Here - American Geriatrics Society

P OSTER
A BSTRACTS
Discussion/Conclusion
Distress at the end of life may be from treatable factors such as
urinary retention but often results from a complex interplay of delirium,
pain and psychosocial factors. Effective palliation requires a
multimodal approach targeting all sources of suffering. Geriatricians
and palliative care experts have much to learn from each other and to
teach trainees and hospitalists. To ease patients’ final hours and relieve
the guilt of families, the American Academy of Hospice and Palliative
Medicine and the American Geriatrics Society should collaborate
on educational and clinical initiatives on end of life care
C29
Galantamine Induced Generalized Myoclonus.
G. Luna, 1 N. Sharma, 2 J. Makela. 3 1. Geriatric, UIC, Chicago, IL; 2.
Geriatric, UIC, Chicago, IL; 3. Geriatric, UIC, Chicago, IL.
Supported By: No financial support provided
Introduction: Myoclonus is a brief, involuntary twitching of a
muscle or a group of muscles characterized by spastic-ballistic disabling
jerking movements. It describes a medical sign and is not itself
a diagnosis. While respiratory myoclonus associated with galantamine
has been previously described, generalized myoclonus second to
galantamine use has not been described before in the published geriatric
literature.
Case: A 87-year-old male with vascular dementia was started on
galantamine for dementia. Four months later, at 16mg dosing, the
caregiver reported that the patient started to experience a fine right
hand tremor, but refused further work-up at the time. The patient
continued on galantamine 16 mg. Nine months after galantamine
therapy was started, the patient came to the clinic complaining of a
new disabling movement disorder. The movements first started three
months previous, as infrequent, short, brief jerks. These episodes did
not follow a day cycle pattern or involve loss of consciousness. On
clinical exam, high amplitude, frequent, multifocal myoclonus was observed.
These jerks involved the whole body; however they were
more prominent in the upper extremities. After discussion with a
movement disorder specialist, who assisted in the assessment, galantamine
was identified as a possible cause of myoclonus. Subsequent
laboratory work-up for other causes was negative. Two weeks after
stopping galantamine all movement symptoms had successfully disappeared,
confirming the suspicion.
Discussion:
In the geriatric practice we see a number of conditions that can
cause generalized myoclonus. Few of these conditions are reversible.
This case report suggest that when we see a patient present with generalized
myoclonus we should consider the possibility of galantamine
induced myoclous, as it is easily reversible. It is important to note that
the development of myoclonus was not abrupt, as might be expected
in a drug reaction. Rather, the myoclonus worsened over the course
of several months while on treatment. However, the rapid resolution
of symptoms after galantamine withdrawal implicated it as a cause.
The insidious onset and progression of myoclonus, as seen in this
case, may hinder recognition of galantamine as a cause. We would encourage
physicians treating generalized myoclonus to consider galantamine
as a possible reversible cause.
C30
Bilateral pulmonary emboli in a patient with renal angiomyolipoma.
G. Ratnarajah, D. Seminara, A. Szerszen . Geriatrics, Staten Island
University Hospital, Staten Island, NY.
Renal angiomyolipoma is a benign hamartoma that can rarely
extend into the renal vasculature and subsequently into the inferior
vena cava (IVC) . An even more rare occurrence is embolism of the
tumor from the IVC into the pulmonary circulation
A 72 year old lady with a history of hypertension was found to
have renal insufficiency on routine evaluation by her private medical
doctor. Her physical examination was unremarkable and workup of
the renal insufficiency revealed a mass in the left kidney by ultrasound.
Further inquiry of this renal mass was undertaken with abdominal
computerized tomography ( CT ) scan which revealed a left
sided renal mass with extension into the left renal vein; a preliminary
diagnosis of renal angiomyolipoma was made. The scan also showed
suspicion for a loculated effusion of the left lung. A chest CT scan was
then performed to investigate the pleural effusion which incidentally
revealed bilateral pulmonary emboli. In addition, the right sided embolus
was seen to contain macroscopic fat.
On admission to the hospital, the patient denied any chest pain,
shortness of breath, abdominal pain, or hematuria. Her physical examination
was unremarkable with no signs of tachycardia, fever, hypoxia,
or petechiae. Her labs were significant for a glomerular filtration
rate of 39 ml/min/1.73 m 2 . An echocardiogram was performed
which revealed no signs of right ventricular strain pattern. The patient
was started on intravenous heparin and the decision was made to
bridge her with Coumadin therapy upon discharge. An open radical
nephrectomy was planned on an outpatient basis.
In conclusion, we present an asymptomatic elderly patient with
bilateral pulmonary emboli from renal angiomyolipoma. The extension
of renal angiomyolipoma into the renal vasculature is an uncommon
entity. In these patients, clinicians should be aware of the complication
of embolization and consider further workup to rule out
pulmonary embolism.
C31
Cerebral Infarction: A Rare Presentation of Cryptococcal
Meningoencephalitis in an Immunocompetent Patient.
I. P. Resurreccion. Medicine, UAB Montgomery, Montgomery, AL.
Cerebral cryptococcosis is common fungal opportunistic infection
in immunocompromised, but a rare disease in immunocompetent
patients. We report an unusual case of CNS cryptococcosis as
cerebral infarction in an immunocompetent patient.
A 78-year-old Caucasian male with hypertension, hyperlipidemia
and osteoarthritis was admitted with confusion, left-sided
weakness, dizziness, falls, headache and anorexia. No head trauma nor
fever. On physical, he was disoriented to time and place and decreased
strength on the left side with preserved sensation. Brain CT
was negative. Brain MRI showed subacute infarct in anterior right
middle cerebral territory. Lumbar puncture had normal opening pressure,
showed 18 WBC with 100% mononuclears, high protein
82.5mg/dL, low glucose 18mg/dL, positive India ink and cryptococcal
antigen titer 1:1024. CSF culture grew Cryptococcus neoformans.
HIV screening was negative. Induction therapy initiated with liposomal
amphotericin and flucytosine. He continued to have altered mental
status and headache. He was planned for another lumbar puncture
every 2 weeks or earlier to relieve headaches. He continued to deteriorate
with multi-organ failure and died.
Cerebral infarction is an unusual presentation of CNS cryptococcosis.
Rarely, cryptococcus can cause cerebral infection in immunocompetent
patients. Manifestations include fever, headache, altered
mental status, personality changes and memory loss. Lumbar
puncture is useful for diagnostic and therapeutic. Opening pressure is
elevated and CSF has elevated protein, low glucose with positive
India ink stain, cryptococcal antigen titer and culture. Treatment includes
induction therapy with amphotericin B and flucytosine. Duration
in patients without neurological complications with a negative 2
week CSF culture is 4 weeks and in patients with neurological complications
is 6 weeks. Consolidation therapy with fluconazole is 8
weeks. Maintenance therapy is 6-12 months. The incidence of cerebral
infarction due to cryptococcal meningitis in HIV-negative patients is
4%. Mechanisms include antigen-antibody complexes with vasculitis
and direct toxic effects of viral antigen on vascular endothelium. Poor
prognostic factors are cerebral infarcts, high opening pressure, CSF
WBC