Here - American Geriatrics Society

P OSTER
A BSTRACTS
then awoke spontaneously and continued to wretch. His mental status
was at baseline and he reported feeling well as he was taken to the ED
for further evaluation. EKG was notable for first degree AV block
(PR interval 224ms, unchanged from prior). Results of a CBC, serum
chemistries, Echocardiogram (done one month prior), and abdominal
CT scan were normal. He was able to eat and drink and had no further
syncopal episodes during 8 hours of observation in the ED. Our
clinical impression was reflex mediated vasovagal syncope secondary
to significant upper gastrointestinal distress. Despite this benign explanation
of his syncope, the ED physician admitted him to a telemetry
bed. Hours later he displayed multiple episodes of complete heart
block (CHB), with one episode resulting in loss of consciousness followed
by vomiting.A temporary pacing wire was placed followed by a
permanent pacemaker the next day. He experienced complete resolution
of his GI symptoms following pacemaker implantation.
Conclusion: Current practice guidelines emphasize the preeminence
of an accurate history in determining the etiology of syncope.
This patient’s atypical presentation of CHB mimicked reflex mediated
vasovagal syncope. His age and remote history of MI led to his
admission, though it seems likely that many physicians would have
discharged this patient. This case demonstrates the importance of
maintaining a high index of suspicion for atypical presentations of arrhythmic
syncope in very elderly patients with cardiac risk factors.
D14 Encore Presentation
A fatal case of treatment resistant C. difficile colitis.
K. S. Malik, M. Reisner ( AGS-F ). internal medicine, jersey city medical
center, Jersey City, NJ.
Introduction: C.diff colitis is frequently associated with previous
antibiotic use especially in the elderly population and those with recent
exposure to hospitals, nursing homes and daycare centers. The
“National Prevalence Study of C.Diff in U.S. Healthcare Facilities”
indicates that 13 out of every 1,000 inpatients were either infected or
colonized with C.Diff. Mortality rate as high as 25% in elderly patients
who are frail and immuno-compromised.
Recurrence occurs in approximately 25 percent of cases. Oral
vancomycin is the preferred therapy for severe or refractory cases.
Combination of oral vancomycin and intravenous metronidazole for
patients of C. diff with ileus is shown to be very effective. Efficacy of
this treatment in geriatric population is still questionable.
We present a treatment resistant case of C.diff colitis.
Case Description: Ms L was a 95 year old female with a history
of dementia and recent appendectomy who presented with C.diff colitis
to the hospital. Her colitis resolved after 10 days course of
Metronidazole.
Approximately 4 weeks later Ms. L developed watery diarrhea,
five to six times a day associated with weight loss. There were no
symptoms of nausea, vomiting, abdominal pain, fever, chills or rash.
Upon arrival in ER, she was thermodynamically stable, Normal
physical exam with leukocytosis of 16. Patient was admitted and
Metronidazole restarted.
Stool for C.diff toxin was positive. Within 48 hours, her condition
deteriorated. WBC rose from 16 to 50 and progressed to septic shock.
Ms L was transferred to MICU and aggressive intravenous fluid therapy
with vasopressors and oral vancomycin was added to the regimen.
Subsequently she developed diffuse abdominal tenderness.
WBC further increased to 112 with lactic acidosis of 11. Despite the
classic presentation of C.Diff, leukocytosis of 112 prompted an evaluation
for acute leukemia, and a flow cytometry was done which was
normal.
CAT scan of the abdomen revealed diffuse pseudomembranous
colitis; developed multiorgan failure, ARDS and deceased within 96
hours of admission.
Conclusion:
C. diff colitis is associated with significant mortality in the geriatrics
patients. Extensive leukocytosis is associated with poor prognosis.
Decreased immunity and multiple co morbidities are responsible
for this increased incidence in the elderly population. The clinical syndrome
of chronic C. diff and the best treatment options in this population
group needs to be further investigated.
D15
Diabetes is Associated with Functional Impairments in HIV+ Older
Adults.
K. Shah, 1 T. N. Hilton, 2 A. E. Luque, 1 W. J. Hall. 1 1. Medicine,
University of Rochester, Rochester, NY; 2. Physical therapy, Ithaca
College, Rochester, NY.
Supported By: This abstract was supported in part by the University
of Rochester Developmental Center for AIDS Research (NIH
P30AI078498)and John A Hartford Foundation Center for
Excellence in Geriatric Medicine and Training.
BACKGROUND: The prevalence of glucose intolerance and
diabetes in HIV+ patients has increased dramatically following the
widespread use of highly active antiretroviral therapy and the improved
survival rate in this population. The risk is further exacerbated
as this population ages. Although it is known that HIV+ patients
are at increased risk of frailty, little is known regarding the
impact of diabetes on physical function in HIV+ older adults (HOA).
PURPOSE: To explore the nature of functional impairment in HOA
with glucose intolerance status as measured by having diabetes.
METHODS: Twenty HOA (mean age=60 y; 30% female) participated
in a case-control study at an urban HIV clinic. Ten HOA with
diabetes were matched to ten HOA controls without diabetes on age,
gender and BMI. Subjective and objective measures of functional status
were evaluated using the Physical Performance Test (PPT),
graded treadmill test, isokinetic dynamometer, gait speed, balance
and functional status questionnaires (FSQ). Body composition was
evaluated using DXA. Muscle quality was evaluated by determining
the ratio of leg strength to leg lean mass. RESULTS: The two groups
were comparable in duration of HIV, CD4 count and viral load. Compared
with matched controls, the case patients had lower scores in
PPT, peak aerobic power, and FSQ (p