An unusual case of cholecystitis and liver abscesses in an older adult

(1)

Article

Reference

An unusual case of cholecystitis and liver abscesses in an older adult

SOROKEN, Cindy, et al.

SOROKEN, Cindy, et al . An unusual case of cholecystitis and liver abscesses in an older adult.

Journal of the American Geriatrics Society , 2012, vol. 60, no. 1, p. 160-1

DOI : 10.1111/j.1532-5415.2011.03759.x PMID : 22239299

Available at:

http://archive-ouverte.unige.ch/unige:26291

Disclaimer: layout of this document may differ from the published version.

1 / 1

(2)

started to develop just days after he started levetiracetam and resolved within 5 days of cessation.

The reduction in mobility and the psychotic symptoms were most likely due to levetiracetam. Given that there is not sufficient literature on such side effects involving older adults and the unique feature of reduced mobility, it was felt that this warranted highlighting.

Anne Robins, MBchB Martyn Patel, MBchB Abul Azim, MBBS West Suffolk Hospital, Suffolk, UK

ACKNOWLEDGMENTS

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

Author Contributions: Robins: Preparation of manuscript. Patel: Literature search and data collection. Azim:

Lead consultant.

Sponsor’s Role:None.

REFERENCES

1. Wilmore LJ, Wheless JW, Pellock JM. Adverse effects of anti-epileptic drugs.

In: Pellock JM, Dodson WE, Bourgeois BF. Pediatric Epilepsy. New York:

Demos. 2001, pp 343–355.

2. Cereghino JJ, Biton V, Abon-khalil B et al. Levetiracetam for partial sei- zures. Neurology 2000;55:236–242.

3. Kossoff EH, Bergey GK, Freeman JM et al. Levetiracetam psychosis in chil- dren as epilepsy. Epilepsia 2001;42:1611–1613.

4. Youroukos S, Lazopoulou D, Michelakou D et al. Acute psychosis associated with levetiracetam. Epileptic Disord 2003;2:117–119.

5. Mula M, Trimble MR, Yuen A et al. Psychiatric adverse events during levetiracetam therapy. Neurology 2003;61:704–706.

6. Mula M, Trimble MR, Sander JW. Are Psychiatric adverse events of antiepi- leptic drugs unique entity? A study on topiramate and levetiracetam. Epilep- sia 2007;48:2322–2326.

7. Foley KT, Bugg KS. Separate episodes of delirium associated with levetiracetam and amiodarone treatment in an elderly woman. Am J Geriatr Pharmac- other 2010;8:170–174.

8. VandeGriend JP, Linnebur SA, Bainbridge JL. Probable Levetiracetam associated depression in the elderly: Two case reports. Am J Geriatr Pharmac- other 2009;7:281–284.

9. Naranjo CA, Busto U, Sellers EM et al. A method for estimating the proba- bility of adverse drug reactions. Clin Pharmacol Ther 1981;30:239–245.

AN UNUSUAL CASE OF CHOLECYSTITIS AND LIVER ABSCESSES IN AN OLDER ADULT

To the Editor: A 76-year-old man was admitted to the emergency department (ED) for anorexia, weight loss of 5 kg in 2 months, fatigue, and anhedonia after his sole sis- ter’s death. He had no other complaints: no abdominal pain, transit abnormalities, fever, or chills. He had a history of type 2 diabetes mellitus, severe chronic kidney failure, peripheral neuropathy, hypertension, stage 2 lower extremity vascular disease, hypothyroidism, and atrial fibrillation. His regular medication consisted of acetylsali- cylic acid, venlafaxine, hydrochlorothiazide, torasemide, levothyroxine, atenolol, and insulin.

Upon admission, he was awake and responsive but weak and appeared depressed. Temperature, blood pressure, and heart rate were normal. Abdominal examination showed active bowel sounds, no tenderness or rebound tenderness, and no masses. Lower liver border was not palpable, and Murphy maneuver was negative.

