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P OSTER
A BSTRACTS
two synergistic mechanisms caused the hyponatremia. The first was
the syndrome of inappropriate antidiuretic hormone (SIADH) secondary
to citalopram. Her presentation is consistent with SIADH as
evidenced by euvolemia, low serum osmolality, and worsening hyponatremia
with a normal saline challenge. We find support for a second
mechanism from the unusually rapid and severe onset of the
SSRI-induced SIADH. The addition of TMP/SMX may have worsened
the hyponatremia through trimethoprim-mediated aldosterone
antagonism. Consistent with this hypothesis, the patient showed rapid
improvement of her hyponatremia by hospital day 4, when citalopram
was still present in her serum while TMP/SMX was already
eliminated. (Given the patient’s age and renal function, TMP/SMX’s
T½=18hrs and citalopram’s T½=50hrs.)
The potential synergism between TMP/SMX and citalopram, as
observed in this case, merits a warning as a potential drug interaction.
Providers should take care when adding TMP/SMX to a regimen containing
other potentially hyponatremia-inducing medications, particularly
in cases of renal dysfunction.
D8
Missed Diagnosis of Waldenstrom’s Macroglobulinemia and
Systemic Amyloidosis in a Patient Diagnosed as Follicular
Lymphoma.
J. Silvestre, S. Saad. Montefiore Medical Center / Albert Einstein
College of Medicine, Bronx, NY.
Supported By: No financial disclosures
Waldenstrom’s Macroglobulinemia (WM) is a rare lymphoplasmacytoid
malignancy present in 2.5/million/year. Of these, < 5% develop
systemic amyloidosis (AL). We present a case of WM complicated
by AL, erroneously diagnosed as a benign follicular lymphoma.
Cardiac amyloidosis and WM were found on postmortem pathology.
Case: A 79 year old male was transferred from a nursing home
because of fever and hypotension.
His past medical history included hypertension, seizure disorder,
anemia, peptic ulcer disease, Parkinson’s disease. Patient had an excellent
functional and cognitive status until diagnosed with follicular
center lymphoma with M-gammopathy by biopsy 15 months before
presentation. On retrospective analysis, flow cytometry was CD10+,
CD19+, and CD20+. PET CT scan showed minimal involvement of
retroperitoneal lymph nodes but no hepatosplenomegaly. Bone scan
was negative, IgM > 5 g/dL, and beta-2-microglobulin was elevated.
He had received one month of rituximab. Soon afterwards, he developed
diverticular perforation requiring colostomy. Later, a delayed
colostomy reversal surgery was complicated by sepsis and acute kidney
injury, needing dialysis. Subsequent clinical course worsened with
functional decline and multiple admissions due to urinary tract infections,
C. difficile diarrhea, and health care associated pneumonia.
Hospital Course: On the Emergency Department, the patient
was hypotensive and unresponsive. Laboratory data showed pyuria,
leukocytosis, and anemia. Electrocardiogram showed normal sinus
rhythm. Chest X-ray showed mild congestive heart failure. Prior
echocardiogram showed normal function but left ventricular hypertrophy.
The patient was fluid resuscitated and treated with broad
spectrum antibiotics for presumed sepsis. Later he defervesced and
stabilized, however his heart failure worsened. His overall prognosis
remained poor. Palliative care was instituted and he expired 12 days
after admission.
On postmortem pathology, extensive systemic amyloidosis was
found and significant cardiac involvement was reported. Lymphoplasmacytoid
cells were identified, suggestive of WM.
Discussion -
When patients with lymphoma and gammopathy develop symptoms
of heart failure, AL should be suspected since it drastically reduces
the survival. Expression of CD10 and CD23 may be found in 10
to 20% of cases and should not exclude WM. Coexistence of WM and
AL carry a grim prognosis.
D9
Topical clindamycin phosphate use for chest wall follicultis
complicated by severe Clostridium difficle infection.
J. Palla, 1 S. M. Imam, 1,2 S. B. Johnson. 3,4 1. Geriatrics, Edward Hines
VA Hospital, Hines, IL; 2. Internal Medicine, Loyola university
Hospital, Maywood, IL; 3. Infectious Disease, Edward Hines VA
Hospital, Hines, IL; 4. Infectious Disease, Loyola university Hospital,
Maywood, IL.
Back ground: Topical application of clindamycin is not a well
recognized risk for Clostridium difficile infection (CDI) but the association
has been reported. We report a rare case of severe CDI following
topical clindamycin phosphate use.
Case report: A 62 year old male resident of a nursing home was
transferred to the emergency room with fever, hypotension and
tachycardia. He had history of Hartmann’s Colostomy done 4 months
ago for recurrent diverticulitis followed by severe CDI. No history of
exposure to antibiotics in the past 4 months or any other symptoms
were elicited. Medication review did show 1% clindamycin phosphate
ointment prescribed 3 weeks ago for chest wall folliculitis.
Physical exam was non-contributory. Initial workup showed leukocytosis
and a normal chest x-ray. Although bacterial sepsis was suspected
initially, he developed loose colostomy output shortly after
presentation and the white blood count increased to 23000 per cc 3 .
Oral vancomycin treatment was started for suspected CDI and the diagnosis
was confirmed by stool C.difficile toxin assay. The leukocytosis
and loose colostomy output improved within 48 hrs. He was transferred
back to the nursing home, where the clindamycin ointment was
identified as a possible trigger for the colitis and was discontinued.
Discussion: Twenty cases of topical clindamycin related diarrhea
and two case reports of proven CDI were published from 1978 to
1986. Pharmacokinetic and pharmacodynamic studies after topical
clindamycin application have shown detectable serum concentrations
and presumptive effects on intestinal flora. Animal studies have
shown that the lethal dose applied topically to hamsters was similar to
doses given to humans for treatment of acne. It is important to recognize
this potential side effect of topical administration of clindamycin
and use it cautiously, particularly in patients at high risk for CDI.
D10
Uncommon causes of intractable hallucinations in the demented
elderly.
K. Alagiakrishnan. Medicine, University of Alberta, Edmonton, AB,
Canada.
Introduction: Hallucinations are false sensory perceptions or experiences
that a person sees, hears, smells or feels something but do
not exist. It can be the result of the brain changes in dementia or as a
result of medical problems. In this report, three uncommon causes of
hallucinations in dementia patients are presented.
Case reports:
Case 1:
A 75 year old female came for cognitive assessment. She had
cognitive decline for the past two years. For the past four months, patient
smelled sour gas (olfactory hallucinations) in the basement and
it was thought to be due to confusion, which was secondary to dementia.
A short course of antipsychotics did not help with the symptom.
On one occasion, patient called the police for this problem. At
that time a neurologist saw the patient in the ER and was sent home
with a suspicion of query small stroke. During our assessment, we
found no history of epilepsy or psychiatric disorders. There was no evidence
of delirium or no neurological deficits were seen. MRI of the
head showed large infiltrating mass involving both cerebral hemispheres
and the differential diagnosis was an astrocytoma or possible
lymphoma.
Case 2:
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