Here - American Geriatrics Society

P OSTER
A BSTRACTS
Case: A 78 year-old male with history of coronary artery disease,
hypertension and chronic atrial fibrillation was admitted following a
fall without major injury. He presented with a two-month history of
progressive muscle weakness and pain resulting in difficulty in ambulation.
He underwent coronary artery bypass graft two months prior.
Medications included cardizem, digoxin, warfarin, simvastatin, amiodarone.
Physical examination was remarkable for generalized muscle
tenderness and decreased muscle strength of 3-4/5 in all four extremities.
Laboratory tests showed elevated CK of 10,280, aspartate
aminotransferase of 563, alanine aminotransferase of 403, alkaline
phosphatase of 99, normal renal function. Urinalysis showed large
blood with 5-10 red blood cells. Simvastatin was stopped and patient
was started on intravenous hydration. His CK level transiently decreased
to 8,900, but on the third day it increased to 11,600. Intravenous
hydration was continued and bicarbonate drip was started.
Patient’s family later reported that amiodarone was just recently
started after the bypass graft two months prior. Amiodarone was
stopped and the patient’s clinical status steadily improved. By day
seven, his CK level dropped to 700.
Discussion: The severity of rhabdomyolysis ranges from asymptomatic
elevations in serum muscle enzymes to life-threatening cases
with extreme enzyme elevations, electrolyte imbalances and renal
failure. Classic presentation includes myalgia, red to brown urine due
to myoglobinuria, and elevated serum CK levels. Many drugs are
known to cause rhabdomyolysis including statins, colchicine, and cocaine.
Few cases of amiodarone-induced rhabdomyolysis have been
reported. In this case, the patient continued showing worsening CK
levels in spite of stopping the statin. His clinical status and CK level
dramatically improved upon discontinuation of amiodarone. Physicians
must keep in mind that amiodarone can be one of the uncommon
causes of rhabdomyolysis.
D2
Chronic Subdural Hygroma presenting as Dementia.
E. C. Ong, 1 N. Maheshwari, 1 E. Roffe, 2 S. Chaudhari, 1,2 D. Kumari, 2
M. Belal. 1 1. Internal Medicine, Metropolitan Hospital Center, New
York, NY; 2. Geriatric Medicine, Metropolitan Hospital Center, New
York, NY.
Introduction: Chronic subdural hygroma is common among elderly
individuals. It is a lesser-known potentially reversible cause of
dementia. We present a case of an elderly male with chronic subdural
hygroma presenting as dementia.
Case: An 81 year-old male with medical history of mild hypertension
was brought in by his daughter to Geriatric clinic to establish
medical care. Patient was recently seen by psychiatry and neurology
due to insomnia and agitation (especially at night), started on Memantine
and Donepezil for diagnosis of Dementia. Physical examination
was unremarkable except for disorientation to place and time, inability
to do three-item recall, and Mini-mental state examination
score of 17/30. Laboratory tests were normal including thyroid functions,
vitamin B12, and Syphillis IgG. CAT scan of the brain revealed
chronic subdural hygroma overlying the right cerebral convexity with
midline shift, moderate cerebral and cerebellar atrophy. Patient was
referred to neurosurgery clinic, however patient and family refused to
undergo any neurosurgical intervention. Repeat brain CAT scan
showed increase in subdural hygroma with possible subacute and/or
acute component, but patient had no worsening of clinical
signs/symptoms on subsequent clinic follow-ups. Patient will be followed
in neurosurgery, neurology and geriatric clinic with serial brain
CAT scan.
Discussion: Chronic subdural hygroma is a subdural collection
of cerebrospinal fluid (CSF). This results from sudden decrease in
pressure by ventricular shunting leading to leak of CSF from the subarachnoid
space into the subdural space especially in cases with moderate
to severe brain atrophy. Elderly patients are prone to develop
hygromas owing to frequent falls sustaining head trauma, and significant
cerebral atrophy related to old age. Large hygromas may cause
secondary localized mass effects on the adjacent brain parenchyma
causing neurologic symptoms. Global deficits such as disturbances of
consciousness are more common than focal deficits. Brain CAT scan
would show crescent-shaped extra-axial lesions. Surgical evacuation
is recommended if there is evidence of moderate to severe cognitive
impairment or progressive neurologic deterioration. Physicians
should recognize chronic subdural hygroma as a reversible cause of
dementia among the geriatric population.
D3
Actinomyces israelii - A rare cause of prosthetic joint infection in
the elderly.
G. Gulati, S. Gulati, D. Powell. Internal Medicine, The Reading
Hospital and Medical Center, West Reading, PA.
INTRODUCTION: Actinomyces prosthetic joint infections are
extremely rare, described in only half a dozen case reports in medical
literature. Our case describes a patient who presented with new onset
prosthetic joint infection with no identifiable local or systemic source
or trauma.
CASE PRESENTATION: A 72 year old male with a history of
left total hip replacement in 2002 presented to the hospital with a one
month history of night sweats and progressively worsening pain in the
left leg. He denied any fever, trauma or injury to the affected side. On
physical exam, he had a temperature of 38.7 degrees Celsius and a
pulse of 115 per minute. Musculoskeletal examination was significant
for a tender left hip joint at the groin with limited range of motion.
On laboratory work up, he had an ESR of 82mm/sec, CRP of 15
mg/dL and leukocytosis of 31,300/cu mm with 90% neutrophils. CT
scan of the hip revealed an attenuated fluid-filled distended region
anterior to the hip prosthesis and muscular asymmetry suspicious for
an abscess. Surgical arthrotomy of the left hip joint with debridement
was done. On histopathology, the specimen showed granulation tissue
with acute-on-chronic inflammation and grew Actinomyces israelli
on cultures. He was started on ampicillin and later switched to doxycycline
due to a significant allergic reaction to the former for 6 weeks.
He was discharged with instructions for outpatient follow up for prosthesis
removal.
DISCUSSION: Actinomyces israelii, a gram positive anaerobic
bacterium, causes infections involving the oral cervicofacial area,
lungs and abdomen. Involvement of the musculoskeletal system is
rare and attributable to adjacent soft tissue infections, occasionally to
local trauma or hematogenous spread. Late infections of prosthetic
joints have been described in literature as spread from an extra articular
site. Diagnosis is established by bacteriological identification
using sterile cultures showing characteristic appearance and sulfur
granules. Penicillins are the mainstay of treatment, and use of tetracycline
class has been reported in cases of penicillin allergy. A combination
of medical and surgical therapy with consideration for prosthesis
removal needs to be considered. Some experts recommend prolonged
antibiotic courses for better results. Early recognition of this
entity even in the absence of an obvious predisposing cause is required
for early diagnosis and institution of therapy.
D4
Confusion, ataxia and psychosis - amphetamine toxicity in the
elderly.
G. Gulati, S. Gulati. Internal Medicine, The Reading Hospital and
Medical Center, West Reading, PA.
INTRODUCTION: Amphetamine abuse is the primary cause
of emergency visits in 73,400 patients per year in the United States.
Classic presentations include psychosis, agitation and sympathomimetic
signs.
CASE PRESENTATION: A 62 year old male with a past history
of recreational drug abuse presented with acute onset unsteady
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AGS 2012 ANNUAL MEETING