Whipple's disease differential diagnosis: Difference between revisions

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__NOTOC__
__NOTOC__
[[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Whipple%27s_disease]]
{{CMG}}; {{AE}} {{SSH}}
{{CMG}}; {{AE}} {{SSH}}
==Overview==
==Overview==
Whipple's disease must be differentiated from other diseases that cause [[malabsorption]], [[chronic diarrhea]], multi system involvement, such as [[Celiac disease]], [[systemic infections]], and [[inflamatory bowel disease]].
Whipple's disease must be differentiated from other diseases that cause [[malabsorption]], [[chronic diarrhea]], multisystem involvement, such as [[celiac disease]], [[cystic fibrosis]], [[inflammatory bowel disease]] and systemic [[infections]].


==Differentiating Whipple's disease from other Diseases==
==Differentiating Whipple's disease from other Diseases==
Whipple's disease must be differentiated from other diseases that cause [[malabsorption]], [[chronic diarrhea]], joins involvement, and neurologic symptoms.
Whipple's disease must be differentiated from other diseases that cause [[malabsorption]], [[chronic diarrhea]], [[abdominal pain]] and multisystem involvement.<ref name="pmid8694025">{{cite journal| author=Hertzler SR, Savaiano DA| title=Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance. | journal=Am J Clin Nutr | year= 1996 | volume= 64 | issue= 2 | pages= 232-6 | pmid=8694025 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8694025  }} </ref><ref name="pmid9414969">{{cite journal| author=Briet F, Pochart P, Marteau P, Flourie B, Arrigoni E, Rambaud JC| title=Improved clinical tolerance to chronic lactose ingestion in subjects with lactose intolerance: a placebo effect? | journal=Gut | year= 1997 | volume= 41 | issue= 5 | pages= 632-5 | pmid=9414969 | doi= | pmc=1891556 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9414969  }} </ref><ref name="pmid15391722">{{cite journal| author=BLACK-SCHAFFER B| title=The tinctoral demonstration of a glycoprotein in Whipple's disease. | journal=Proc Soc Exp Biol Med | year= 1949 | volume= 72 | issue= 1 | pages= 225-7 | pmid=15391722 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15391722  }} </ref><ref name="pmid14201408">{{cite journal| author=SCOBIE BA, MCGILL DB, PRIESTLEY JT, ROVELSTAD RA| title=EXCLUDED GASTRIC ANTRUM SIMULATING THE ZOLLINGER-ELLISON SYNDROME. | journal=Gastroenterology | year= 1964 | volume= 47 | issue=  | pages= 184-7 | pmid=14201408 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14201408  }} </ref><ref name="pmid16151544">{{cite journal| author=Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR et al.| title=Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology. | journal=Can J Gastroenterol | year= 2005 | volume= 19 Suppl A | issue=  | pages= 5A-36A | pmid=16151544 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16151544  }}</ref><ref name="pmid12135027">{{cite journal| author=Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D| title=Bowel habits and bile acid malabsorption in the months after cholecystectomy. | journal=Am J Gastroenterol | year= 2002 | volume= 97 | issue= 7 | pages= 1732-5 | pmid=12135027 | doi=10.1111/j.1572-0241.2002.05779.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12135027  }}</ref><ref name="pmid1702075">{{cite journal| author=Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R et al.| title=Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia. | journal=Gastroenterology | year= 1991 | volume= 100 | issue= 2 | pages= 359-69 | pmid=1702075 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=1702075  }}</ref><ref name="pmid14439871">{{cite journal| author=RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC| title=Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue. | journal=Gastroenterology | year= 1960 | volume= 38 | issue=  | pages= 28-49 | pmid=14439871 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=14439871  }}</ref><ref name="StreetDonoghue1999">{{cite journal|last1=Street|first1=Sara|last2=Donoghue|first2=Helen D|last3=Neild|first3=GH|title=Tropheryma whippelii DNA in saliva of healthy people|journal=The Lancet|volume=354|issue=9185|year=1999|pages=1178–1179|issn=01406736|doi=10.1016/S0140-6736(99)03065-2}}</ref><ref name="pmid8903578">{{cite journal |vauthors=Marth T, Strober W |title=Whipple's disease |journal=Semin. Gastrointest. Dis. |volume=7 |issue=1 |pages=41–8 |year=1996 |pmid=8903578 |doi= |url=}}</ref><ref name="SchneiderMoos2008">{{cite journal|last1=Schneider|first1=Thomas|last2=Moos|first2=Verena|last3=Loddenkemper|first3=Christoph|last4=Marth|first4=Thomas|last5=Fenollar|first5=Florence|last6=Raoult|first6=Didier|title=Whipple's disease: new aspects of pathogenesis and treatment|journal=The Lancet Infectious Diseases|volume=8|issue=3|year=2008|pages=179–190|issn=14733099|doi=10.1016/S1473-3099(08)70042-2}}</ref>
* [[Malabsorption]] with [[small intestine]] involvement ([[celiac disease]], [[sarcoidosis]], and [[lymphoma]])
 
