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P OSTER
A BSTRACTS
dration. Therefore, careful clinical monitoring by facility staff or families
and laboratory assessments are essential for patients receiving
lithium. Finally, there should be a consideration of changing therapy
to other medications if appropriate, especially for those at highest
risk for lithium-induced complications.
A13
Clinical Challenge of diagnosing Amyotrophic Lateral Sclerosis
(ALS) in Elderly Patients.
S. Rana, 1,2 N. Manov, 2 S. S. Rana. 3 1. Geriatrics, University of
Pittsburgh School of Medicine, Pittsburgh, PA; 2. Geriatrics, UPMC-
St Margaret Hospital, Pittsburgh, PA; 3. Neurology, Allegheny
General Hospital, Pittsburgh, PA.
Amyotrophic Lateral Sclerosis (ALS) occurs in 2 to 3 per 100
thousand population and predominantly affects elderly.Diagnosis is
made on clinical examination and ruling out other possible disorders.
Since the elderly patients commonly have other confounding comorbidities,
ALS is often misdiagnosed. We present two cases of ALS that
underwent spine surgery with misdiagnosis of weakness secondary to
degenerative spine disease.
Methods: Chart review of two patients
Case studies
Case 1: 78 year male with history of prostate and lung cancers
treated with chemotherapy in 2008, developed footdrop in fall of
2009. Initial EMG studies showed denervating process involving legs
which were felt to be secondary to peripheral neuropathy.Based on
imaging studies he underwent decompressive surgery at L4-5 level
with presumed diagnosis of radiculopathy. Patient continued to
worsen and developed diffuse weakness, progressive weight loss, and
respiratory failure for which he required tracheostomy and ventilator
support. Follow up EMG studies revealed widespread denervating
process, consistent with ALS.
Case 2: 71 year female with history of hypertension, coronary artery
disease, presented with weakness in legs, recurrent falls and “sciatic
pain”. She underwent imaging studies of spine and was diagnosed
with scoliosis. She underwent surgery at the thoracic level. She continued
to get weaker in her extremities and then developed
dysarthria. EMG studies showed widespread denervating process and
she was diagnosed with ALS.
Conclusion: Early ALS can be difficult to diagnose as there is no
diagnostic test available. In elderly patients, initial presentation of
ALS is commonly attributed to radiculopathies secondary to degenerative
spine disease. Better diagnostic tools are needed to help diagnose
patients with ALS. In the interim, patients with painless onset of
weakness, absence of sensory symptoms and presence of fasciculations,
should raise suspicion for ALS. In these patients, judicious approach
ie EMG studies by experienced electromyographers, and
carefully correlating the results to imaging studies are warranted. Increased
awareness, and multidisciplinary approach can prevent unnecessary
spine surgeries in these patients.
A14
A Stuttering Discovery of Lithium Toxicity.
S. Sabillo, 1 R. V. Samala, 2 J. O. Ciocon. 1 1. Geriatrics, Cleveland Clinic
Florida, Weston, OH; 2. The Harry R. Horvitz Center for Palliative
Medicine, Cleveland Clinic, Cleveland, OH.
Objectives
1. Describe a case of lithium toxicity presenting as stuttering
2. Enumerate the medications that may cause stuttering
3. Discuss the mechanisms and management of drug-induced
stuttering
Case
An 86-year-old female nursing home resident was typically described
by the care staff as alert, pleasant, and conversant, though disoriented
to time and place at times. She was frequently seen in the
hallways, interacting with personnel and patients, and often breaking
into song with her melodious voice. Her past medical history was significant
for dementia, epilepsy, and bipolar disorder. Chronic medications
included donepezil, risperidone, primidone, and lithium carbonate.
One day, she complained to her nurse that she had been
stuttering, finding it difficult to complete a sentence, as well as sing.
She grew increasingly bothered by her faltering speech as the days
wore on, and also pointed out that her grip on objects was becoming
weak. Her attending physician was subsequently informed of these
new symptoms. Physical and neurological examinations were unremarkable
aside from her obvious stutter. She was able to talk straight
for a few words, and then would begin to repeat syllables and words
until she became obviously frustrated and abruptly terminate her
sentence. A CT scan of her head was done which was similarly unremarkable.
Her stuttering persisted for 3 more months until a lithium
level was checked, and came back elevated at 2.0 mmol/L (0.6 to 1.2
mmol/L). Lithium carbonate was promptly stopped and after about 2
weeks, her level was back to normal, and her stuttering had completely
resolved.
Discussion
A broad array of drugs has been shown to cause stuttering. Included
in the list are phenothiazines, tricyclic antidepressants, benzodiazepines,
selective serotonin reuptake inhibitors, theophylline,
phenytoin, carbamazepine, and clozapine. Proposed mechanisms involve
different drug-receptor systems: cholinergic, dopaminergic, noradrenergic,
and serotonergic. In all previously reported cases, stuttering
stopped when the offending agent was discontinued. We find
great interest in this case since there has been a scarcity of literature
implicating lithium. Clinicians should, therefore, be aware of stuttering
as a potential sign of drug toxicity.
A15
Elderly Female with Hypercalcemia: Hodgkin Lymphoma
Masquerading as Relapsed Breast Cancer.
S. Lee, Y. Ang, S. Bellantonio. Internal Medicine, Baystate Medical
Center, Springfield, MA.
INTRO
Malignancy-associated hypercalcemia is common in metastatic
breast and prostate cancers as well as multiple myeloma. Hodgkin
Lymphoma(HL) infrequently causes hypercalcemia. In the elderly, it
can present as delirium and fatigue. We report a septuagenarian female
breast cancer survivor with hypercalcemia who was found to
have stage IVA HL.
CASE
A 76-year-old lady with history of right breast cancer status post
mastectomy and type 2 diabetes presented to her PCP with a 5 day
history of generalized malaise, intermittent confusion, nausea, vomiting,
diarrhea, and epigastric pain. An enlarged right supraclavicular
lymph node was found. Due to concern for cancer relapse, she was
sent to the hospital for evaluation. She was found to be hypercalcemic(iCa
1.6mmol/L) with normal phosphorous(3.4mg/dL),
PTH(52pg/ml), and PTHrP(0.74pmol/L) levels. Renal function was
good, and she had not been on vitamin D supplementation. CT scans
show multiple splenic masses, a liver lesion, and an enlarged right
subclavicular lymph node. Bone scan revealed no osseous involvement.
She was treated with IV fluids, zoledronic acid, and glucocorticoids
with normalization of serum calcium and resolved symptoms.
Eventually, a supraclavicular lymph node biopsy confirmed HL,
nodular sclerosing type. She was discharged with prednisone and
plans for outpatient chemotherapy.
DISCUSSION
Malignancy-associated hypercalcemia affects 20% of cancer patients.
This is most often PTHrP mediated. Also common is osteolytic
hypercalcemia due to cancer metastasis to bone. Overproduction of
calcitriol is a rare cause of hypercalcemia in malignancy(1% of cases).
Incidence of this complication in HL is about 5%[1]. HL can produce
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