A 67‐Year‐Old Man with Diarrhea and Weight Loss

1Duke University Medical Center, Durham, NC

Meeting: Hospital Medicine 2011, May 10-13, Dallas, Texas.

Abstract number: 365

Case Presentation:

A 67‐year‐old man presented to his doctor with 3 months of poor appetite, weight loss, and persistent nonbloody diarrhea. He complained of fatigue and intermittent chest pain with a chronic nonproductive cough. He denied fevers, chills, or night sweats. He denied any allergies. He took no medications. He had a remote smoking history (8 pack‐years) and quit 30 years ago. He denied alcohol or illicit substance abuse. He lived on a farm with his wife along with cattle, goats, and several dogs and cats as pets. Travel and family history were unremarkable. Physical exam was notable for cachectic body with proximal muscle atrophy. An exhaustive outpatient workup including cardiac stress test, colonoscopy, and stool studies revealed no abnormality. He experienced severe depression and marked impairment of activities of daily living. He was admitted to the hospital 9 months after onset of symptoms because of failure to thrive and altered mental status. A CT scan of his abdomen revealed retroperitoneal and mesenteric lymphadenopathy without evidence of malignancy. He ultimately underwent upper endoscopy, which showed only linear reflux‐induced esophagitis. A duodenal mucosal biopsy revealed small round cells of the lamina propria stained densely and coarsely for PAS. Rod‐shaped bacilli were seen on electron microscopy. Both findings are diagnostic of Whip‐ple's disease.

Discussion:

Late‐onset Whipple's disease is extremely rare. Between 1907 and 1987 there were 696 reported cases; the annual incidence since 1980 has been approximately 30 cases per year internationally. It has a predilection for men of European ancestry, farmers, and people with exposure to soil and animals. It is a systemic disease that may present only with cardiopulmonary symptoms or neurologic symptoms in more advanced cases, although it usually presents with weight loss and diarrhea. In our patient, the presentation was atypical, with isolated retroperitoneal lymphadenopathy on CT. If a PAS stain is not specifically investigated, the disease can go unrecognized and prove fatal.

Conclusions:

The purpose of this report is to present an uncommon presentation of Whipple's disease and to review its various clinical manifestations as a rare cause of weight loss and diarrhea. Diagnosis and management of the disease will be explored from the hospitalist's point of view. Earlier hospital admission with a more efficient evaluation and workup by a hospitalist may have proven medically and fiscally beneficial for our patient, given the severity and chronicity of his symptoms (Dobbins WO III. Whipple's disease. Springfield, IL: Charles C Thomas; 1987. Dobbins WO III. The diagnosis of Whipple's disease. N Engl JMed. 1995; 332:390 Fenollar F, Puechal X, Raoult D. Whipple's disease. N EnglJMed. 2007;356:55. Michota F. Trends in hospital medicine: hospitalist advantages revealed. Clev ClinJMed. 2001;68:7).

Disclosures:

V. Patel ‐ Duke University, resident; B. Balmadrid ‐ Duke University, fellow.

To cite this abstract:

Patel V, Balmadrid B. A 67‐Year‐Old Man with Diarrhea and Weight Loss. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 365. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/a-67yearold-man-with-diarrhea-and-weight-loss/. Accessed November 15, 2019.

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