Ultima epistola?

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11 Anni 9 Mesi fa #199548 da jerryleelewis
Risposta da jerryleelewis al topic Re:Ultima epistola?
Se non vado errando da altre discussioni e da quello che ho sentito a lezione la celiachia è associata al 99% con due aplotipi (ora non me li ricordo mi pare dq qualcosa)


Quindi prima di inserire un tubo in gola al paziente aspetterei di vedere il risultato di questo esame che avevo già richiesto all'inizio del caso proprio per il motivo che ho appena detto

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11 Anni 9 Mesi fa #199549 da ILBecchino
Risposta da ILBecchino al topic Re:Ultima epistola?

Se non vado errando da altre discussioni e da quello che ho sentito a lezione la celiachia è associata al 99% con due aplotipi (ora non me li ricordo mi pare dq qualcosa)


Quindi prima di inserire un tubo in gola al paziente aspetterei di vedere il risultato di questo esame che avevo già richiesto all'inizio del caso proprio per il motivo che ho appena detto


gli anticorpi sono negativi.

Prima di scavare una fossa, prepara bene il terreno.
Prima di seppelire un Cadavere accertati della sua morte. Prima di chiudere il cancello del cimitero controlla che siano usciti tutti....... i visitatori non i defunti

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11 Anni 9 Mesi fa #199550 da HelterSkelter
Risposta da HelterSkelter al topic Re:Ultima epistola?
ed il risultato del test per HIV?

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11 Anni 9 Mesi fa #199551 da ILBecchino
Risposta da ILBecchino al topic Re:Ultima epistola?

ed il risultato del test per HIV?


neg

Prima di scavare una fossa, prepara bene il terreno.
Prima di seppelire un Cadavere accertati della sua morte. Prima di chiudere il cancello del cimitero controlla che siano usciti tutti....... i visitatori non i defunti

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11 Anni 9 Mesi fa #199553 da HelterSkelter
Risposta da HelterSkelter al topic Re:Ultima epistola?
whipple
Il quadro è quello di un malassorbimento severo. L’esame istologico rivela presenza nei linfonodi (ingranditi, specie mesenterici), nel tratto intestinale e in altri tessuti, di macrofagi PAS +
Tropheryma whipplei

giusto?

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11 Anni 9 Mesi fa #199554 da ILBecchino
Risposta da ILBecchino al topic Re:Ultima epistola?

whipple
Il quadro è quello di un malassorbimento severo. L’esame istologico rivela presenza nei linfonodi (ingranditi, specie mesenterici), nel tratto intestinale e in altri tessuti, di macrofagi PAS +
Tropheryma whipplei

giusto?


EGDS
>M. di whipple
>

quale trattamento?

Prima di scavare una fossa, prepara bene il terreno.
Prima di seppelire un Cadavere accertati della sua morte. Prima di chiudere il cancello del cimitero controlla che siano usciti tutti....... i visitatori non i defunti

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11 Anni 9 Mesi fa #199555 da HelterSkelter
Risposta da HelterSkelter al topic Re:Ultima epistola?
penicillina e streptomicina in associazione, oppure il trimetoprim-sulfametossazolo, l’eritromicina ed agenti come la teraciclina. Talora si impiega anche il cloramfenicolo, che supera la barriera ematoencefalica, con l’intento di impedire una sequela neurologica


i dosaggi?

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11 Anni 9 Mesi fa #199556 da ILBecchino
Risposta da ILBecchino al topic Re:Ultima epistola?

penicillina e streptomicina in associazione, oppure il trimetoprim-sulfametossazolo, l’eritromicina ed agenti come la teraciclina. Talora si impiega anche il cloramfenicolo, che supera la barriera ematoencefalica, con l’intento di impedire una sequela neurologica


i dosaggi?


REATMENT — Whipple's disease was uniformly fatal prior to the availability of antibiotics. The first successful use of antibiotics (chloramphenicol) was reported in 1952 [3].

