The combination of chloroquine and minocycline, a therapeutic option in cerebrospinal infection of Whipple's disease refractory to treatment with ceftriaxone, meropenem and co-trimoxazole.

6 Souli M, Kontopidou FV, Koratzanis E et al. In vitro activity of tigecycline against multiple-drug-resistant, including pan-resistant, Gram-negative and Gram-positive clinical isolate from Greek hospitals. The combination of chloroquine and minocycline, a therapeutic option in cerebrospinal infection of Whipple's disease refractory to treatment with ceftriaxone, meropenem and co-trimoxazole Keywords: Tropheryma whipplei, T. whipplei, cerebral Whipple's disease Sir, Whipple's disease is a chronic infection caused by Tropheryma whipplei. In a prospective study, the CNS was found to be involved in 38.5% of the cases. 1 Treatment is not always successful. 2 – 6 Co-trimoxazole (trimethoprim/sulfamethoxazole) has been reported to be significantly more effective than tetracycline; 2 however, resistance to co-trimoxazole has also been observed. 2 – 6 More recently, there have even been reports describing resistance of CNS infections to treatment with ceftriaxone, a bactericidal antibiotic penetrating the blood –brain barrier. In 2002, a patient presented with diarrhoea, weight loss to 64 kg, anaemia (8.4 g/dL haemoglobin) and erythrocyte sedimentation rate of 33 mm/h. The medical history revealed relapsing arthritis since 1991 and pericarditis necessitating pericardial resection in 1993. Gastrointestinal biopsies disclosed periodic acid-Schiff (PAS)-positive macrophages typical of untreated Whipple's disease in the mucosa of the duodenum and the ileum and in the submucosa of the colon. The patient had no cerebral symptoms. However, microscopic examination of centrifuged CSF obtained by spinal puncture showed a PAS-positive macrophage typical of Whipple's disease (histopathology carried out by Dr Reinhard Golz, Wuppertal), and the PCR to T. whipplei in the CSF was positive. The patient was admitted to a prospective treatment trial, as reported in Feurle et al. 1 He was randomized to 2 g of ceftriaxone infused intravenously once daily for 2 weeks, followed by oral co-trimoxazole at a dosage of 160/300 mg twice daily for 12 months. While the patient recovered from all signs and symptoms of Whipple's disease, the PCR for T. whipplei remained positive in the CSF for 5.5 years despite additional treatment with 1 g of meropenem infused intravenously thrice daily for 2 weeks followed by co-trimoxazole for another year. 1 After a further year of co-trimoxazole, the CSF was still positive in the T. whipplei PCR, while the patient was receiving this treatment. PAS-positive macrophages in duodenal mucosal biopsies and in the CSF had disappeared. CT and magnetic resonance imaging of the brain did not reveal any structural abnormality. At this time, the patient had no symptoms …