* [[Infection|Infections]] such as [[tuberculosis]], endemic [[Fungus|fungi]] (eg, [[Histoplasma capsulatum|Histoplasma]] spp), [[Rhodococcus]] and [[Human Immunodeficiency Virus (HIV)|HIV]] infection
'''The table below summarizes the diseases that cause [[malabsorption]], [[diarrhea]] and [[abdominal pain]].'''
* [[Inflammatory bowel disease|Inflammatory bowel diseases]]
 
*[[Connective tissue disease|Connective tissue diseases]]
<span style="font-size:85%">'''Abbreviations:'''
*Neurologic disease
'''WBC:''' [[White blood cells]]; '''Plt:''' [[Platelet|Platelets]], '''Hgb:''' [[Hemoglobin]], '''IgE:''' [[Immunoglobulin E]], '''IgA:''' [[Immunoglobulin A]]
*[[Addison's disease]]
</span>
The following diseases have presentations similar to that of Whipple's disease.
<small><small>
{| style="border: 0px; font-size: 100%; margin: 3px;" align="center"
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Cause
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Peak age of onset
! colspan="5" align="center" style="background:#4479BA; color: #FFFFFF;" |History
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Physical exam
! colspan="4" rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Lab findings
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Additional findings
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Cause/Pathogenesis
! rowspan="3" align="center" style="background:#4479BA; color: #FFFFFF;" |Gold standard diagnosis
|-
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Fever
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Abdominal pain
! colspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Diarrhea
! rowspan="2" align="center" style="background:#4479BA; color: #FFFFFF;" |Weight loss
|-
! align="center" style="background:#4479BA; color: #FFFFFF;" |Watery
! align="center" style="background:#4479BA; color: #FFFFFF;" |Fatty
! align="center" style="background:#4479BA; color: #FFFFFF;" |WBC
! align="center" style="background:#4479BA; color: #FFFFFF;" |Hgb
! align="center" style="background:#4479BA; color: #FFFFFF;" |Plt
! align="center" style="background:#4479BA; color: #FFFFFF;" |Other lab findings
|-
! align="center" style="background:#DCDCDC;" |Whipple's disease
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |40-60
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Ocular motility disorders|Abnormal extraocular movement]]
* [[Lymphadenopathy]]
* [[Hyperpigmentation]]
* Decreased breathing sound
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓/↑
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*[[Hypoalbuminemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Uveitis]]
* [[Endocarditis]]
* [[Encephalitis]]
* [[Dementia]]
* [[Hepatosplenomegaly]]
* [[Ascites]]
* [[Pleural effusion]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Tropheryma whipplei]]
* [[HLA-B27]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Small intestine]] [[biopsy]] for [[Tropheryma whipplei]] testing
* [[PCR]] testing
|-
! align="center" style="background:#DCDCDC;" |[[Celiac disease]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Childhood
Adult
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +/-
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal distention]]
* [[Tetany]]
* [[Mouth ulcers]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[IgA]] endomysial antibody
* Anti-tissue transglutaminase antibody
* Anti-gliadin antibody
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Signs of the fat-soluble [[Vitamin A|vitamins A]], [[Vitamin D|D]], [[Vitamin E|E]], and [[Vitamin K|K]] deficiency
* [[Dementia]]
* [[Hepatosplenomegaly]]
* [[Ascites]]
* [[Dermatitis herpetiformis]]
* Must follow [[Gluten-free diet]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[HLA-DQ2]]
* [[HLA-DQ8]]
* Innate responses to [[wheat proteins]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[IgA]] endomysial antibody
* [[IgA]] tissue transglutaminase antibody
|-
! align="center" style="background:#DCDCDC;" |[[Cystic fibrosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Childhood
Adult
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Digital clubbing]]
* Abnormal [[breathing sounds]]
* [[Cyanosis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Positive [[DNA]] analysis for [[CFTR]]
* Evaluated [[nasal]] transepithelial potential difference (NPD)
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Diabetes]]
* Recurrent upper and lower [[respiratory tract infections]]