Initial laboratory values showed normocytic anemia (hemoglobin 10.0 g/dL), leukocytosis with no left shift (white blood cell count 14,000 cells/lL) and C-reactive pro- tein (CRP) of 246 mg/dL. Electrolytes were normal despite severe chronic renal failure (calculated creatinine clearance of 21 mL/min according to the Cockroft formula). Liver enzymes were normal except for a slightly high gamma- glutamyltranspeptidase (76 IU/L, normal <40 IU/L) and bilirubin (1.75 mg/dL, normal<1.46 mg/dL).

Because of suspected depression, he was referred to a specialized geriatric ward where a combined follow-up by geriatricians and psychiatrists is provided. During the fol- lowing days, he developed no new symptoms but still refused any food. Biological inflammatory markers remained high. Liver enzymes remained unchanged except for normalization of bilirubin values. Chest X-ray was normal. Urine and blood cultures were negative. The dose of venlafaxine was doubled at admission to 75 mg/d and thereafter remained unchanged.

Because of persistent inflammation, he underwent a thoracoabdominal computed tomography scan without contrast injection. The imaging revealed a dilated gallbladder (9.695.3 cm in the axial cross-section) with thick- ened walls, compatible with acute cholecystitis, and multiple hypodense lesions of liver segments V and VIII, suggestive of liver abscesses (Figure 1).

Cholecystectomy and surgical drainage were per- formed. Cultures grewEscherichia coli. He was prescribed ceftriaxone for 3 weeks. He was discharged 2 months later, after a normal abdominal ultrasound and major mood improvement. Signs and symptoms consistent with normal grieving remained.

DISCUSSION

We present the case of an older adult with acute cholecystitis and multiple liver abscesses, with no suggestive symptoms except for anorexia and biological signs of inflammation. Atypical presentation of acute cholecystitis is frequent in older adults, with 5–25% presenting without Figure 1.Abdominal computed tomography scan showing acute cholecystitis.

160 LETTERS TO THE EDITOR JANUARY 2012–VOL. 60, NO. 1 JAGS

(3)

pain and 30–50% without fever.^1,2Gallbladder disease in older adults has one of the highest discrepancy rates (70%) between ED and hospital discharge diagnosis.³ Acute cholecystitis mortality rate in both older adults and people with diabetes mellitus is higher than in the general population.⁴

Pyogenic liver abscess is a life-threatening disease and may appear in single or multiple form. The main bacte- rium isolated in multiple abscesses isE. coli. In a previous study, multiple abscesses were of biliary origin in 45% of cases and were related to an overall mortality rate of 22%, regardless of the therapeutic strategy taken. Medical treatment alone was associated with the highest mortality rates (28.9%); 44% of patients had concurrent diabetes mellitus.⁵

This case illustrates the unusual presentations that can be encountered in older adults. This individual had a highly atypical case of cholecystitis and liver abscesses, with symptoms suggesting depression. Physical and laboratory findings were almost entirely normal. Persistent ele- vation of CRP was the principal indication of severe somatic illness in this case. Physicians should not rely purely on physical and biological findings but should also be alert to psychiatric symptoms that may be masking a medical illness, thereby ensuring proper diagnosis and treatment.

Cindy Soroken, MD Nikolaos Samaras, MD Dimitrios Samaras, MD Philippe Huber, MD Department of Internal Medicine, Rehabilitation, and Geriatrics, Geneva Medical School and University Hospitals, Geneva, Switzerland

ACKNOWLEDGMENTS

Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper.

Author Contributions: All authors contributed to the preparation of the manuscript and the revision of the related literature. All authors were involved in the ongoing supervision of the patient.

Sponsor’s Role: No financial contributions were received for the preparation of this manuscript.

REFERENCES

1. Morrow DJ, Thompson J, Wilson SE. Acute cholecystitis in the elderly: A surgical emergency. Arch Surg 1978;113:1149–1152.

