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P OSTER
A BSTRACTS
C8
Blisters from my surgery: clinical history helped by internet pictures.
A. I. Garrido, A. Chakka, T. Iloabuchi, F. Perez, A. Nazir.
Geriatrics/Internal Medicine, Indiana University-Geriatrics fellowship,
Indianapolis, IN.
84 y/o WF admitted to a sub-acute rehab. to recover from complication
from a total knee arthroplasty. PMHx. consists of DM, HTN,
anemia, HLD, CAD, COPD, CKD, anxiety, and Hypothyroidism.
After two weeks of successful rehabilitation, she developed blisters
in her extremities and torso, with no other symptoms. When the
blisters burst, they express a clear fluid, then crust and new blisters
appear in other parts of her body.
The patient was started on Prednisone while in the hospital but
no documentation was found regarding the reason for it. With further
interrogation, she stated that she had the blisters before and that
steroids usually improved them. Until then, since no documentation
found about her blisters, COPD exacerbations were the presumable
cause for her steroid treatments.
After reviewing and taking in consideration that the patient is a
female older than 60, with previous episodes of non-complicated blistering,
also that those blisters have responded to steroids treatment,
and finally and foremost after comparing her lesions with the ones
posted online in multiple sites Our patient was diagnosed with Bullous
Pemphigoid and started on a long prednisone taper after which
she improved and was successfully discharged home.
Discussion:
Bullous Pemphigoid is a fairly uncommon disease, but when
present is usually in elderly females, it is one differential diagnosis we
should think of when blisters are present in the elderly, followed by
Pemphigus (similar but less common blistering disease). The difference
between the two is auto antibodies to intradermal epitopes in
the latter vs. sub dermal auto antibodies in the former. Both have
been linked with higher risk of death, and this is why primary care
geriatricians and anyone taking care of the elderly should be vigilant
to diagnose and treat Bullous Pemphigoid, the treatment is mainly
wound care (treat like a burn) and oral steroids. Recurrence is common
and even longer steroid tapers might be required. Etiology is
not well understood but an autoimmune response is known. The diagnosis
is clinical. An association with some medications use is
known (Furosemide, Penicillamine, and Captopril –among the most
prominent-).
References:
1. Beth G Goldstein, MD, Bullous pemphigoid and other pemphigoid
disorders. Topic review/Uptodate 2011
2. González Ramírez A, Romero de Ávila AD, Mazoteras
Muñoz V, Rev Esp Geriatr Gerontol. 2011 Nov 16.
C9
When Safe is Really Sad: Omeprazole Induced Depression with
Psychotic Features.
A. Tucker, B. Setters. Family and Geriatric Medicine, University of
Louisville, Louisville, KY.
Introduction: Omeprazole, a proton pump inhibitor, is used to
reduce acid production and relieve symptoms associated with gastric
reflux disease and is considered highly effective with relatively few
side effects. As a result, it is considered a safe medication even for
elderly patients and those sensitive to other medication classes.
Case Report: A 70 yo female presented to the hospital with
complaints of confusion. She had developed an acute change in her
mentation with audio- visual hallucinations, delusions about her family
and severe depression with vegetative type symptoms including
anhedonia, anorexia and self-neglect which was very atypical for this
active, fully independent woman. She had been recently diagnosed
with Sjogren’s syndrome and had been referred for an endoscopy
after persistent complaints of stomach discomfort. She was diagnosed
with lower esophageal sphincter dysfunction and was started on
omeprazole and fluconazole for oral thrush. Within the next two
weeks, the patient’s mental status changed and she declined into a
vegetative state. Examination found an unkempt, withdrawn, nonverbal
woman fixated upon the death of her family and everyone around
her. She was very bradykinesic and her mental status was equally
slowed and impaired with a 20/30 MMSE score and a 2/4 clock drawing
and she was hyponatremic (sodium 128). Her medications
(omeprazole and losartan) save fluconazole were stopped for a medication
washout. A complete work up ensured due to concern over
acute mental changes; including CT and MRI of the head, EEG, lumbar
puncture, cultures, toxicology and viral screens were all negative.
Neuropsychological testing for dementia was also negative. As a result,
she was started on olanzapine. Her symptoms persisted and she
eventually required electroconvulsive therapy to restore her function
and reverse her depression. She responded immediately to the ECT
therapy and was able to return home to her active, independent,
happy life.
Conclusion: While cognitive changes and other psychological
symptoms such as depression and hallucinations have been reported
with proton pump inhibitors, they are very rare and often overlooked.
This case illustrates the importance of considering unusual pharmacologic
side effects as an underlying cause of acute psychotic and depressive
symptoms, especially in the elderly patient. If overlooked,
this patient may not have recovered.
C10
Follow the polypharmacy leader: medication induced heart block in
a frail elderly female after failed cardio version.
A. Burke, 1 B. Setters. 2 1. Internal Medicine, University of Louisville,
Louisville, KY; 2. Family and Geriatric Medicine, University of
Louisville, Louisville, KY.
Introduction: Physicians continue to treat elderly patients with
the same goals and protocols used for less complicated, younger patients.
Slowed physiological responses, normal aging changes and
often times frailty mean many elderly patients do not have the ability
to appropriately respond to acute illness. Medical comorbidities and
polypharmacy complicate this already convoluted treatment picture
and lead to unexpected adverse events.
Case Report: Mrs. M, a 71 year old female with a history of oxygen
dependent COPD, diastolic dysfunction, paroxysmal atrial fibrillation
(Afib) treated with cardioversion, obesity and diabetes, present
to the emergency department with “trouble breathing” and palpations.
EKG revealed Afib with a heart rate in the 120’s. She was admitted
to the hospital for rate control, management of mild COPD
exacerbation, and acute renal insufficiency (Cr 2.99; clearance 16
ml/min). Mrs. M’s baseline rhythm on previous EKG was sinus bradycardia
with a first degree AV block. Cardiology was consulted due to
her complicated heart history and propafenone (225mg three times
daily) and digoxin (0.125mg daily) were continued at home dosages
with an increase dose of metoprolol (100mg twice daily from 75mg
twice daily). Mrs. M then developed two episodes of unresponsiveness
and subsequent code despite having a DNR code status. After
the second episode of unresponsiveness, the continuous telemetry
monitor revealed a wide irregular complex bradycardia without evidence
of a p wave. The digoxin was held, a dig level checked and her
beta blocker stopped as it was determined she was experiencing erratic
complete heart block. She then has a pacemaker placed to control
her bradycardia and heart block while the medications cleared
her system. After her pacemaker placement, she did not experience
any additional episodes of unresponsiveness and was discharged back
to her nursing facility the following week after her renal function recovered
and her medication effects wore off.
Conclusion: In the elderly, medication titration and goals need
to be adjusted from traditional protocols used in younger patients.
With slower medication titration, reduction of polypharmacy, or decrease
doses of home cardiac medications, Mrs. M may have avoided
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