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Whipple's Disease and Granulomatous SynovitisComment on the Article by Gravallese et a1.

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different disease states and for comparisons and standardization of the assays used to measure cICAM-1 and other
circulating adhesion molecules.
Justin C. Mason, MRCP
Dorian 0. Haskard, DM, MRCP
Hammersmith Hospital
London, UK
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Whipple’s disease and granulomatous synovitis:
comment on the article by Gravallese et a1
To the Editor:
The recent Rheumatology Grand Rounds entitled
“Synovitis of the Knee in a 42-Year-Old Man” (1) was an
elegant and comprehensive discussion of granulomatous
synovitis. I note that the differential diagnosis did not
include Whipple’s disease, which on occasion, can indeed
give rise to a multisystem granulomatous disease (2,3) that
results in granulomatous synovitis (4). Since Whipple’s
disease generally affects middle-aged men, and synovitis can
be its heralding feature, it should have been included in the
differential diagnosis.
Mori Schwartzberg, MD
Jersey Shore Medical Center
Neptune, NJ
1. Gravallese EM, Weissman BN, Corson JM, Greene JM: Syno-
vitis of the knee in a 42-year-old man: clinicopathologic conference. Arthritis Rheum 36:8W70, 1993
2. Wilcox GM, Tronic BC, Schecter DJ, Arron MJ, Righi DF,
Weiner NJ: Periodic acid-Schiff-negativegranulomatous lymphadenopathy in a patient with Whipple’s disease: localization of
the Whipple bacillus to noncaseating granulomas by electron
microscopy. Am J Med 83:165-170, 1987
3. Southern JF, Moscicki RA, Magro C, Dickersin GR, Fallon JT,
Bloch KJ: Lymphedema, lymphocytic myocarditis, and sarcoid-
like granulomatosis: manifestations of Whipple’s disease. JAMA
261~1467-1470, 1989
4. Rouillon A, Menkes CJ, Gerster JC, Perez-Sawka I, Forest M:
Sarcoid-like forms of Whimle’s disease: report of 2 cases. J
Rheumatol20:107&1072, 1993
To the Editor:
We thank Dr. Schwartzberg for his favorable comments, and for directing our attention to the report by
Rouillon et al, which describes the synovial pathology of a
patient with Whipple’s disease, in whom, “clumps of epithelioid cells” were seen. Their photomicrograph of one
such clump could be interpreted as a noncaseating granuloma. As Dr. Rouillon and colleagues note, theirs is the first
report of Whipple’s disease with granulomatous changes
within the synovium.
At the time the Clinicopathologic Conference discussion was being prepared, granulomatous inflammation of the
synovium due to Whipple’s disease had not yet been described. Although Whipple’s disease was known to cause
granulomatous changes in other organs, the lack of fever,
central nervous system involvement, or gastrointestinal
manifestations led away from its inclusion in the differential
diagnosis. Had Rouillon’s report been available at the time,
Whipple’s disease would certainly have been added to the
list of causes of granulomatous synovitis.
Jerry M. Greene, MD
BrocktonlWest Roxbury V A Medical Center
Ellen M. Gravallese, MD
Brigham and Women’s Hospital
Boston, MA
Improvement in esophageal motor abnormalities in
systemic sclerosis patients treated with cyclosporine:
comment on the article by Clements et al
To the Editor:
We read with interest the article by Clements et al
concerning the use of cyclosporine in patients with systemic
sclerosis (SSc) (Clements PJ, Lachenbruch PA, Sterz M,
Danovitch G, Hawkins R, Ippoliti A, Paulus HE: Cyclosporine in systemic sclerosis: results of a forty-eight-week open
safety study in ten patients. Arthritis Rheum 36:75-83,
1993). Their study suggests that cyclosporin A, an immunosuppressive agent, reduces skin thickening, but has no effect
on visceral involvement. Our experience is in contrast with
these findings, particularly with regard to esophageal motor
We have studied 2 female patients (ages 29 and 35
years), who had SSc for 5 years and 6 months, respectively.
The diagnosis was confirmed by skin biopsy. Both patients
had serious cutaneous involvement in the digits, forearms,
and face, sclerodactyly, loss of substance of the distal finger
pads, Raynaud’s phenomenon, dysphagia, and heartburn.
Renal function was good in both, and neither had a history of
hypertension. Both patients were treated with cyclosporin A
(2.5 mg/kg/day, to achieve plasma drug levels of 150-500
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