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| __NOTOC__
| | == Do's == |
| {{Whipple's disease}}
| | '''Thyroglobulin level monitoring''' |
| {{CMG}};{{AE}}{{BHA}}
| | *Order serum Tg periodically during follow-up of patients with differentiated thyroid cancer who have undergone less than total thyroidectomy |
| | *Order serum Tg periodically during follow-up of patients with differentiated thyroid cancer who have had a total thyroidectomy but not radioactive iodine ablation |
| | '''Cervical ultrasound''' |
| | *Perform cervical ultrasound to evaluate thyroid 6–12 months following surgery |
| | '''18FDG-PET scanning''' |
| | *Consider 18FDG-PET scanning in high-risk differentiated thyroid cancer patients with elevated serum Tg (generally >10 ng/mL) and negative radioactive iodine imaging |
| | '''CT scans''' |
| | *Order chest CT scan with or without IV contrast in high-risk differentiated thyroid cancer patients with elevated serum Tg (generally >10 ng/mL) or rising Tg antibodies with or without negative radioactive iodine imaging |
| | '''TSH range''' |
| | *Maintain serum TSH below 0.1 mU/L in patients with a structural incomplete response to therapy, indefinitely in the absence of specific contraindications |
| | *Maintain serum TSH between 0.5-2 mU/L in patients with an excellent or indeterminate response to therapy, especially those at low risk for recurrence |
| | '''Surgery for nodal disease''' |
| | *Perform surgery in patients with clinically apparent, macroscopic nodal disease |
| | *Perform therapeutic compartmental central and/or lateral neck dissection in a previously operated compartment, in patients with biopsy-proven persistent or recurrent disease for central neck nodes ≥8 mm and lateral neck nodes ≥10 mm |
| | *Perform compartmental surgery |
| | *Perform combination of surgery and RAI and/or EBRT in patients with aerodigestive invasive disease |
| | *Perform combination of surgery and 131I and/or external beam radiation therapy in patients who have tumors that invade the upper aerodigestive tract |
| | *Order complete blood count and assessment of renal function before administration of radioactive iodine |
| | *Discuss preventive strategies for dental caries with patients with xerostomia |
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| ==Overview==
| | '''Radioactive iodine therapy''' |
| Patients with Whipple's disease have varied presentation. Most common symptoms of the classical Whipple's disease include [[joint pain]], [[weight loss]], [[diarrhea]], and [[arthropathy]]. Other organ systems can be involved in Whipple's disease including [[central nervous system]], [[cardiac]] system, [[renal]] system, [[skeletal]], [[muscles]] and [[pulmonary]] system.
| | *Order pregnancy test before radioactive iodine administration |
| | | *Administer radioactive iodine therapy in patients with iodine-avid bone metastases |
| ==History and Symptoms==
| | *Administer radioactive iodine therapy in patients with pulmonary micrometastases |
| | | *Repeat radioactive iodine therapy in patients with pulmonary micrometastases every 6-12 months |
| == Common Symptoms ==
| |
| | |
| ==== Non specific symptoms ====
| |
| * [[Fever]]
| |
| * [[Weight loss]]
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| | |
| ====Gastrointestinal system====
| |
| * [[Diarrhea]]: The most common complaint
| |
| * [[Steatorrhea]]
| |
| * [[Abdominal pain]]
| |
| * Occult [[mucosal bleeding]]
| |
| * [[Ascites]]
| |
| * [[Hepatosplenomegaly]]
| |
| * [[Hepatitis]]
| |
| | |
| ====Articular system====
| |
| * Intermittent migratory [[arthralgias]]: The second most common complaint
| |
| * [[arthritis]]: Affecting peripheral joints, such as [[knees]], [[elbows]], [[wrists]]
| |
| * Multiple [[joint]] involvement
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| | |
| == Less Common Symptoms ==
| |
| '''Central nervous system''' | |
| * Asymptomatic involvement with detection of [[Tropheryma whipplei]] [[DNA]] in [[CSF]]: The most common finding | |
| * Focal CNS involvement: | |
| ** [[dementia]]
| |
| ** [[cerebral ataxia]]
| |
| ** [[hemiparesis]]
| |
| ** [[Personality changes]]
| |
| ** [[opthalmoplegia]]
| |
| ** [[nystagmus]]
| |
| ** Supranuclear opthalmoplegia (50% of patients)
| |
| ** [[myoclonus]] (25% of patients)
| |
| * [[Hypothalamic]] involvement (rarely)
| |
| ** P[[polydipsia|olydipsia]]
| |
| ** [[hyperphagia]]
| |
| ** Change in [[libido]]
| |
| ** Change in sleep wake cycle
| |
| * [[Eye movements|Eye movement]] abnormalities (pathognomic)
| |
| ** Oculomasticatory myorhythmia (OMM)
| |
| ** Oculofacial-skeletal myorhythmia (OSFM)
| |
| * CNS involvement usually has poor prognosis.<ref name="pmid17202456">{{cite journal| author=Fenollar F, Puéchal X, Raoult D| title=Whipple's disease. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 1 | pages= 55-66 | pmid=17202456 | doi=10.1056/NEJMra062477 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17202456 }} </ref><ref name="pmid11432814">{{cite journal| author=Dutly F, Altwegg M| title=Whipple's disease and "Tropheryma whippelii". | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 3 | pages= 561-83 | pmid=11432814 | doi=10.1128/CMR.14.3.561-583.2001 | pmc=88990 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11432814 }} </ref> | |
| '''Ocular involvement'''
| |
| | |
| rare and can involve: <ref name="pmid11432814" />
| |
| * [[uveitis]],
| |
| * [[retinitis]] ,
| |
| * [[vitritis]]
| |
| * [[retrobulbar neuritis]]
| |
| * [[papilledema]] .
