Monitoring

During antibiotic treatment, remission of symptoms and of abnormal diagnostic findings should be followed and documented at regular intervals. The initial response of patients is usually prompt. Diarrhea often resolves within several days, arthralgias within a few weeks, and significant weight gain occurs within a few months. When this clinical improvement is occuring, noninvasive laboratory examinations may be sufficient during the first 6 months.

A potential pitfall of monitoring patients is that intestinal biopsies do not equate with extraintestinal WD. It requires multiple invasive follow-up examinations in parallel. In brief, monitoring repeats staging examinations (see Table 53-1).

After 6 months, CSF analysis should be repeated, either to confirm eradication of previously detected silent CNS infection with T. whippelii or to ascertain its absence. Although the bactericidal effects of antibiotics will arise much earlier, there is a lag of clearance of bacterial DNA from the CSF. Up to several weeks, DNA fragments may still be detected by PCR. During this lag phase, interpretation of positive PCR results is difficult and may result in the erroneous impression of treatment failure. Similiarly, interpretation of cytologic findings is difficult during treatment and should be jointly performed with PCR results. Endoscopy with biopsies should be repeated. Although grossly visis-ble mucosal lesions may or may not be absent, histology of biopsies should document partial remission of mucosal lesions, which indicates the common response to treatment (Von Herbay et al, 1996). At this time intestinal mucosal remission is always incomplete, but subtypes of PAS posi tive macrophages have significantly changed. Abdominal sonography should expect to indicate partial, but still incomplete, remission of abdominal lymphadenopathy.

After 12 months, before stopping treatment, CSF analysis should be repeated to ascertain eradication of previously detected silent CNS infection with T. whippelii. This is of critical importance for the patient's outcome. At this time, a DNA-negative result from PCR analysis is more important than the cytologic detection of PAS positive cells, because subtyping of PAS-positive macrophages in the CSF is not established. Endoscopy will usually be normal. When multiple biopsies are obtained, histology will document intestinal remission, although a variable number of PAS positive macrophages may still be present. Subtyping of PAS macrophages can reliably differentiate between remission and persisting infection. This can be confirmed by subsequent PCR analysis. Abdominal sonog-raphy may document complete remission of previous lesions, but, in some patients, remission is still incomplete and fibrosis may remain.

After remission is established, the physician and patients should be alert to the possible recurrance of symptoms. If this happens, it does not necessarily indicate a relapse of WD. A tissue-based diagnosis of relapse should be attempted.

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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