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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


==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]]
 
====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
 
== 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}}

Revision as of 20:39, 20 November 2017

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
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