| |
| * Ocular involvement is often seen in patients with CNS disease. <ref name="pmid11432814">{{cite journal| author=Dutly F, Altwegg M| title=Whipple's disease and "Tropheryma whippelii". | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 3 | pages= 561-83 | pmid=11432814 | doi=10.1128/CMR.14.3.561-583.2001 | pmc=88990 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11432814 }} </ref>
| |
| '''Skeletal muscle''' '''involvement'''
| |
| * seen as [[myalgias]] and muscle cramps <ref name="pmid17202456">{{cite journal| author=Fenollar F, Puéchal X, Raoult D| title=Whipple's disease. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 1 | pages= 55-66 | pmid=17202456 | doi=10.1056/NEJMra062477 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17202456 }} </ref> | |
| '''Cardiac involvement''' :may have varied presentation .<ref name="pmid17202456" /> <ref name="pmid11432814" />
| |
| * [[pericarditis]]
| |
| * [[myocarditis]]
| |
| * [[heart failure]]
| |
| * [[sudden Cardiac death]]
| |
| * [[Endocarditis]] : associated with negative blood cultures. Endocarditis is often preceded by [[arthritis]] and [[arthralgias]] .<ref name="pmid17202456">{{cite journal| author=Fenollar F, Puéchal X, Raoult D| title=Whipple's disease. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 1 | pages= 55-66 | pmid=17202456 | doi=10.1056/NEJMra062477 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17202456 }} </ref> <ref name="pmid11432814">{{cite journal| author=Dutly F, Altwegg M| title=Whipple's disease and "Tropheryma whippelii". | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 3 | pages= 561-83 | pmid=11432814 | doi=10.1128/CMR.14.3.561-583.2001 | pmc=88990 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11432814 }} </ref>
| |
| '''Pulmonary involvement <ref name="pmid11432814" />'''
| |
| * manifest as pleuritic chest pain
| |
| * non productive cough
| |
| * [[dyspnea]]
| |
| * Chest x-ray often shows [[pleural effusion]] , pulmonary infiltration, or granulomatous mediastinal adenopathy. Often abdominal lymph nodes may be involved.
| |
| '''Hematological finding'''
| |
| * [[anemia]] which may be due to malabsorption or mucointestinal bleeding.<ref name="pmid11432814">{{cite journal| author=Dutly F, Altwegg M| title=Whipple's disease and "Tropheryma whippelii". | journal=Clin Microbiol Rev | year= 2001 | volume= 14 | issue= 3 | pages= 561-83 | pmid=11432814 | doi=10.1128/CMR.14.3.561-583.2001 | pmc=88990 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11432814 }} </ref>
| |
| '''Cutaneous finding'''
| |
| * [[melanoderma]] : less frequently reported these days as Whipple's disease is increasingly recognized early. <ref name="pmid17202456">{{cite journal| author=Fenollar F, Puéchal X, Raoult D| title=Whipple's disease. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 1 | pages= 55-66 | pmid=17202456 | doi=10.1056/NEJMra062477 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17202456 }} </ref>
| |
| '''Renal involvemen'''t : late in course, may be seen rarely. <ref name="pmid17202456">{{cite journal| author=Fenollar F, Puéchal X, Raoult D| title=Whipple's disease. | journal=N Engl J Med | year= 2007 | volume= 356 | issue= 1 | pages= 55-66 | pmid=17202456 | doi=10.1056/NEJMra062477 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17202456 }} </ref>
| |
| | |
| ==References==
| |
| {{Reflist|2}}
| |
| | |
| {{WH}}
| |
| {{WS}}
| |
Do's
Thyroglobulin level monitoring
- Order serum Tg periodically during follow-up of patients with differentiated thyroid cancer who have undergone less than total thyroidectomy
- Order serum Tg periodically during follow-up of patients with differentiated thyroid cancer who have had a total thyroidectomy but not radioactive iodine ablation
Cervical ultrasound
- Perform cervical ultrasound to evaluate thyroid 6–12 months following surgery
18FDG-PET scanning
- Consider 18FDG-PET scanning in high-risk differentiated thyroid cancer patients with elevated serum Tg (generally >10 ng/mL) and negative radioactive iodine imaging
CT scans
- Order chest CT scan with or without IV contrast in high-risk differentiated thyroid cancer patients with elevated serum Tg (generally >10 ng/mL) or rising Tg antibodies with or without negative radioactive iodine imaging
TSH range
- Maintain serum TSH below 0.1 mU/L in patients with a structural incomplete response to therapy, indefinitely in the absence of specific contraindications
- Maintain serum TSH between 0.5-2 mU/L in patients with an excellent or indeterminate response to therapy, especially those at low risk for recurrence
Surgery for nodal disease
- Perform surgery in patients with clinically apparent, macroscopic nodal disease
- Perform therapeutic compartmental central and/or lateral neck dissection in a previously operated compartment, in patients with biopsy-proven persistent or recurrent disease for central neck nodes ≥8 mm and lateral neck nodes ≥10 mm
- Perform compartmental surgery
- Perform combination of surgery and RAI and/or EBRT in patients with aerodigestive invasive disease
- Perform combination of surgery and 131I and/or external beam radiation therapy in patients who have tumors that invade the upper aerodigestive tract
- Order complete blood count and assessment of renal function before administration of radioactive iodine
- Discuss preventive strategies for dental caries with patients with xerostomia
Radioactive iodine therapy
- Order pregnancy test before radioactive iodine administration
- Administer radioactive iodine therapy in patients with iodine-avid bone metastases
- Administer radioactive iodine therapy in patients with pulmonary micrometastases
- Repeat radioactive iodine therapy in patients with pulmonary micrometastases every 6-12 months