* [[Infertility]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Mutations in the [[cystic fibrosis transmembrane conductance regulator]] ([[CFTR]]) protein
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Elevated [[Sweat chloride test|sweat chloride]] ≥60 mmol/L
|-
! align="center" style="background:#DCDCDC;" |[[Crohns disease]]
| align="center" style="background:#F5F5F5;" | Young adults
(20th)
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness]]
* [[Tachycardia]]
* [[Hypotension]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↑
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Iron deficiency]]
* [[Vitamin B12]] deficiency
* Elevated [[erythrocyte sedimentation rate|ESR]]
* Elevated [[C-reactive protein|CRP]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Blood seen on [[rectal exam]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Abnormal immune response to self [[antigens]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Colonoscopy]] with [[biopsy]]
|-
! align="center" style="background:#DCDCDC;" |[[Irritable bowel syndrome]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |30-50
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness]]
* [[Flatulence]]
* Hard stool in the rectal vault
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Diagnosis of exclusion
|-
! align="center" style="background:#DCDCDC;" |[[VIPoma]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |30-50
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
* [[Tachycardia]]
* [[Rash]]
* [[Facial flushing]]
* [[Abdominal distention]]
* Abdominal RUQ tenderness
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
*Elevated [[VIP]] level
*[[Hypokalemia]]
*[[Hypochlorhydria]] or [[achlorhydria]]
*Low osmotic gap (<50 mOsm/kg)
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Dehydration]]
* [[Lethargy]]
* [[Muscle weakness]]
* [[Nausea]]
* [[Vomiting]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Primary secretory tumor
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Elevated [[VIP]] levels
* Followed by imaging
|-
! align="center" style="background:#DCDCDC;" |[[Zollinger-Ellison syndrome]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |20-50
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="Left" |
* [[Abdominal tenderness]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Positive [[secretin]] stimulation test
* Elevated serum [[chromogranin A]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Heartburn]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Gastrin]] producing [[tumor]] mainly in [[duodenum]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Elevated basal or stimulated serum [[gastrin]]> 120 pg/mL
|-
! align="center" style="background:#DCDCDC;" |[[Lactose intolerance]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Any age
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness ]]
* [[Hypotension]]
* [[Tachycardia]]
* [[Nausea and vomiting]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Hydrogen breath test]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Bloating]]
* [[Flatulence]]
* Symptoms begin mainly after ingestion of [[lactose]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Reduction of lactase enzyme activity or inability to produce persistent [[lactase]]
* Congenital [[lactase deficiency]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Lactase]] activity assay
|-
! align="center" style="background:#DCDCDC;" |[[Eosinophilic gastroenteritis]] 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | 30th
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal distention]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | ↑
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |  
* Elevated [[serum]] [[IgE]] levels
* [[Eosinophilia]]
* Elevated [[ESR]]
* [[Hypoalbuminemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Other [[Allergic disorders|allergic disorders]]
* Associated with an identifiable [[dietary]] [[antigen]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Autoimmunity|Autoimmune]] [[Allergy|allergic]] response to food [[antigens]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Eosinophilic]] infiltration of the [[gastrointestinal tract]] on [[biopsy]]
|-
! align="center" style="background:#DCDCDC;" |[[Primary bile acid malabsorption]]
| align="center" style="background:#F5F5F5;" | Childhood Adult
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
 
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Low  [[Vitamin A|vitamins A]], [[Vitamin D|D]], E, and K
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |


