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urinary frequency of more than 10 episodes daily for last 10 days; review
of systems was negative except for polyuria, On physical examination
(PE) revealed tachycardia of 200 beats/min, Cardiovascular
examination revealed tachycardia with irregular pulse, left eye blindness,
rest of PE including genitourinary examination was normal.
Electrocardiogram (EKG) showed atrial flutter and repeat EKG
showed atrial fibrillation (AF), Troponin of 0.17ng/mL, normal renal
bladder ultrasound. She was started on diltiazem drip and subsequently
switched to oral long acting beta blocker (BB) and her urinary
frequency and tachycardia resolved, started on Coumadin for
AF. Echocardiogram showed ejection fraction of less than 25%. Next
day patient again have tachycardia and urinary frequency and BB
dose was increased and she improved. During the hospital stay patient
developed multiple episodes of tachycardia and urinary frequency
until BB dose titrated to achieve a controlled heart rate with
normal sinus rhythm and urinary frequency resolved.
DISCUSSION: Polyuria associated with abnormal atrial activity
like atrial flutter or atrial fibrillation has been reported in few
cases in past, but no exact mechanism is known. Wood suggested that
polyuria is secondary to anti diuretic hormone inhibition; later
Michael J et al speculate that human atrial hyperactivity from an
atrial arrhythmia represents a natural experiment in man simulating
volume expansion, and signaling the kidney to decrease renal tubular
sodium and water reabsorption. The diuresis begins at once and becomes
manifest in few minutes, stops immediately when the attack
ends, as seen in our case. Physicians should keep polyuria as one of the
rare presentation or differential diagnosis of atrial tachyarrhythmia.
B13
Diffuse Lewy Body Dementia (DLBD): Missed diagnosis can be life
threatening.
N. Bansal, D. Manocha, S. Brangman. SUNY Upstate Medical
University, Syracuse, NY.
Background: DLBD accounts for around 20% cases of adults
with dementia. Clinical features include cognitive impairment with
fluctuating course, neuropsychiatric manifestations, motor and autonomic
dysfunction. Heightened sensitivity to neuroleptics is a grievous
complication.
Case Report: We present a unique learning case of a 65 year old
lady with past medical history of remitting relapsing multiple sclerosis(MS)
on betasetron prophylaxis. She had two recent hospitalizations
for worsening agitation and hallucinations at an outside facility
which were interpreted as manifestations of MS flare. Escalating
doses of antipsychotics (19 mg of haloperidol intravenously over 24
hours) were administered besides the therapy for MS. Subsequently,
she was transferred to our institution for need of neuro ICU management
of MS. She was dehydrated, febrile(102 F), had rigidity and myoclonus
on initial evaluation. Her metabolic profile revealed elevated
creatine kinase levels(9812 IU/ L) and acute kidney injury. A diagnosis
of neuroleptic malignant syndrome was made. She responded well
to medical management. After resolution of acute complications, patient
started re experiencing visual hallucinations, depressive symptoms
and memory lapses to create a diagnostic and management
dilemma for the primary team. A detailed geriatric assessment was
then performed. It revealed history of worsening short term memory
loss with fluctuations over the past 1year, complicated by bradykinesia
and depression for 7 months and visual hallucinations for 4
months. The mental status testing revealed impaired visuospatial orientation,
recall and execution. Work up for reversible causes (including
Vitamin B12/ TSH/RPR-VDRL) and brain imaging were noncontributory.
Thus a diagnosis of Diffuse Lewy Body Dementia with
sensitivity to neuroleptics with neuroleptic malignant syndrome was
made. The patient was started on donapezil for cognition, citalopram
for depression and valproic acid for other secondary behavior problems
with partial stabilization of her symptoms. Discussion: Use of
neuroleptics has been associated significant adverse reactions in 54-
81% patients with DLBD. Studies have shown increased mortality
and shortened survival times in affected patients. Compromised nigrostriatal
dopaminergic transmission predisposes to neuroleptic sensitivity
even at modest doses.Co-existing medical conditions may
delay the diagnosis and appropriate management as was the case in
our patient.
B14 Encore Presentation
Getting the Patient Out of the Woods - Near Death from Babesiosis
in an Elder.
R. Jaber, M. Brennan. Internal Medicine, Baystate Medical Center,
Springfield, MA.
Supported By: Baystate Medical Center/Tufts Univ. School of
Medicine
Introduction
Babesiosis is a tick-borne disease common in the Northeast and
Midwest. The parasite, Babesia microti, infects red blood cells and can
cause serious illness. The authors report a case of life threatening infection
in an elder who recovered after prompt diagnosis and aggressive
treatment.
Case summary
An 85-year-old man had 5 days of malaise, lethargy, and fever.
PMH included ischemic stroke, hyperlipidemia and possible
myelodysplastia. He lived in Monson, Massachusetts and had recently
been gardening in a wooded area.
On physical examination he appeared ill, was diaphoretic,
slightly confused and febrile (101.7 F). He had a regular tachycardia
(115 bpm). His bp was 137/75, RR was 20 and his O2 saturation was
93% on 3 ls; there was no rash or lymphadenopathy. He had a few
coarse crackles at the left base but his exam was otherwise normal.
His wbc count was 3.9 K and left shifted with 13% bands. His hemoglobin
was 9.7 gm/dl and the platelet count was 40 K. Most notably,
he had an RBC parasitemia of 10 % classic for Babesiosis.
Chest X-ray revealed left lower lobe atelectasis. Azithromycin and
atovaquone were begun and he was tested for anaplasmosis (Human
Monocytic Ehrlichiosis) since patients often have concomitant infections
and this requires adjusting antibiotics. This was positive, so
doxycycline was added. On hospital day 4, he developed severe hemolysis;
his hemoglobin dropped to 6 and his parasitemia rose to 19
%. Red blood cell exchange was performed; antibiotics were switched
to clindamycin and quinine. The patient improved; at discharge the
parasitemia was under 1 %.
Discussion:
Life-threatening Babesiosis occurs most often in elders (age> 75
yrs) and those who are immunosuppressed or asplenic. Most deaths
are due to hemolysis, thrombocytopenia, DIC, or multi-organ failure.
Early recognition is critical. This patient’s life likely was saved by
prompt diagnosis in a community hospital. This resulted in rapid
transfer to tertiary care thereby facilitating immediate response to
subsequent massive hemolysis. The case also highlights the importance
of assessing for co-infection with Ehrlichia. Failing to identify
all major infections would probably have proved fatal. Geriatricians
often care for immunocompromised, frail elders. To prevent unnecessary
deaths they must be aware of the presentation, natural history,
treatments and complications of Babesiosis and screen promptly for
co-infections.
B15
An Unusual Case of a Prosthetic Joint Infection with Lactobacillus.
R. Zitnay, S. Chao. Section of Geriatrics, Boston University Medical
Center, Boston, MA.
Background: Lactobacillus is a Gram positive organism found
as normal flora in the oral cavity, genital, and gastrointestinal tract. It
is classically a nonpathogenic organism, found in fermented food
products and probiotic supplements. Serious infections are very rare,
AGS 2012 ANNUAL MEETING
S77