Giardia lamblia was treated with metronidazol. After 12 months of treatment, the patient was in clinical remission with marked improvement of the spinal lesions (Fig (Fig1C).1C). In July 2007, cotrimoxazol was switched to doxycyclin plus hydroxychloroquine because the laboratory markers they of inflammation were still mildly elevated (CRP 5.5 mg/l, ESR 26 mm/h). In August 2008 there were no clinical or serological signs of inflammation, another control MRI showed no signs of activity. Treatment was discontinued in October 2008 due to doxycyclin induced phototoxic skin eruptions [5]. At his last follow-up in February 2009, there was no sign of relapse. Conclusion Spondylitis is a rare manifestation of Whipple’s disease. Multisegmental involvement has to our knowledge not been reported before.

The first symptom of Whipple’s disease usually is a polyarthritis. Typically the diagnosis of the underlying infection is delayed for several years [6]. The physician and rheumatologist should be aware of this rare differential diagnosis of arthritis and spondyloarthritis. Erosive intervertebral disease and a L4/5 location of inflammatory lesions are not typical for primary spondyloarthritis. An accelerated progression and onset of new gastrointestinal symptoms has been described in a few cases of Whipple’s disease treated with non-biologic and biologic immunosuppressants [7]. A septic, life-threatening disease course has been reported under immunosuppression [8]. Tropheryma whipplei should be considered even in the absence of gastrointestinal symptoms; therefore routine PCR from vertebral biopsies is recommended [9].

Typically, the diagnosis is made by PAS staining of small-bowel-biopsy specimens and occasionally also other tissues, which on light microscopy show magenta-stained inclusions within macrophages. Immunohistochemistry may provide greater sensitivity and specificity than does PAS staining but is not widely available. Our case suggests that PCR from gastrointestinal sources can be more sensitive than the demonstration of PAS-positive macrophages in histopathology. Last but not least, the case provides further support for an association between Whipple’s disease and Giardia lamblia infection [10]. The pathogenesis of this coinfection is unclear but may be promoted by a common immune defect, a common source of infection, or the circumstance that infection with one organism may predispose to infection with the other [10].

If untreated, Whipple’s disease is invariably fatal. An effective antibiotic regimen Brefeldin_A consists of ceftriaxone (2 g daily) for 2 weeks, followed by cotrimoxazole (160 mg of trimethoprim and 800 mg of sulfamethoxazole twice per day) for 1 to 2 years. In case of an unsatisfactory clinical response or a relapse, doxycycline (200 mg/day) plus hydroxychloroquine (200 mg three times per day), an alkalinizing agent which decreases the viability of Tropheryma whipplei in phagosomes, is recommended [10].