Case Study: Episodic Wrist and MCP Pain with Left-Sided Chest Pain and Marked Weight Loss

A male patient in his 60s presents with a one-year history of episodic wrist and metacarpal joint pain suggestive of rheumatoid arthritis. He had negative serologies, but his c-reactive protein was elevated consistently over the course of the year. He is complaining of a new symptom: left-sided chest pain, which gets worse with breathing and laying on his side. With a history of tobacco use and a 40-pound weight loss in the last six months, the team was concerned for a possible malignancy. What’s causing this patient’s inflammatory arthritis and weight loss?

Watch as Adam Brown, MD, staff in Cleveland Clinic’s Department of Rheumatic and Immunologic Diseases, describes the case, treatment and outcomes.

When to consider Whipple disease

Whipple disease is a rare systemic disease with a very low incidence rate worldwide. Thus, its prevalence is difficult to estimate accurately. It is caused by a gram-positive bacterium, Tropheryma whippelii. The typical clinical manifestations are diarrhea, abdominal pain, weight loss, and fever. In most patients, these are often preceded by articular symptoms. The pathogenesis of Whipple disease is thought to be related to bacterial replication within macrophages, which leads to a systemic immune response and tissue infiltration by the organism. Histologic evaluation is the most common way to confirm the diagnosis. Whipple disease should be part of the differential diagnosis of arthritis, as antibiotic therapy alone leads to a dramatic clinical response.

“It takes a prolonged course [of antibiotics], but this patient completely recovered of all the symptoms, including the weight loss – completely recovered and is doing well,” says Dr. Brown. He notes that it is important to remember that “there’s a curable cause of inflammatory arthritis that can be lifesaving if picked up.”