Whipple's disease physical examination: Difference between revisions

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{{Whipple's disease}}
{{Whipple's disease}}
{{CMG}}; {{AE}} {{BHA}}; {{SSH}}
{{CMG}}; {{AE}} {{SSH}}; {{BHA}}


==Overview==
==Overview==
Patients with Whipple's disease usually appear weak. Physical examination of patients with Whipple's disease is usually remarkable for [[weight loss]] and joint pain. Further physical findings depend on the systems involved in the disease.
Patients with Whipple's disease usually appear weak. Physical examination of patients with Whipple's disease is usually remarkable for [[weight loss]] and signs of [[vitamin deficiency]]. Further physical findings depend on the systems involved in the disease. Abnormal [[eye movements]] including oculomasticatory myorhythmia, or oculofacial-skeletal myorhythmia are pathognomonic for the Whipple's disease.
 
==Physical Examination==
==Physical Examination==
*Physical examination of patients with Whipple's disease is usually remarkable for generalized weakness secondary to [[weight loss]].
*Physical examination of patients with Whipple's disease is usually remarkable for generalized weakness secondary to [[weight loss]].<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><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="pmid18291339">{{cite journal |vauthors=Schneider T, Moos V, Loddenkemper C, Marth T, Fenollar F, Raoult D |title=Whipple's disease: new aspects of pathogenesis and treatment |journal=Lancet Infect Dis |volume=8 |issue=3 |pages=179–90 |year=2008 |pmid=18291339 |doi=10.1016/S1473-3099(08)70042-2 |url=}}</ref><ref name="MarthMoos2016">{{cite journal|last1=Marth|first1=Thomas|last2=Moos|first2=Verena|last3=Müller|first3=Christian|last4=Biagi|first4=Federico|last5=Schneider|first5=Thomas|title=Tropheryma whipplei infection and Whipple's disease|journal=The Lancet Infectious Diseases|volume=16|issue=3|year=2016|pages=e13–e22|issn=14733099|doi=10.1016/S1473-3099(15)00537-X}}</ref><ref name="Schoniger-HekelePetermann2007">{{cite journal|last1=Schoniger-Hekele|first1=M.|last2=Petermann|first2=D.|last3=Weber|first3=B.|last4=Muller|first4=C.|title=Tropheryma whipplei in the Environment: Survey of Sewage Plant Influxes and Sewage Plant Workers|journal=Applied and Environmental Microbiology|volume=73|issue=6|year=2007|pages=2033–2035|issn=0099-2240|doi=10.1128/AEM.02335-06}}</ref><ref name="BurešKopáčová2013">{{cite journal|last1=Bureš|first1=Jan|last2=Kopáčová|first2=Marcela|last3=Douda|first3=Tomáš|last4=Bártová|first4=Jolana|last5=Tomš|first5=Jan|last6=Rejchrt|first6=Stanislav|last7=Tachecí|first7=Ilja|title=Whipple’s Disease: Our Own Experience and Review of the Literature|journal=Gastroenterology Research and Practice|volume=2013|year=2013|pages=1–10|issn=1687-6121|doi=10.1155/2013/478349}}</ref><ref name="DutlyAltwegg2001">{{cite journal|last1=Dutly|first1=F.|last2=Altwegg|first2=M.|title=Whipple's Disease and "Tropheryma whippelii"|journal=Clinical Microbiology Reviews|volume=14|issue=3|year=2001|pages=561–583|issn=0893-8512|doi=10.1128/CMR.14.3.561-583.2001}}</ref><ref name="DolmansBoel2017">{{cite journal|last1=Dolmans|first1=Ruben A. V.|last2=Boel|first2=C. H. Edwin|last3=Lacle|first3=Miangela M.|last4=Kusters|first4=Johannes G.|title=Clinical Manifestations, Treatment, and Diagnosis of Tropheryma whipplei Infections|journal=Clinical Microbiology Reviews|volume=30|issue=2|year=2017|pages=529–555|issn=0893-8512|doi=10.1128/CMR.00033-16}}</ref><ref name="pmid18159328">{{cite journal |vauthors=Conly JM, Johnston BL |title=Rare but not so rare: The evolving spectrum of Whipple's disease |journal=Can J Infect Dis |volume=12 |issue=3 |pages=133–5 |year=2001 |pmid=18159328 |pmc=2094813 |doi= |url=}}</ref><ref name="FenollarLagier2014">{{cite journal|last1=Fenollar|first1=Florence|last2=Lagier|first2=Jean-Christophe|last3=Raoult|first3=Didier|title=Tropheryma whipplei and Whipple's disease|journal=Journal of Infection|volume=69|issue=2|year=2014|pages=103–112|issn=01634453|doi=10.1016/j.jinf.2014.05.008}}</ref><ref name="KeitaBrouqui2013">{{cite journal|last1=Keita|first1=Alpha Kabinet|last2=Brouqui|first2=Philippe|last3=Badiaga|first3=Sékéné|last4=Benkouiten|first4=Samir|last5=Ratmanov|first5=Pavel|last6=Raoult|first6=Didier|last7=Fenollar|first7=Florence|title=Tropheryma whipplei prevalence strongly suggests human transmission in homeless shelters|journal=International Journal of Infectious Diseases|volume=17|issue=1|year=2013|pages=e67–e68|issn=12019712|doi=10.1016/j.ijid.2012.05.1033}}</ref><ref name="SchwartzmanSchwartzman2013">{{cite journal|last1=Schwartzman|first1=Sergio|last2=Schwartzman|first2=Monica|title=Whipple's Disease|journal=Rheumatic Disease Clinics of North America|volume=39|issue=2|year=2013|pages=313–321|issn=0889857X|doi=10.1016/j.rdc.2013.03.005}}</ref>
*The presence of [[eye]] findings namely oculomasticatory, or oculofacialskeletal, myorhythmia are pathognomic.  
 
