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P OSTER
A BSTRACTS
with only about 125 cases published in the literature. When encountered,
PVAs are usually unilateral, with only 7 reported cases of bilateral
PVAs. The causes of PVA are unclear, but are thought to result
from congenital vascular malformation, inflammation, trauma or degenerative
changes. Age at presentation is variable, ranging from 27
to 79 years. We describe the oldest case of PVAs to date.
CASE: An 81 year old retired mail carrier presented with burning
sensation in his lower extremities and discomfort after prolonged
standing, which began to limit his activities. Physical examination revealed
bilateral lower extremity varicose veins along the greater
saphenous vein and pain on palpation of the right leg. Duplex ultrasonography
showed bilateral PVAs without any evidence of thrombosis.
Three months later, his leg pain became more persistent, with
worsening pain at night. Serial resections of the PVAs were performed,
leading to complete resolution of the leg pain and return to
his previous activity level and independent functional status.
DISCUSSION: First described by Sir William Osler in 1915,
PVAs are uncommon and the exact incidence is unknown. The clinical
presentation of PVAs is widely variable; however, over 50% of the
reported cases present as thromboembolic disease, with pulmonary
embolism being the most common presentation (47% of cases vs. 7%
for deep venous thrombosis). Diagnosisof PVAs because of leg pain
has been reported in only 12% of cases, while 20% have been associated
with the presence of varicose veins. Since only 5% of reported
cases have been bilateral, this case represents an unusual presentation
of PVAs. Duplex ultrasonography remains the diagnostic test of
choice, although newer techniques have emerged such as CT angiography
and MRI. Surgery is indicated whenever thromboembolic disease
is present regardless of PVA size or if the PVA size is greater
than 20mm. Anticoagulation for six months is generally recommended
during the post-operative period. Geriatricians need to be
aware of this condition since it can present in older adults.
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Challenges in diagnosing Creutzfeldt - Jakob disease.
G. K. Penmetsa, 1 E. Zamrini. 2 1. Geriatrics, University of Utah hospital,
Salt lake city, UT; 2. Center for Alzheimer’s Care, Imaging and
Research, University of Utah, Salt Lake City, UT.
Background:The rate of progression of cognitive impairment
provides important insight into the differential diagnosis of dementia.
Creutzfeldt-Jakob disease (CJD) is a rare neuro-degenerative disorder
characterised by very rapid decline in cognitive and motor function.
Diagnosis can be challenging
Case history: A 65 year old previously healthy and fully functional
man with no significant past medical problems was admitted to
an outside hospital for sub-acute change in alertness and cognitive
function over a period of 2 weeks. He could no longer engage in any
family activities, communicate fluently or name family members, and
required moderate assistance with all activities of daily living
(ADLs). Extensive inpatient work-up included blood work, CSF
studies and brain MRI, but the patient remained without a specific diagnosis
at discharge on a tapering burst of prednisone. When referred
to the University of Utah neuro-cognitive disorders clinic four weeks
later, he was doubly incontinent and fully dependent in all ADLs. He
also had personality changes, myoclonic jerks, ataxia and falls. CJD
was suspected by the consultant and review of the outside hospital
MRI with adjustment of the contrast windows revealed cortical ribbons
and increased signal in the basal ganglia on diffusion weighed
images (DWI) and FLAIR. The family was counselled. The patient
was placed in hospice and died shortly afterwards.
Discussion: CJD is a fatally progressive prion disease characterized
by rapidly deteriorating dementia. The diagnosis of CJD may be
made by performing an EEG, brain MRI or CSF studies for 14.3.3
protein. MRI findings of cortical ribbons on DWI windows have
higher sensitivity and specificity for CJD. The brain MRI was initially
reported as inconclusive,but further review of the same images by the
cognitive neurologist and a neuro-radiologist demonstrated cortical
ribbons. This case highlights the need to consider CJD in patients
with rapidly progressing dementia. It also offers insight towards the
utility of expediting clinical consultation and expert review of imaging
studies in diagnosing CJD.
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Encephalopathy Responsive to Zolpidem.
M. Howard, 1 D. Rye, 2 J. Greene, 2 A. I. Levey. 2 1. Geriatrics, Emory
University, Atlanta, GA; 2. Neurology, Emory University, Atlanta, GA.
Encephalopathy has a wide variety of etiologies and presentations
as in this case of sub acute persistent altered mental status.
Zolpidem is FDA approved for treatment of primary insomnia. A
newer active area of research is exploring its activity in patients with
altered levels of consciousness.
A 64 year old Caucasian woman was referred to a university
neurology memory clinic with sub acute onset of altered mental status
over the preceding 3 months. Shortly following a European vacation,
the previously healthy woman became progressively more paranoid,
anxious, confused, insomnic, and dependent in activities of daily
living. Previous evaluation included brain imaging and lumbar puncture
without definitive diagnosis. She was given empiric treatments
including benzodiazepines, antipsychotics, and antidepressants which
had no effect except for zolpidem which her husband noticed caused
normalization of her behaviors and functional and cognitive abilities
for a few hours following the dose. In clinic, exam showed marked
anxiety with prominent deficits in attention and concentration as well
as problems with memory and language (particularly fluency), increased
rigidity, and frontal release signs.
Upon hospital admission, workup included neurologic examination
on and off of zolpidem, placebo, lorazepam and flumazenil. Objective
improvement in neuropsychological function was noted only
with zolpidem and worsening with flumazenil. Continuous EEG
monitoring was normal. On functional MRI she was unable to do
tasks before medication but after 24 hours on zolpidem she was able
to do tasks and had normal activation of expected areas. FDG-PET
imaging showed improvement in hypometabolism of multiple brain
regions on zolpidem. Whole body imaging, cerebrospinal fluid, and
serum studies were negative for infection, occult malignancy and
paraneoplastic antibodies. Lumbar puncture before and after continuous
zolpidem administration showed a small decrease in protein
level from 60 to 46 mg/dL, and was otherwise unremarkable. She was
discharged on zolpidem CR 12.5 mg three times a day with some improvement
maintained at follow up several weeks later.
The activating effects of zolpidem in the setting of altered levels
of consciousness have been described in a few studies, mainly in the
setting of persistent vegetative and minimally conscious states. This
case appears to represent a case of encephalopathy of unknown etiology
that responds to zolpidem.
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ATRIAL TACHYARRHYTHMIA PRESENTING AS
POLYURIA.
N. Maheshwari, 1 S. Anand, 1 D. Kumari, 2 J. Hanoi, 1 E. Ong, 1 E. Roffe, 2
S. Mushiyev, 3 S. Chaudhari. 2 1. Internal Medicine, New York Medical
College Metropolitan Hospital Centre, Manhattan, New York, NY; 2.
Geriatrics, New York Medical College Metropolitan Hospital Center,
New York, NY; 3. Cardiology, New York Medical College
Metropolitan Hospital Center, New York, NY.
INTRODUCTION: Polyuria is associated with atrial flutter and
atrial fibrillation and excessive urine formation associated with any
abnormal atrial rhythm or activity has been seen in few case reports.
We report an unusual case of atrial tachyarrhythmia presenting as
polyuria.
CASE REPORT: 87 years-old female with history of blindness
in left eye presented to the emergency department with complains of
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AGS 2012 ANNUAL MEETING