Endoscopy 2010; 42: E310-E311
DOI: 10.1055/s-0030-1255809
Unusual cases and technical notes

© Georg Thieme Verlag KG Stuttgart · New York

In vivo identification by confocal laser endoscopy of foamy macrophages associated with Whipple’s disease

W.  Dolak1 , J.  Leitner2 , J.  Maresch3 , F.  Wrba3 , C.  Mueller1
  • 1Department of Medicine III, Clinical Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
  • 2Department of Medicine I, Clinical Division of Infectious Diseases, Medical University of Vienna, Vienna, Austria
  • 3Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
Further Information

Publication History

Publication Date:
26 November 2010 (online)

Whipple’s disease is a very rare illness caused by the actinobacterium Tropheryma whipplei. The diagnosis is confirmed by demonstration of macrophages staining positive in the periodic acid-Schiff (PAS) reaction in histological biopsy sections, but cannot be made on the basis of the macroscopic appearance during endoscopy [1] [2]. We report the in vivo findings typical of Whipple’s disease at the single cell level, captured by confocal laser endomicroscopy (CLE) in the duodenal mucosa of a 69-year-old woman with confirmed Whipple’s disease.

Macroscopically, edematous duodenal villi were seen, diffusely patterned with small whitish dots ([Fig. 1]).

Fig. 1 Macroscopic appearance, showing whitish patterned duodenal mucosa.

Endomicroscopy showed massive capillary leak and a thickened epithelial layer, both unspecific signs of inflammation ([Fig. 2]).

Fig. 2 Superficial endomicroscopy showing capillary leak in the duodenal mucosa.

Going into depth, several grouped cells (B in [Fig. 3]) appeared within the lamina propria, clearly distinguishable from single goblet cells (A in [Fig. 3]) in the surroundings.

Fig. 3 Deep endomicroscopic image of the duodenal mucosa. A Goblet cells, B foamy macrophages within the lamina propria.

Biopsies were taken from the locations observed by CLE. Directly linking in vivo findings to histological sections, we were able to identify the grouped cells as foamy macrophages which showed PAS-positive staining properties ([Fig. 4]), characteristic of Whipple’s disease.

Fig. 4 Periodic acid–Schiff staining of a histological section of the duodenum. A Goblet cells, B foamy macrophages within the lamina propria.

Zambelli et al. already reported CLE findings in Whipple’s disease in 2008 [3]. While their case report mainly focused on tissue patterns, we were able to obtain CLE images at the single cell level, which may be partly attributed to improvements that have taken place in the meantime in the visual properties of the CLE technique. The identification of foamy macrophages within the lamina propria in vivo underlines the uniqueness of CLE, which depicts directly gastrointestinal pathologies that could formerly be evaluated only on the basis of biopsy results.

Competing interests: None



W. Dolak, MD 

Medical University of Vienna
Department of Internal Medicine III
Clinical Division of Gastroenterology and Hepatology

Währinger Gürtel 18 – 20
1090 Vienna

Fax: +43-1-404004735

Email: werner.dolak@meduniwien.ac.at