Internal Medicine

0521779407-23 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 21:24

1552 Whipple’s Disease

WHIPPLE’S DISEASE

GARY M. GRAY, MD

history & physical

History

■Fatigue, abdominal bloating/distention, large volume loose stools,

arthralgias and arthritis, weight loss, mental changes

Physical

■Smooth, red tongue; cracking at mouth corners; evidence of weight

loss; cardiac murmur; mental slowing

tests

Basic Blood:

■anemia (iron deficiency; folate/vitamin B 12 deficiency); hypoalbu-

minemia

Basic Urine:

■none usually helpful; see xylose test under specific diagnostic tests

Special Diagnostic Tests

■Functional tests of malabsorption: elevated quantitative fecal fat (72-

hour); reduced xylose absorption (25 g ingested; 5-hour urine excre-

tion)

■Small intestinal biopsy (via upper GI endoscopy to distal duo-

denum): prominent and irregularly shaped folds; microscopic: bro-

adened and shortened villi, often with normal surface enterocytes;

prominent infiltration of lamina propria with large round cells

(macrophages; PAS-positive)

■Positive PCR test for responsible genetic material of the bacterial

agent (Tropheryma whippelii) in intestinal biopsy

■Identification of PCR-positive material in other tissues involved

(cerebral-spinal fluid, joint aspirates, liver, heart valves)

■Altered heart valves on cardiac ECHO (if heart valve involvement)

differential diagnosis

Differential Diagnosis

■Other intestinal enteropathies, especially celiac sprue, a more com-

mon disease

■Other causes of arthritis, especially immunologic (rheumatoid

arthritis)