Whipple's Disease (WD) Without Arthropathy in an Immunocompromised Patient.

Whipple's disease (WD) is a rare disorder caused by the pathogen Tropheryma whipplei (T. whipplei). We report a unique presentation of WD in which the patient did not exhibit arthralgia which is characteristic of this disease. A 67-year-old man with a history of chronic hepatitis B infection and human immunodeficiency virus (HIV) infection presented with weight loss, nausea, vomiting, and myalgia. Endoscopy demonstrated erythema in the gastric body, lymphangiectasia of the duodenum, and increased granularity of the terminal ileum. Mucosal biopsies revealed macrophages in the lamina propria with focal histiocytic aggregates throughout the small bowel and cecum, consistent with WD. Confirmatory T. whipplei polymerase chain reaction(PCR) testing was positive. WD is a rare diagnosis that must be considered in the differential diagnoses of patients presenting with unexplained nausea, vomiting, diarrhea, and anemia. Furthermore, in patients with HIV, the possibilities would also include opportunistic gastrointestinal pathogens. Classic WD is characterized by diarrhea, weight loss, abdominal pain, and extra-intestinal involvement manifesting as joint pain. We describe a case of WD occurring in a patient with HIV, without the disease's characteristic joint involvement.

Acalculous Cholecystitis: An Uncommon Presentation of Babesiosis.

Human babesiosis is commonly caused by Babesia microti, an infectious protozoan with a preference for erythrocytes. We describe a case of babesiosis presenting with acute acalculous cholecystitis. A 74-year-old man with a history of diabetes mellitus presented with four days of fever, chills, dyspnea on exertion, and dark brown urine. A physical exam was notable for scleral icterus. Laboratory findings were significant for lactate dehydrogenase (LDH) of 518, total bilirubin of 7.4, and direct bilirubin of 6.2. Imaging, including abdominal ultrasound, CT abdomen and pelvis, magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary iminodiacetic acid (HIDA) scans, demonstrated acute acalculous cholecystitis. On further history, the patient confirmed a recent hiking trip in Virginia. Further evaluation, including peripheral smear and polymerase chain reaction (PCR), was consistent with Babesia microti infection. Babesiosis is common in the Northeastern and Midwestern United States, and symptoms can range from asymptomatic infection to nonspecific malaise and fever to severe end-organ dysfunction. Diagnosis is via peripheral smear or PCR, which can be confirmed via serology. The combination of clindamycin and quinine or atovaquone and azithromycin are the cornerstones of pharmacotherapy. Acute acalculous cholecystitis is a very uncommon presentation of babesiosis. Babesia infection must be considered in the differential in a patient with nonspecific symptoms living in an endemic area.

Primary Choledocholithiasis 15 Years Postcholecystectomy.

Gallstone disease is extremely prevalent in the western society with laparoscopic cholecystectomy (LC) being the standard treatment for patients with symptomatic gallstones. The prevalence of common bile duct (CBD) stones with concomitant gallstones increases with age from 8-15% in patients <60 years of age and up to 60% in the elderly. There have been only a few case reports of postcholecystectomy bile duct stones occurring more than 10 years following surgery in the literature. Most of these reports describe the presence of stones within the gallbladder/cystic duct remnant or secondary to migrating surgical clips.

Isolated Pancreatic Tuberculosis Mimicking Pancreatic Cancer: A Diagnostic Challenge.

Isolated pancreatic tuberculosis is an exceedingly rare condition, even in areas of the world where the disease is highly prevalent. Abdominal tuberculosis is a common form of extrapulmonary tuberculosis but involvement of the pancreas is very rare. We report a case of isolated pancreatic tuberculosis presenting as a pancreatic mass in a patient with persistent abdominal pain and jaundice. Clinically and radiologically, the mass mimicked a malignant pancreatic tumor with a vastly different prognostic implication and therapeutic approach. Endoscopic ultrasound with fine-needle aspiration (EUS-FNA) can provide valuable diagnostic information in this scenario. After the tissue showed evidence of acid-fast bacilli and the cultures showed growth of Mycobacterium tuberculosis, antituberculosis therapy was initiated. Conservative management is usually successful in alleviating symptoms and leading to a cure. The excellent response to ATT makes it imperative that these patients are diagnosed early and managed appropriately to avoid unnecessary surgery and associated morbidity.