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P OSTER
A BSTRACTS
been ruled out. It is then recommended that in patients who present
with delirium, ammonia level should be considered as part of the
workup especially if they have accompanying constipation.
A4 Encore Presentation
Delirious Because of Treatment: An Adverse Effect of Imipenem.
B. L. Africa, 1,2 D. Carthen, 1,2 H. Arabelo. 1,2 1. Geriatrics, St. Luke’s
Roosevelt Hospital Center, New York, NY; 2. Columbia University
College of Physicians and Surgeons, New York, NY.
The mainstay treatment of delirium is the reversal of the underlying
cause. In the elderly population, this is often caused by an infection,
for which antibiotics are initiated. However in this case, it was
the antibiotic that led to the delirium.
This is a case of a 91 year old woman with a history of chronic osteomyelitis
from an infected hip implant, who was admitted due to
weakness and lethargy. She was found to have a sinus tract in the left
hip with draining fluid and a urinary tract infection. She was started
on cefepime and vancomycin. On the subsequent day, her mental status
and leukocytosis has improved. Fluid cultures taken from her hip
grew Pseudomonas resistant to cefepime and thus imipenem was
started. Two days later she was found to be lethargic. She was diagnosed
that time with hypoactive delirium from the
osteomyelitis/hardware infection. Orthopedic surgery was consulted
for removal of her hip hardware; however she was deemed not a candidate
for surgery. Her symptoms progressed and she became comatose.
The family was informed regarding her poor prognosis. Subsequently,
her antibiotics were stopped due to futility. Two days after
stopping imipenem, she was awake and asking for food. Her condition
continued to improve and she was then eventually discharged home.
This case shows the clinical implication of an adverse effect of a
medication. Hypoactive delirium although not a known side effect of
imipenem, was observed in this particular case. This indicates the investigation
of other underlying causes of delirium, in which antibiotics
maybe one of them. There have been no known published articles
relating hypoactive delirium due to imipenem. It may be
worthwhile to investigate on this matter.
A5
Title: Multiple myeloma with spontaneous tumor lysis syndrome in
an elderly patient; a rare entity.
H. Chataut, M. Bednarczyk, M. Gorbien, M. Leiding, J. Olson.
Division of Geriatrics Medicine and Palliative Medicine, RUSH
University Medical Center, Chicago, IL.
Purpose: To recognize complications especially tumor lysis
which can be associated with multiple myeloma ( MM) in an elderly
patient.
Case Report: An 83 year old woman with history of coronary artery
disease presented with fatigue, weakness and unintentional 15
lbs weight loss over 3 months. She denied fever/chills, night sweats,
bladder/bowel complaints, bleeding from any site. Physical exam revealed
normal vital signs and unremarkable systemic exam. Laboratory
analysis revealed Hb 6 g/dL with normal MCV, Platelet count
48,000/dL creatinine 3.7 mg/dL, total protein 12.1g/dL with albumin
2.4 g/dL, Calcium 10.6 mg/dL, LDH 346 U/dL. Serum protein electrophoresis
showed monoclonal band. She was hydrated and transfused
packed RBCs and a bone marrow biopsy showed sheets of
plasma cells consisting of 70% of marrow cellularity. Bone survey revealed
multiple lytic lesions in skull, humerus, mandible. Chemotherapy
was being planned but in the interim the symptoms worsened and
laboratory analysis showed worsening creatinine 4.8 mg/dL, uric acid
13.9 meq/dL, phosphorus 6 meq/dL and potassium 5.3 meq/dL. She
was started on aggressive hydration and rasburicase for presumed
tumor lysis syndrome, which resulted in improvement in symptoms
and laboratory parameters. Dexamethasone was added for MM. Further
therapy is being planned as outpatient with bortezomib with
very close follow-up.
Discussion: The incidence of MM increases considerably with
age. The number of geriatric patients with MM is expected to increase
over time as a consequence of the increased life expectancy of the
normal population, and management of these patients is likely to become
particularly pertinent in coming years. MM in the elderly can be
a therapeutic challenge. Acute tumor lysis syndrome is rarely observed
in MM. The incidence is probably less than 1% of patients who
are treated with intermediate or high-dose chemotherapy. It is only
occasionally observed with dexamethasone or prednisone treatment.
Few case reports exist of the same. Spontaneous tumor lysis syndrome,
on the other hand, has not been reported in untreated
myeloma. Our case is unique with spontaneous tumor lysis in a very
elderly patient with new diagnosis of MM, rapidly declining performance
status with co-morbidities, presenting a therapeutic challenge.
A6
A case of atypical Gastro-intestinal bleeding (GIB) in an elderly; not
just diverticulosis.
H. Chataut, 1 M. Bednarczyk, 1 M. Gorbien, 1 M. Leiding, 1 J. Olson, 1
C. Teodoro, 1 R. Arora. 2 1. Department of Geriatric Medicine, RUSH
university medical center, Chicago, IL; 2. Gastroenterology, Rush
University Medical Center, Chicago, IL.
Purpose: GIB may present with vague symptoms and can be fatal.
Background: GIB that required multiple procedures along with
octreotide.
Method: Case report
Case report: A 85 year old man with receiving aspirin and
coumadin presented with confusion, hypotension, tachycardia, guaiac
positive and Hgb 5 gm/dl, INR 2.2. After resuscitation emergent
colonoscopy revealed diverticulosis, non bleeding angiodysplasia
(AVMs) and colon full of blood up to cecum with no blood in the terminal
ileum, suggesting colonic source for bleeding. EGD up to duodenum
showed no evidence of recent or active bleeding. Patient’s
Hgb continues to drop requiring 17 units of Packed RBC transfusion
in 2 days. Technetium labeled RBC scan localized the bleeding to
duodenum and jejunum. Enterescopy showed bleeding site in the
duodenum at junction of bulb and second portion of duodenum along
with non bleeding AVMs in small bowel. Bleeding site was treated
with epinephrine and cauterization. This temporarily stopped the
bleeding; however bleeding recurred in the following day. Then patient
underwent visceral arteriogram and empiric embolization of
gastroduodenal artery (GDA), superior rectal artery of inferior
mesenteric artery (IMA). In the setting worsening GIB, patient had a
trial of octreotide infusion along with pantoprazole intravenously.
Octreotide inhibits gastric acid secretion and decreases splanchnic
blood flow due to its vasoconstrictive effect. Thereafter, hemoglobin
stabilized and patient recovered.
Discussion: This is a complex case of GIB from multiple angiodysplasia
concurrent with diverticulosis. Patient presented with
hypovolemic shock from GI bleed, requiring multiple blood transfusions.
Thus we can initially assume that GIB from a large and readily
visible source. However, this was not the case. This presented a diagnostic
dilemma, which necessitated multiple procedures. To conclude,
a trial of octreotide was given in the context of worsening GIB. In this
case, looking and targeting a specific lesion may not be the best therapeutic
option. Thus we step back and treat the GI system with a
medication that affects it at all levels. This clinical scenario is not uncommon
since both occur in elderly patients. Octreotide has been
shown to halt bleeding in cases of angiodysplasia and was successful
in our patient.
A7
The four-year mystery diagnosis.
M. Walker, D. A. Pasquale. UPMC, Pittsburgh, PA.
Background:
S18
AGS 2012 ANNUAL MEETING