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P OSTER
A BSTRACTS
calcitriol via 1alpha-hydroxylase activity. This syndrome is characterized
by normal phosphate levels, normal or suppressed PTH and
PTHrP concentrations, and no osseous involvement. As with our patient,
glucocorticoids can reduce extrarenal calcitriol production and
inhibit osteoclastic bone resorption.
CONCLUSION
Advanced age is a cancer risk factor. The elderly account for
60% of newly diagnosed malignancies. Hypercalcemia is a common
cancer complication that can present in the frail elder with subtle
symptoms and oftentimes, delirium. This, in setting of a possible neoplasia,
should be entertained.
REFERENCE
1.Seymour JF, Gagel RF.Calcitriol:the major humoral mediator
of hypercalcemia in Hodgkin disease and nonHodgkin
lymphoma.Blood 1993;82:1383–94
A16
Describing an atypical variant of Guillain-Barré syndrome.
S. Gulati, S. Gupta, G. Gulati. Internal Medicine, The Reading
Hospital and Medical Center, West Reading, PA.
CASE:62-year-old Asian male, presented to the hospital with bilateral
extremity weakness after a trip to India 3 weeks ago, at which
time he had developed severe gastroenteritis. Weakness had started
in his upper extremities, followed by the lower. During hospitalization
he experienced wide fluctuations in his blood pressure and heart
rate (systolic blood pressure of 100-190 mm of Hg and heart rate
ranging from 60-130 bpm). On neurologic, he had 3/5 motor strength
of bilateral upper extremities, 4/5 of lower extremities, areflexia in
upper with normal reflexes in the lower extremities. Gait was normal,
so was the sensory and cranial nerve exam. Routine laboratory studies
including a CBC, basic metabolic panel, thyroid panel, vitamin
B12, folate levels and autoimmune markers were normal. ESR was
elevated at 48 mm/hour (normal: 0-15mm/hour). CSF analysis revealed
an elevated protein of 86 mg/dL (normal: 20-45mg/dL), with
normal glucose level and zero WBC’s. This suggested albuminocytologic
dissociation. Nerve conduction studies showed evidence of demyelination.
Despite his atypical presentation, he was diagnosed with
Guillain-Barré syndrome(GBS) and started on IVIGg for five days.
His respiratory status remained stable with an improved neurologic
exam. The patient was discharged on prednisone to an acute rehabilitation
facility.
DISCUSSION: GBS, a post infectious immune mediated disease,
manifests as an acute inflammatory ascending polyradiculoneuropathy
(with weakness and diminished reflexes). It has an annual incidence
in US of 1.2-3 per 100,000, making it the most common cause
of acute flaccid paralysis. The disease has a bimodal distribution, with
peaks in age 15-35 years and a second, higher peak in elderly patients
aged 50-75 years. There is a history of an antecedent illness (GI or
upper respiratory), 1-3 weeks prior to the onset.
Many clinical variants have been well documented. These include
acute inflammatory demyelinating polyneuropathy (AIDP),
acute motor axonal neuropathy (AMAN), acute motor-sensory axonal
neuropathy (AMSAN), Miller-Fisher syndrome, a pure sensory
variant of GBS.
CONCLUSION: A disease not fitting the typical definition of
GBS should not dissuade physicians from complete work up and
treatment. This becomes especially important in the elderly population,
because there is a 6-fold increase in the rate of death in patients
aged 60 years or older compared to persons aged 40-59 years.
A17
Recognize the likely association between herpes encephalitis and
cardiac arrhythmias.
S. Gulati, G. Gulati, R. Alweis. Internal Medicine, The Reading
Hospital and Medical Center, West Reading, PA.
CASE: A 73 year old male with past medical history of hypertension
and coronary artery disease on beta blocker therapy presented
to the hospital with an acute change in mental status following
an episode of witnessed tonic-clonic seizure-like activity. The patient
had recently flown and had developed low grade intermittent fever
since. Examination revealed obtundation with an otherwise non-focal
neurological exam. He was intubated for airway protection and transferred
to the ICU. Laboratory evaluation revealed only mild leukocytosis
with a normal differential. Blood chemistries were normal with
negative toxicology screening. Lumbar puncture revealed clear appearance
of the CSF, normal glucose of 76 mg/dl, elevated protein of
64 mg/dl (nl 20-45 mg/dl), elevated white cell count of 304 cmm (nl 0-
5 cmm), with 80% lymphocytes (nl 0-50%) and 1% neutrophils. Herpes
Simplex type 1 DNA was detected by PCR. A diagnosis of herpes
encephalitis was made and the patient was started on intravenous
acyclovir. After transfer out of the unit, he was noted to have sinus
bradycardia with heart rate ranging from 40-60 beats per minute. Review
of his rhythm revealed a first degree heart block. The patient
was evaluated and, for unclear reasons, restarted on his home dose of
metoprolol. This was followed by development of complete heart
block which necessitated implantation of a dual-chamber pacemaker.
DISCUSSION: Herpes simplex virus is the most common cause
of acute, sporadic viral encephalitis, accounts for 10% to 20% of all
cases. Of these more than 95% are caused by subtype I virus. The clinical
hallmark of HSV encephalitis is acute onset of fever accompanied
by focal neurologic signs (most commonly involving the temporal
lobes). There have been isolated case reports in literature
connecting cases of herpes encephalitis with development of cardiac
arrhythmias. Hence patients with encephalitis need close cardiac
monitoring. Literature search reveals that these patients spontaneously
recover with treatment of the underlying infection and have
not needed pacemakers.
Physicians taking care of patients need to recognize the association
of cardiac arrhythmias with non-cardiac causes like viral infection.
This can help avoid catastrophic sequelae.
A18
An unusual presentation of deep vein thrombosis due to May-
Thurner syndrome in an elderly man.
S. Nakagawa, 1 A. Fischman, 2 J. Farber, 1 F. Ko. 1 1. Department of
Geriatrics and Palliative Medicine, Mount Sinai School of Medicine,
New York, NY; 2. Departments of Radiology and Surgery, Mount
Sinai School of Medicine, New York, NY.
Case
A 79 year-old man presented with 2 weeks of progressive left
lower extremity (LLE) swelling with pain precluding ambulation. He
had significant unilateral non-pitting edema with skin discoloration
in the entire LLE and a positive Homans’ sign. A Doppler ultrasound
showed acute deep vein thrombosis (DVT). Despite starting anticoagulation,
swelling and pain worsened. A subsequent CT venogram
showed an extensive occlusive DVT from the left common iliac vein
to the popliteal vein. Endovascular Catheter Directed Thrombolysis
(CDT) and pharmacomechanical thrombectomy was performed with
successful clot removal. An intravascular ultrasound (IVUS) showed
focal narrowing of the left common iliac vein due to a crossing right
common iliac artery consistent with May-Thurner syndrome (MTS).
A self-expanding iliac stent restored iliofemoral venous system patency
and resolved LLE swelling. A small post-procedure hematoma
was seen which subsequently resolved. The patient remained stable
on enoxaparin with a patent stent 5 weeks after treatment.
Discussion
MTS typically occurs in women of childbearing age. The right
common iliac artery causes chronic external compression of the left
common iliac vein and predisposes patients to LLE proximal DVT.
Iliac vein compression needs aggressive management because it results
in recurrent thrombosis and post-thrombotic syndrome (PTS)
on anticoagulation therapy alone. Venography with IVUS is a superior
modality for diagnosis. CDT and stent placement followed by anticoagulation
is the most effective treatment. Due to its rarity in eld-
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AGS 2012 ANNUAL MEETING