Treatment studies — Tetracycline became the mainstay of therapy for many years. However, a comprehensive review subsequently revealed a disturbingly high relapse rate of 35 percent among patients treated primarily with tetracycline [63]. Even more alarming was a high rate of CNS relapse, and a dismal response (five percent) to retreatment of CNS relapse with tetracycline.

These observations led the authors to recommend an initial course of parenteral ceftriaxone followed by maintenance therapy with oral trimethoprim-sulfamethoxazole (TMP-SMX, one double-strength tablet twice daily) for one year. The rationale for prolonged therapy is to permit complete eradication of the organism, thereby reducing the likelihood of relapse.

The efficacy of both TMP-SMX and the combination of penicillin and streptomycin was illustrated in a retrospective study of 52 patients treated in France from 1967 to 1994 [43]. No relapse was observed in patients treated with trimethoprim-sulfamethoxazole, alone or following a combination of penicillin and streptomycin, or after the combination of penicillin and streptomycin, whatever the oral follow-up treatment prescribed.

Treatment with trimethoprim-sulfamethoxazole was significantly superior to treatment with tetracycline in inducing clinical remission of Whipple's disease in a nonrandomized treatment trial in 30 patients [64]. TMP-SMX induced remission in 12 of 13 treatment cycles (92 percent) compared to only 13 of 22 treatment cycles (59 percent) with tetracycline. TMP-SMX was also more effective for CNS disease although it was not curative in all cases.

No prospective studies are available on the choice or duration of antibiotic treatment. At present, therapy is based on observations in small patient groups and personal experience. The first prospective antibiotic trial in Whipple's disease, directed by the European project on Whipple's disease, is investigating the use of ceftriaxone compared to meropenem intravenously for two weeks followed by oral trimethoprim-sulfamethoxazole for one year to prevent central nervous system manifestations (www.whipplesdisease.info) [65].

Outcomes — There have been several reported cases of Jarisch-Herxheimer reactions one to two hours after initial therapy of Whipple's disease with intravenous antibiotics, especially penicillin. The reaction consists of fever of 39º to 40ºC, chills, headache, hypotension, and severe abdominal pain or pleuritic chest pain [26].

The response to treatment can be monitored by following the patient's hematocrit, weight, and symptom resolution. Surveillance endoscopy and small bowel biopsy are not necessary and may be misleading since PAS staining material may persist long after clinical resolution of the disease; this probably represents dead organisms rather than a propensity to relapse. It has been suggested, however, that follow-up PCR testing may have greater predictive value. In one series of small bowel biopsies obtained after successful initial therapy, relapse occurred in none of five patients who were PCR-negative compared to 12 of 17 who were PCR-positive [58].

Most adequately treated patients do well. Clinical improvement is often dramatic, occurring within 7 to 21 days [43]. The two major problems are CNS disease and relapsing infection. A case report suggested that the addition of recombinant human interferon gamma might be beneficial in such patients [34].

Central nervous system disease — CNS involvement continues to be very difficult to manage. The incidence of CNS disease increases over time in an infected patient [31]. In patients with CNS symptoms, computed tomography (CT) or magnetic resonance imaging (MRI) of the brain may reveal nonspecific focal lesions that generally resolve with therapy [43].

The observation that PCR of the cerebrospinal fluid is often positive in patients without neurologic symptoms suggests that late CNS symptoms probably reflect progression of initially occult infection [61]. Similarly, CNS relapses are thought to reflect primary infection that was not eradicated during initial treatment [43]. Supporting information for these hypotheses comes from a report of the successful cultivation of T. whipplei from the CSF of two patients with intestinal involvement but no neurologic symptoms or signs; one of these patients had completed 12 months of therapy with remission of intestinal symptoms [15].