2. Parker LJ, Vukov LF, Wollan PC. Emergency department evaluation of geriatric patients with acute cholecystitis. Acad Emerg Med 1997;4:51–55.

3. Lewis LM, Banet GA, Blanda M et al. Etiology and clinical course of abdominal pain in senior patients: A prospective, multicenter study. J Geron- tol A Biol Sci Med Sci 2005;60A:1071–1076.

4. Kimura Y, Takada T, Kawarada Y et al. Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines.

J Hepatobiliary Pancreat Surg 2007;14:15–26.

5. Chou FF, Sheen-Chen SM, Chen YS et al. Single and multiple pyogenic liver abscesses: Clinical course, etiology, and results of treatment. World J Surg 1997;21:384–388; discussion 388–389.

ACHALASIA IN A NONAGENARIAN PRESENTING WITH RECURRING ASPIRATION PNEUMONIA To the Editor: Approximately 10% of community- acquired pneumonia cases are thought to be aspiration pneumonia.¹ Aspiration pneumonia is more common in older adults than in younger individuals. Common risk factors for aspiration pneumonia are neurological disor- ders, including stroke, dementia, and Parkinson’s disease.¹ Esophageal conditions such as strictures and gastroesophageal reflux disease are also well-described risk factors.^2,3 Despite being a known risk factor for aspiration pneumonia, achalasia often does not make the list of differential diagnoses in evaluating aspiration pneumonia in older adults because of its rare incidence. A case of a nonagenarian who developed recurrent episodes of aspiration pneumonia secondary to achalasia is presented. Treatment of achalasia resulted in resolution of dysphagia and preven- tion of aspiration pneumonia.

A 91-year-old white man presented to the hospital with a productive cough and wheezing for 2 weeks. He had begun experiencing dyspnea and low‐grade fever 1 day before admission. He denied recent travel, sick contacts, chest pain, palpitations, abdominal pain, nausea, or vomit- ing. He complained of difficulty swallowing solids and frequent regurgitation. His past medical history included atrial fibrillation, hypertension, mitral regurgitation, transient ischemic attack, colon cancer, and hemicolectomy 7 years before hospitalization. His outpatient medications included metoprolol, omeprazole, baclofen, ferrous sulfate, levalbu- terol, and docusate sodium. Vital signs on admission were temperature, 99.8°F; blood pressure, 124/69 mmHg; and pulse, 100 beats/min. Wheezing was heard in the right lower lung field on auscultation. Chest X-ray showed findings of right middle lobe consolidation. He was treated for community-acquired pneumonia.

Review of his past medical records revealed that he had presented to the primary care physician four times over 15 months with complaints of productive cough, dyspnea, or both, two of which had resulted in hospitalization. There was no history of pneumonia during 5 years before the onset of this sequence of respiratory illnesses.

He had seen his primary care physician 2 months before complaining of dysphagia and regurgitation of food 10–

15 minutes after eating. Two months after hospitalization, he underwent a barium esophagram, which showed that the esophagus was dilated throughout its course in the chest except at the gastroesophageal junction, where there was a smooth tapering to a narrowed gastroesophageal junction (Figure 1). Subsequent upper endoscopy showed a dilated esophagus with stasis-related esophagitis. There was resistance to passage of a scope consistent with achalasia. He underwent serial upper endoscopies with botulinum toxin injections to the lower esophageal sphincter. Symptoms of dysphagia and regurgitation resolved after treatment, and he remained free of pneumonia for 2 years after resolution of achalasia symptoms.

Achalasia is a Greek term that means “failure to relax.” It is an uncommon esophageal disease characterized by impaired peristalsis in the distal esophagus and failure of the lower esophageal sphincter relaxation. It is a rare

JAGS JANUARY 2012–VOL. 60, NO. 1 LETTERS TO THE EDITOR 161