00:01
Welcome.
00:02
With this talk,
we're going to cover Whipple's Disease.
00:05
This is not exactly a
public health menace,
and you may never see a
case in your entire career.
00:11
But when you do,
you won't forget it.
00:15
So Whipple's disease is a relatively
rare malabsorption syndrome
that does have systemic
manifestations including
things involving the
central nervous system,
a heart and the
musculoskeletal system.
00:28
And it's caused
specifically by one bacteria,
the bacterium
Tropheryma whipplei.
00:33
And you're probably
thinking to yourself,
"Why is there a
bearskin rug here?"
We'll see why
that is in a moment.
00:41
But I'll tell you that the
characteristic lesions in the GI tract
have been likened to
the fur on a bearskin rug.
00:50
At least you won't forget it.
00:53
The epidemiology.
00:54
There is a
worldwide distribution,
the bacterium
Tropheryma whipplei
is present throughout the world.
01:01
It is more commonly
affecting older males.
01:06
And it is specifically associated
with the HLA-B27 haplotype.
01:11
In fact, it's not because it's
more of an autoimmune disease,
but because you
don't specifically elicit
a strong immune
response to the bacterium.
01:20
And that's why
you get the disease.
01:22
The mean age of
symptom onset is in
the latter half of life
over the age of 50.
01:28
There are rare cases that will
happen in the pediatric population.
01:31
The pathophysiology
of this disease.
01:33
So again, the causal agent
is Tropheryma whipplei,
I probably ought
to remember that,
it's one of the bugs that
you should remember.
01:41
And it's a host.
01:42
It's not an immunodeficiency,
but it's a hole in the
immune repertoire.
01:48
And you will have
diminished helper type 1,
and increased helper type 2
responses to this particular bacteria.
01:56
For the vast majority
of the population,
you have a very robust Th1
or helper type 1 response
and that typically will
eliminate the microorganism.
02:06
If you don't have that
good robust response,
then you will have reduced
macrophage activation.
02:11
And what happens is
macrophages will ingest,
they will phagocytose
the organism,
but they don't,
they don't kill it.
02:19
And so the organism
very happily proliferates
within the macrophage
that has eaten them.
02:24
And with time,
you will get an overwhelming infection.
02:30
When this happens,
you get lots and lots and lots
of very overstuffed macrophages
within the lamina propria.
02:37
And that leads to
increased transit distance
and therefore poor absorption.
02:42
And I'll show you what that
looks like on this slide here.
02:46
This is a Periodic acid-Schiff
or a PAS stained slide
that highlights
glycoproteins the very
dark intense pink
material is glycoprotein.
02:58
And in this particular
case that means
bacterium the
Tropheryma whipplei.
03:03
The taller columnar
blue looking cells
all the way around
are the epithelium.
03:08
So the epithelium is intact,
we have normal villi length,
we have normal crypt depth.
03:15
But what we have is
expanded lamina propria.
03:18
So the epithelium lining the
lamina propria is absorbing just fine.
03:25
But the organisms are by
expanding the lamina propria
are increasing
the transit distance,
the diffusion distance for
things that get absorbed
and we are overall
getting less material
into the bloodstream
and into lymphatics.
03:41
And along the way,
the bacteria are also
happily metabolizing everything.
03:46
What does this look
like on endoscopy?
So here's our bearskin rug.
03:49
Underneath the green patches,
you see areas where
there's very distended villi.
03:55
It's someone maybe with
a lot of caffeine on board.
03:59
I thought, I think that looks
like a bearskin rug, whatever.
04:03
But that's a very
characteristic appearance.
04:06
It's not just in the GI tract,
any organ, which is every organ
that has macrophages
can potentially have
manifestations related
to the accumulation
of the bacterium.
04:17
So the intestinal epithelium
is a significant target.
04:22
And that's why it's represented
here in GI pathophysiology.
04:25
But it can happen in capillary
and lymphatic endothelium
throughout the body,
and then in the liver,
the brain, kidneys,
everywhere there's a
macrophage and that's everywhere.
04:35
You can get an accumulation,
you can get secondary
manifestations.
04:39
The clinical presentation.
04:41
So the GI manifestations are
all about the malabsorption.
04:44
You're gonna have diarrhea
because you're going to have
osmotic material that isn't
being appropriately absorbed,
and the bacteria, well,
that osmotic force is going to
pull fluid into the GI tract
and you'll have diarrhea.
04:58
You will also not
absorb fats appropriately.
05:00
So you'll have foul
smelling floating stool.
05:05
There will be weight loss
because there's malnutrition.
05:07
There'll be abdominal
pain because the bacteria
are happily fermenting
all of those metabolites
that aren't being absorbed.
05:14
And they will cause
gas formation which will
distend the bowel which
causes abdominal pain.
05:21
There is also an
inflammatory response.
05:24
It's not just the macrophages
that are present within
the lamina propria.
05:27
But we may also
see macrophages
that are in the draining
nodes also be expanded.
05:33
So there'll be lymphadenopathy,
kind of throughout the GI tract.
05:37
Peripheral edema happens
as a result of malnutrition.
05:40
You're not making the
appropriate amounts of albumin
so your oncotic
pressure is diminished.
05:46
Outside of the GI tract,
you can have
cardiac manifestations.
05:49
So you can have endocarditis
involving the valves,
myocarditis involving
the myocardium,
pericarditis involving the
lining around the heart.
05:57
And it can eventually progress
to congestive heart failure.
06:02
In the CNS in the brain,
you can have seizures, delirium,
you can sleep all the time,
you can have abnormal walking,
you may have abnormal
muscle jerking or clonus.
06:12
And arthralgias with involvement
of the vasculature
within the joints.
06:19
How do we make the diagnosis?
Well, sometimes this
is one of those entities
that patients,
the poor patient who has this,
they go and see
multiple different doctors,
before someone
thinks to himself,
"Could this be
Whipple's disease?"
Once you get that notion that
all these funny manifestations
and malabsorption,
diarrhea, etc.
06:42
Once you think, "Gosh,
maybe this is Whipple's?"
This is a very rare patient,
then you will do endoscopy.
06:48
And endoscopy on
small bowel biopsy,
makes your diagnosis.
06:52
So hurray, again,
for the pathologist.
06:57
Management.
06:59
Basically, it's a bug.
07:00
It is a bacterium.
07:01
So it's going to be responsive
to antibiotics which is fortunate.
07:04
If you make the diagnosis,
you can cure your patient.
07:07
I don't think you need to
memorize which antibiotics work.
07:10
Just think, "Oh, it's bacteria,
we ought to be able to treat this."
It is important to
realize that if there is
central nervous
system involvement,
you have a blood
brain barrier that
normally blocks
a lot of antibiotics.
07:22
So you need to select those that
will penetrate that
particular barrier.
07:26
Snd with that,
a relatively rare entity,
kind of an
interesting discussion
and hopefully you'll never
forget the bearskin rug.