33%; 95% confidence interval 8% to 58%). Trimethoprim-sulfamethoxazole was also more efficacious than te tracycline in the treatment of cerebral Whipple's disease. However, tr imethoprim-sulfamethoxazole did not prevent cerebral manifestations in all cases. The only deaths due to Whipple's disease occurred in patie nts with cerebral involvement. It is concluded that treatment with tri methoprim-sulfamethoxazole was significantly superior to that with tet racycline in inducing clinical remission of Whipple's disease. A more active antimicrobial regimen is necessary to treat cerebral involvemen t.