'''The table below summarizes the findings that differentiate [[malabsorption]]'''<ref name="pmid8694025">{{cite journal| author=Hertzler SR, Savaiano DA| title=Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance. | journal=Am J Clin Nutr | year= 1996 | volume= 64 | issue= 2 | pages= 232-6 | pmid=8694025 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8694025  }} </ref><ref name="pmid9414969">{{cite journal| author=Briet F, Pochart P, Marteau P, Flourie B, Arrigoni E, Rambaud JC| title=Improved clinical tolerance to chronic lactose ingestion in subjects with lactose intolerance: a placebo effect? | journal=Gut | year= 1997 | volume= 41 | issue= 5 | pages= 632-5 | pmid=9414969 | doi= | pmc=1891556 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9414969  }} </ref><ref name="pmid15391722">{{cite journal| author=BLACK-SCHAFFER B| title=The tinctoral demonstration of a glycoprotein in Whipple's disease. | journal=Proc Soc Exp Biol Med | year= 1949 | volume= 72 | issue= 1 | pages= 225-7 | pmid=15391722 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15391722  }} </ref>
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Genetic defects]] in ''SLC10A2'' (solute carrier family 10 member 2 gene)
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Elevated total and specific [[bile acids]] in stool
* Positive [[SeHCAT]]
|-
! align="center" style="background:#DCDCDC;" |[[Abetalipoproteinemia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Infancy
Adult
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal distension]]
* [[Visual field defect]]
* [[Dysarthria]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Low [[triglyceride]]
* Low total [[cholesterol]] levels 
* [[Acanthocytes]]
* Low [[vitamin E]] levels
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Visual impairment
* [[Ataxia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Autosomal recessive]] disorder caused by mutations encoding the [[microsomal]] [[triglyceride]] transfer protein (MTP)
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Clinical findings and low [[triglyceride]] and [[cholesterol]] level
|-
! align="center" style="background:#DCDCDC;" |[[Microscopic colitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |50-70
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Abdominal tenderness]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |↓
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Elevated [[autoantibodies]] include:
**[[RF]]
**[[ANA]]
**[[Anti-mitochondrial antibody|AMA]]
**[[ANCA]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Fecal urgency
* Fecal [[incontinence]]
* [[Arthralgia]]
* [[Arthritis]]
* [[Uveitis]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Mucosal]] [[immune responses]] to luminal factors in a genetically predisposed individual
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Colonoscopy]] with [[mucosal]] [[biopsy]] with [[mononuclear]] infiltrates:
** [[Collagenous colitis]] is characterized by a colonic subepithelial [[collagen]] band >10 micrometers in diameter
** [[Lymphocytic]] [[colitis]] is characterized by ≥20 intraepithelial [[lymphocytes]] (IEL) per 100 surface epithelial cells
|-
! align="center" style="background:#DCDCDC;" |[[Hyperthyroidism]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |Any age
| style="padding: 5px 5px; background: #F5F5F5;" align="center" |±
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Lump in the neck
* [[Proptosis]]
* [[Tremor]]
* Increased [[Deep tendon reflex|DTR]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Elevated [[T4]]
* Elevated [[T3]]
* Decreased [[TSH]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Lid lag
* [[Sweating]]
* [[Hyperpigmentation]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Graves' disease]]
* [[Hashimoto's thyroiditis]]
* [[Toxic adenoma]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[TSH]]
|-
! align="center" style="background:#DCDCDC;" |Grain allergy
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | Childhood
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | +
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Vomiting]]
* [[Abdominal distension]]
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="center" | -
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |  
* Elevated [[IgE]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* [[Atopic dermatitis]]
* [[Dysphagia]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Abnormal [[immune response]] to wheat [[antigens]]
| style="padding: 5px 5px; background: #F5F5F5;" align="left" |
* Measurement of grain-specific [[IgE|immunoglobulin E (IgE)]]
|}
</small></small>


==References==
==References==
{{Reflist|2}}
{{reflist|2}}
 
{{WH}}
{{WH}}
{{WS}}
{{WS}}
[[Category:Medicine]]
[[Category:Gastroenterology]]
[[Category:Infectious disease]]
[[Category:Up-To-Date]]

Latest revision as of 00:44, 30 July 2020

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]

Overview

Whipple's disease must be differentiated from other diseases that cause malabsorption, chronic diarrhea, multisystem involvement, such as celiac disease, cystic fibrosis, inflammatory bowel disease and systemic infections.

Differentiating Whipple's disease from other Diseases

Whipple's disease must be differentiated from other diseases that cause malabsorption, chronic diarrhea, abdominal pain and multisystem involvement.[1][2][3][4][5][6][7][8][9][10][11]

The table below summarizes the diseases that cause malabsorption, diarrhea and abdominal pain.