Although TMP-SMX has been the treatment of choice [43], it is not curative in all cases [64] and relapse can occur even while the patient is taking the drug [66,67]. This has led to the suggestion that initial therapy for CNS disease should consist of an intravenous agent, which attains high CSF levels and is active against T. whipplei, such as ceftriaxone (2 g IV once daily) or penicillin G (4 MU IV every 4 hours) for four weeks (table 1) [67]. This should be followed by one year or more of maintenance therapy with oral TMP-SMX (one double strength tablet twice daily) [66,67].

Relapse — Relapses have been reported in as many as 17 to 35 percent of patients [43,68] and, as noted above, in 12 of 17 patients who remained PCR-positive on small bowel biopsy obtained after initial therapy [58]. It is assumed that relapses reflect incomplete eradication of the organism with initial therapy.

Relapses should be treated with initial ceftriaxone (2 g IV twice daily for four weeks) followed by one year or more of oral doxycycline (100 mg twice daily) or TMP-SMX (one double strength tablet twice daily) (table 1). If a CNS relapse occurs after a lower dose of ceftriaxone, a higher dose (2 g IV twice daily) may be more effective [67]. Occasional patients have required chronic intravenous ceftriaxone therapy for control of CNS symptoms [47].

Immune reconstitution — In the first few weeks following initiation of antibiotic treatment, some patients may develop symptoms of relapse or disease progression manifested by high fever [69]. Those at risk for developing an immune reconstitution inflammatory syndrome (IRIS) after starting therapy for Whipple's disease include:

Patients who have been treated with immunosuppressive therapy for presumed rheumatic disease for an extended period prior to the diagnosis of Whipple's disease, whose immunosuppressive therapy is discontinued at the start of antibiotic treatment.
Patients with CNS involvement of Whipple's disease
In these circumstances, corticosteroid therapy may be beneficial.

Recommendations — Treatment regimens in more severely ill patients consist of an initial phase of intravenously administered antibiotics known to penetrate the blood-brain barrier, followed by 12 months of oral maintenance treatment. We suggest initial therapy with one of the following regimens (table 1):

Parenteral ceftriaxone (2 g IV once daily) or penicillin (2 MU IV every 4 hours) for two weeks followed by TMP-SMX (one double-strength tablet twice a day) for one year [70].
For sulfa allergic patients, an alternative maintenance therapy is doxycycline (100 mg PO twice daily) in combination with hydroxychloroquine (200 mg PO thrice daily) [19].

For ceftriaxone and penicillin allergic patients, TMP-SMX (one double-strength tablet three times daily) plus streptomycin (1 g IM daily) for two to four weeks followed by TMP-SMX (one double-strength tablet twice a day) for one year.
The recommendations vary with different sites of infection. For patients with endocarditis, we suggest

Penicillin G (2 MU IV every 4 hours) or ceftriaxone (2 g IV once daily) for four weeks followed by TMP-SMX (one double-strength tablet twice a day) for one year. Surgical resection of the infected valve is usually also needed.
For patients with CNS disease:

Ceftriaxone (2 g IV once daily) or penicillin G (4 MU IV every 4 hours) for four weeks followed by TMP-SMX (one double-strength tablet twice a day) for one year
For patients who relapse:

Penicillin G (4 MU IV every 4 hours) or ceftriaxone (2 g IV twice daily) for four weeks followed by oral doxycycline (100 mg twice daily) in combination with hydroxychloroquine (200 mg PO thrice daily) [18] OR TMP-SMX (one double-strength tablet twice a day) for one year

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11 Anni 9 Mesi fa #199658 da HelterSkelter
Risposta da HelterSkelter al topic Re:Ultima epistola?
toc toc....magister
nuovo caso?

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11 Anni 9 Mesi fa #199659 da DottorD
Risposta da DottorD al topic Re:Ultima epistola?
Concordo con la collega XD

"Even a stopped clock is right twice a day" (Marie von Ebner-Eschenbach)
Sir 26, 14

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