Here - American Geriatrics Society

P OSTER
A BSTRACTS
with typical risk factors being an immunocompromised state, malignancy,
or translocation after invasive gastrointestinal procedures. We
describe a patient with a subacute presentation of prosthetic joint infection
with Lactobacillus as the culprit organism. Case: A 95 year old
female with a history of dementia, a left hip fracture with hemiarthroplasty
one year prior, and a clostridium difficile infection now on probiotic
supplementation, developed a new complaint of left leg pain.
The pain was worse with weight bearing, but did not compromise her
walking. Physical examination was remarkable only for superficial
tenderness to palpation of the distal anterio-lateral quadriceps muscle.
Left hip and femur Xrays were normal with her prosthesis in
anatomic alignment. Six months later she developed new difficulty in
transferring from bed to stand, requiring one person assist and skin
breakdown over the left lateral hip. A CT scan showed femoral diaphyseal
cortical defects and subcutaneous and intramuscular enhancing
collections concerning for infected hip prosthesis with sinus tract.
Intra-operative cultures revealed lactobacillus casei/paracasei. Multiple
peripheral blood cultures were negative. She completed a fourweek
course of intravenous penicillin and then was placed on oral dicloxacillin
for long term suppressive therapy. Discussion: This case
demonstrates the subtle history and physical examination findings
that can accompany subacute prosthetic hip infections in advanced
age. The index of suspicion should remain high despite the reassuring
lack of classic local or systemic infectious signs or symptoms. In the
face of suspicion, the history should consider a broad range of potential
pathogens. Current research argues against a link between systemic
disease and probiotic therapy, but this case suggests such a link.
B16
POEMS Syndrome: A Rare Cause of Gait Imbalance.
S. Arshad, J. Angeles, H. A. Arabelo. Geriatrics, St. Luke’s-Roosevelt
Hospital, Academic Affiliate of Columbia University College of
Physicians & Surgeons, New York, NY.
Gait imbalance is very common in the elderly and could result
from multiple causes, some of which are treatable. Loss of balance
can be very debilitating.
An 87 year old patient presented with bilateral leg weakness
and imbalance. He reported trouble walking for the past year accompanied
with ankle edema. Upon admission he was found on the floor
and unable to ambulate. He complained of tingling in his feet &
hands bilaterally. On physical exam he had no fasciculations, normal
muscle tone, mild finger abductor weakness & 1+ bicep reflexes. He
had weakness in both legs, markedly diminished pinprick in the legs
to the mid thigh bilaterally, absent vibratory sensation in his feet, absent
position sense in the toes, absent Achilles reflexes, and cautious
gait with increased base. MRI of the spine showed DJD and mild
compression fracture of T12 with no nerve impingement or cord lesions.
TSH, B12 levels, and the Lyme Antibody were unremarkable.
An EMG showed moderate to severe peripheral neuropathy with significant
slowing in the right tibial and peroneal nerves, consistent
with acquired demyelination. An IgG lambda spike on protein and
immune fixation electrophoresis was noted. The skeletal survey was
without lytic or blastic lesions. The patient had gait ataxia from severe
peripheral neuropathy with monoclonal gammopathy as the etiology.
Our patient has features of POEMS with sensory motor
polyneuropathy, endocrinopathy with recent diabetes mellitus, edema
and IgG lambda protein monoclonal gammopathy. He will follow up
with his Hematologist & Neurologist for treatment and also have
physical therapy.
POEMS is a multisystemic syndrome that occurs in the setting
of plasma cell dyscrasia. It is rare and can be underdiagnosed leading
to recurrent falls. POEMS syndrome occurs because of the growth of
certain clonal plasma cells that produce an abnormal amount of
blood proteins, which damage body organs & result in this acronym
for the syndrome’s most common features consisting of polyneuropathy,
organomegaly, endocrinopathy or edema, monoclonal protein
and skin changes. Not all features of the disease are required to make
the diagnosis. POEMS syndrome begins around age fifty and affects
twice as many men as women. If untreated it is progressive and often
fatal. Only 60% survive five years after onset. However, the symptoms
can improve if the blood disorder is diagnosed and treated.
B17 Encore Presentation
A Rare Etiology of Acute Cardiomyopathy and Respiratory Failure.
S. Lee, S. Bellantonio, D. Joseph. Internal Medicine, Baystate Medical
Center, Springfield, MA.
INTRO
Adult-onset Still’s Disease(AOSD) is a rare systemic inflammatory
disorder of unknown etiology, commonly presenting with fever,
rash, and arthritis/arthralgias. It more commonly affects women; median
age of onset is 25. We report an atypical presentation of an
AOSD flare with possible Macrophage Activation Syndrome(MAS)
associated with extreme hyperferritinemia in a 60 year old male.
CASE
A 60-year-old high-functioning male with history of AOSD presented
with subacute fever, rigors, and diarrhea. His exam was unremarkable,
with no evidence of rash, synovitis or lymphadenopathy.
Labs revealed mild leukocytosis and creatinine of 3.2mg/dL. He was
admitted for acute renal failure and treated supportively with IV fluids.
The next day, he developed acute, progressively worsening respiratory
distress. CXR showed multifocal atelectasis without pulmonary
congestion. There were no ischemic EKG changes, but
troponinT was elevated(0.37). Echocardiogram revealed new diffuse
hypokinesis with depressed systolic function(EF 30%). Serum ferritin
was markedly elevated(103,670). He was transferred to the ICU and
put on noninvasive ventilation. High dose IV steroids were initiated
with impressive improvement in respiratory status. He was transitioned
to PO steroids, and a week later initiated on an IL1 antagonist(anakinra)
and discharged with normal renal function. Hypoxemia
and dyspnea resolved over the ensuing weeks with ferritin
returning to normal. Repeat echo showed normal cardiac function.
Steroids were eventually tapered and anakinra continued.
DISCUSSION
Besides AOSD and MAS, there are few, if any conditions presenting
with this extraordinary degree of hyperferritinemia. MAS,
commonly associated with rheumatologic conditions, is caused by
overwhelming macrophage activation resulting in phagocytosis of
erythrocytic precursors in bone marrow. Both AOSD flare and MAS
can be triggered by infection, and similarly managed with immunosuppression,
as in our patient. The absence of cytopenias and hypofibrinogenemia
militate against MAS. MAS is only confirmed with bone
marrow biopsy, but with high false negative rates.
CONCLUSION
AOSD flare and MAS are rapidly fatal conditions that can
occur in older adults. Both mimic sepsis with multiorgan dysfunction,
and diagnosis is often delayed. Quick recognition and treatment is
vital for favorable outcome.
B18
Dysphagia with a Large Goiter: What You See Is Not Necessarily
What You Get.
S. McCullough, 1 J. Reckrey, 1,2 B. Shah. 1,2 1. Mount Sinai School of
Medicine, New York, NY; 2. Department of Geriatrics, Mount Sinai
Hospital, New York, NY.
Dysphagia commonly accompanies acute presentations of the
elderly. This case illuminates the importance of maintaining a broad
differential for dysphagia and highlights the phenomenon of
pseudoachalasia.
A 90 year old woman with a history of GERD, dysphagia, hyperthyroidism
with a 7-cm multinodular goiter and atrial fibrillation
with rapid ventricular response was transferred from her nursing
S78
AGS 2012 ANNUAL MEETING