Abbreviations: WBC: White blood cells; Plt: Platelets, Hgb: Hemoglobin, IgE: Immunoglobulin E, IgA: Immunoglobulin A

Cause Peak age of onset History Physical exam Lab findings Additional findings Cause/Pathogenesis Gold standard diagnosis
Fever Abdominal pain Diarrhea Weight loss
Watery Fatty WBC Hgb Plt Other lab findings
Whipple's disease 40-60 ± + + + + ↓/↑
Celiac disease Childhood

Adult

- + +/- +/- + - -
  • IgA endomysial antibody
  • Anti-tissue transglutaminase antibody
  • Anti-gliadin antibody
  • IgA endomysial antibody
  • IgA tissue transglutaminase antibody
Cystic fibrosis Childhood

Adult

± + - + + - -
  • Positive DNA analysis for CFTR
  • Evaluated nasal transepithelial potential difference (NPD)
Crohns disease Young adults

(20th)

+ + + + +
  • Abnormal immune response to self antigens
Irritable bowel syndrome 30-50 - ± ± ± - - - -
  • Diagnosis of exclusion
VIPoma 30-50 - + + + + - - -
  • Primary secretory tumor
  • Elevated VIP levels
  • Followed by imaging
Zollinger-Ellison syndrome 20-50 - + + + + - -
  • Elevated basal or stimulated serum gastrin> 120 pg/mL
Lactose intolerance Any age - + + - - - - -
Eosinophilic gastroenteritis  30th - + + + + - -
Primary bile acid malabsorption Childhood Adult - + + + + - -
Abetalipoproteinemia Infancy

Adult

- + + + + - - -
Microscopic colitis 50-70 - + + - + - -
Hyperthyroidism Any age ± + + - + - - -
  • Elevated T4
  • Elevated T3
  • Decreased TSH
Grain allergy Childhood - + + - + - - -

References

  1. Hertzler SR, Savaiano DA (1996). "Colonic adaptation to daily lactose feeding in lactose maldigesters reduces lactose intolerance". Am J Clin Nutr. 64 (2): 232–6. PMID 8694025.
  2. Briet F, Pochart P, Marteau P, Flourie B, Arrigoni E, Rambaud JC (1997). "Improved clinical tolerance to chronic lactose ingestion in subjects with lactose intolerance: a placebo effect?". Gut. 41 (5): 632–5. PMC 1891556. PMID 9414969.
  3. BLACK-SCHAFFER B (1949). "The tinctoral demonstration of a glycoprotein in Whipple's disease". Proc Soc Exp Biol Med. 72 (1): 225–7. PMID 15391722.
  4. SCOBIE BA, MCGILL DB, PRIESTLEY JT, ROVELSTAD RA (1964). "EXCLUDED GASTRIC ANTRUM SIMULATING THE ZOLLINGER-ELLISON SYNDROME". Gastroenterology. 47: 184–7. PMID 14201408.
  5. Silverberg MS, Satsangi J, Ahmad T, Arnott ID, Bernstein CN, Brant SR; et al. (2005). "Toward an integrated clinical, molecular and serological classification of inflammatory bowel disease: report of a Working Party of the 2005 Montreal World Congress of Gastroenterology". Can J Gastroenterol. 19 Suppl A: 5A–36A. PMID 16151544.
  6. Sauter GH, Moussavian AC, Meyer G, Steitz HO, Parhofer KG, Jüngst D (2002). "Bowel habits and bile acid malabsorption in the months after cholecystectomy". Am J Gastroenterol. 97 (7): 1732–5. doi:10.1111/j.1572-0241.2002.05779.x. PMID 12135027.
  7. Maiuri L, Raia V, Potter J, Swallow D, Ho MW, Fiocca R; et al. (1991). "Mosaic pattern of lactase expression by villous enterocytes in human adult-type hypolactasia". Gastroenterology. 100 (2): 359–69. PMID 1702075.
  8. RUBIN CE, BRANDBORG LL, PHELPS PC, TAYLOR HC (1960). "Studies of celiac disease. I. The apparent identical and specific nature of the duodenal and proximal jejunal lesion in celiac disease and idiopathic sprue". Gastroenterology. 38: 28–49. PMID 14439871.
  9. Street, Sara; Donoghue, Helen D; Neild, GH (1999). "Tropheryma whippelii DNA in saliva of healthy people". The Lancet. 354 (9185): 1178–1179. doi:10.1016/S0140-6736(99)03065-2. ISSN 0140-6736.
  10. Marth T, Strober W (1996). "Whipple's disease". Semin. Gastrointest. Dis. 7 (1): 41–8. PMID 8903578.
  11. Schneider, Thomas; Moos, Verena; Loddenkemper, Christoph; Marth, Thomas; Fenollar, Florence; Raoult, Didier (2008). "Whipple's disease: new aspects of pathogenesis and treatment". The Lancet Infectious Diseases. 8 (3): 179–190. doi:10.1016/S1473-3099(08)70042-2. ISSN 1473-3099.

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