*The presence of [[eye]] findings namely oculomasticatory myorhythmia, or oculofacial-skeletal myorhythmia are pathognomic.  


===Appearance of the Patient===
===Appearance of the Patient===
*Weak and tired some times severe enough to cause cachexia secondary to malabsorption and weight loss.
* Patients with Whipple's disease usually appear tired and weak.
* [[Cachexia]]


===Vital Signs===
===Vital Signs===
 
*Low-grade intermittent [[fever]]
*Low-grade intermittent fever  
*[[Tachycardia]]
*might be associated with night sweats <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>
* [[Hypotension]]
 
* [[Tachypnea]]
===Skin===
===Skin===
*Hyperpigmentation : more frequent in sun exposed areas. <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>
*[[Pallor]]
*Some patients may develop skin nodules  
*[[Hyperpigmentation]] in sun exposed areas
 
*[[Cyanosis]]
<gallery widths="150px">
*[[Skin nodules]]
 
UploadedImage-01.jpg | Description {{dermref}}
UploadedImage-02.jpg | Description {{dermref}}
 
</gallery>


===HEENT===
===HEENT===
* [[Nystagmus]]   
* [[Nystagmus]]   
* Extra-ocular movements abnormal.
* [[Papilledema]]
* Oculomasticatory, or oculofacialskeletal, myorhythmia are pathognomic. <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>
* Abnormal [[eye movements]]
* Oculomasticatory myorhythmia (pathognomonic)
* Oculofacial-skeletal myorhythmia (pathognomonic)


===Neck===
===Neck===
*[[Lymphadenopathy]] is common.
*[[Lymphadenopathy]] (common in peripheral [[lymph nodes]])
*Peripheral lymph nodes may be palpable. <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>


===Lungs===
===Lungs===
In patients who develop pleural effusion  
*In patients who develop [[pleural effusion]], may have:
*lungs are hyporesonant
**Asymmetrical [[chest expansion]]
*asymmetrical chest expansion.
**[[Lungs]] are hyperresonant
*Distant breath sounds
**Distant [[breath sounds]]
*Reduced [[tactile fremitus]]
**Reduced [[tactile fremitus]]


===Heart===
===Heart===
*[[systolic murmur]] with cardiac valve involvement. <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>
*[[Systolic murmur]]
*[[Pericardial friction rub]]
*[[Pericardial]] knock
*Wide split of [[S2]]
*Elevation of [[jugular venous pulse]]


===Abdomen===
===Abdomen===
*[[Abdominal distention|Abdominal bloating]] and cramps . <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>
*[[Abdominal distention]]
*[[hepatosplenomegaly]]  
*[[Hepatosplenomegaly]]
*[[Jaundice]]
*[[Edema]]
*[[Ascites]]  


===Neuromuscular===
===Neuromuscular===
*May be asymptomatic  
*May be [[asymptomatic]]
*May have cognitive changes <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>
*Altered level of [[consciousness]]
*Altered level of consciousness <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>
*[[Seizure]]
*Seizure<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>
*[[Myoclonus]]
* Myoclonus  
*[[Ataxia]]
* Ataxia <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>
*Supranuclear ophthalmoplegia
*[[Dementia]]
*[[Hemiparesis]]


===Extremities===
===Extremities===
*Arthralgia of peripheral joints : frequently seen 
*[[Arthritis]]
*Joint deformity with Whipple's disease is extremely rare  
*[[Joint]] deformity (extremely rare)


==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
 
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Latest revision as of 00:44, 30 July 2020

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Sadaf Sharfaei M.D.[2]; Bhagyashree Deshmankar M.B.B.S.[3]

Overview

Patients with Whipple's disease usually appear weak. Physical examination of patients with Whipple's disease is usually remarkable for weight loss and signs of vitamin deficiency. Further physical findings depend on the systems involved in the disease. Abnormal eye movements including oculomasticatory myorhythmia, or oculofacial-skeletal myorhythmia are pathognomonic for the Whipple's disease.

