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Nawal Bakkali, Florence Fenollar, Jean-Marc Rolain, Didier Raoult, Comment on: Therapy for Whipple's disease, Journal of Antimicrobial Chemotherapy, Volume 61, Issue 4, April 2008, Pages 968–969, https://doi.org/10.1093/jac/dkn035
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Sir,
We read with much interest the article by Knaapen and Barrera1 recently published in JAC on Whipple's disease treatment. It is fascinating as it shows, in this intriguing and rare disease, how successive deductive opinions finally came to be considered as established facts. There are no comparative studies on therapy of Whipple's disease and, until recently, treatment recommendation was empirical, based on anecdotal reports of failures or relapses.2 We believe that this is confusing.
Relapse rates depend on the length of treatment and follow-up. As tetracyclines have been used for many years before co-trimoxazole in the treatment of Whipple's disease, there are more reports on failures with the tetracyclines than with co-trimoxazole.2 There is no published evidence of the superiority of any regimen in terms of relapse rate during 5 years post-treatment follow-up.
The situation is also confusing for primary treatment failure. Whipple's disease can exacerbate when treated, as during leprosy with lepromatous reaction or as in immune reconstitution. These immediate ‘failures’ are not antibiotic failures and when they are excluded, the only difference in failure rates between treatment regimens in the single published comparative study (tetracycline versus co-trimoxazole)2 is observed in patients with initial neurological manifestations. In these patients, doxycycline is poorly effective. In addition, treatment with co-trimoxazole is associated with failures caused by acquired resistance3 and, in our clinical experience, has a frequency of ∼3%.2