Physical Examination

  • The presence of eye findings namely oculomasticatory myorhythmia, or oculofacial-skeletal myorhythmia are pathognomic.

Appearance of the Patient

  • Patients with Whipple's disease usually appear tired and weak.
  • Cachexia

Vital Signs

Skin

HEENT

Neck

Lungs

Heart

Abdomen

Neuromuscular

Extremities

References

  1. Dutly F, Altwegg M (2001). "Whipple's disease and "Tropheryma whippelii"". Clin Microbiol Rev. 14 (3): 561–83. doi:10.1128/CMR.14.3.561-583.2001. PMC 88990. PMID 11432814.
  2. Fenollar F, Puéchal X, Raoult D (2007). "Whipple's disease". N Engl J Med. 356 (1): 55–66. doi:10.1056/NEJMra062477. PMID 17202456.
  3. Schneider T, Moos V, Loddenkemper C, Marth T, Fenollar F, Raoult D (2008). "Whipple's disease: new aspects of pathogenesis and treatment". Lancet Infect Dis. 8 (3): 179–90. doi:10.1016/S1473-3099(08)70042-2. PMID 18291339.
  4. Marth, Thomas; Moos, Verena; Müller, Christian; Biagi, Federico; Schneider, Thomas (2016). "Tropheryma whipplei infection and Whipple's disease". The Lancet Infectious Diseases. 16 (3): e13–e22. doi:10.1016/S1473-3099(15)00537-X. ISSN 1473-3099.
  5. Schoniger-Hekele, M.; Petermann, D.; Weber, B.; Muller, C. (2007). "Tropheryma whipplei in the Environment: Survey of Sewage Plant Influxes and Sewage Plant Workers". Applied and Environmental Microbiology. 73 (6): 2033–2035. doi:10.1128/AEM.02335-06. ISSN 0099-2240.
  6. Bureš, Jan; Kopáčová, Marcela; Douda, Tomáš; Bártová, Jolana; Tomš, Jan; Rejchrt, Stanislav; Tachecí, Ilja (2013). "Whipple's Disease: Our Own Experience and Review of the Literature". Gastroenterology Research and Practice. 2013: 1–10. doi:10.1155/2013/478349. ISSN 1687-6121.
  7. Dutly, F.; Altwegg, M. (2001). "Whipple's Disease and "Tropheryma whippelii"". Clinical Microbiology Reviews. 14 (3): 561–583. doi:10.1128/CMR.14.3.561-583.2001. ISSN 0893-8512.
  8. Dolmans, Ruben A. V.; Boel, C. H. Edwin; Lacle, Miangela M.; Kusters, Johannes G. (2017). "Clinical Manifestations, Treatment, and Diagnosis of Tropheryma whipplei Infections". Clinical Microbiology Reviews. 30 (2): 529–555. doi:10.1128/CMR.00033-16. ISSN 0893-8512.
  9. Conly JM, Johnston BL (2001). "Rare but not so rare: The evolving spectrum of Whipple's disease". Can J Infect Dis. 12 (3): 133–5. PMC 2094813. PMID 18159328.
  10. Fenollar, Florence; Lagier, Jean-Christophe; Raoult, Didier (2014). "Tropheryma whipplei and Whipple's disease". Journal of Infection. 69 (2): 103–112. doi:10.1016/j.jinf.2014.05.008. ISSN 0163-4453.
  11. Keita, Alpha Kabinet; Brouqui, Philippe; Badiaga, Sékéné; Benkouiten, Samir; Ratmanov, Pavel; Raoult, Didier; Fenollar, Florence (2013). "Tropheryma whipplei prevalence strongly suggests human transmission in homeless shelters". International Journal of Infectious Diseases. 17 (1): e67–e68. doi:10.1016/j.ijid.2012.05.1033. ISSN 1201-9712.
  12. Schwartzman, Sergio; Schwartzman, Monica (2013). "Whipple's Disease". Rheumatic Disease Clinics of North America. 39 (2): 313–321. doi:10.1016/j.rdc.2013.03.005. ISSN 0889-857X.

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