Differential Diagnosis Of Older Patients Research Articles

Diagnostic utility of the Alvarado scale in older adults with suspected acute appendicitis.

Acute appendicitis remains as a differential diagnosis in older patients with abdominal pain. The Alvarado scale may assist to guide the diagnosis and treatment of this entity. The operative characteristics of the scale are little known in this population. We conducted a systematic review of original studies published between 1986 and 2022 evaluating the diagnostic performance of the Alvarado scale in older adults with suspected acute appendicitis. The review was conducted according to the PRISMA statement. The evaluation of the methodological quality of the studies was performed according to the ROBINS-I criteria. Four original studies of retrospective design including 480 patients were identified. The heterogeneity and poor methodological quality limited an aggregate statistical analysis (meta-analysis). The value of the ROC curve of the scale varies between 0.799 and 0.969. From the available studies, the value of the ROC curve is lower in comparison to the RIPASA scale and comparable to the Lintula scale. The evidence on the diagnostic performance of the Alvarado scale in older adults is limited. The poor methodological quality of the available studies calls for a prudent use of this tool in this population. Our findings offer opportunities for future research.

The Benign Clone Causing Aplastic Anaemia

Severe Aplastic Anaemia (SAA) is a rare benign disease but carries a high-mortality rate unless treated in a specialised centre. Overwhelming laboratory and clinical evidence points to an autoimmune pathogenesis; although, the aetiology remains obscure in the majority of cases. The differential diagnosis in older patients is problematical and a diagnosis of hypoplastic myelodysplasia remains difficult. This review points out the difficulty in diagnosis without a specific test. Future research needs to define a specific diagnostic test and refine therapeutic interventions.

Atypical femoral fracture mimicking lumbar radiculopathy in two patients taking bisphosphonate long-term: A case report

BackgroundAtypical femoral fracture (AFF) is a rare complication in patients with osteoporosis undergoing long-term bisphosphonate therapy. The most common symptom of incomplete AFF is nonspecific thigh pain, which is often difficult to distinguish from other causes.Case presentationWe present two cases of AFF misdiagnosed as lumbar radiculopathy. Both patients visited our hospital for thigh pain, and in both cases the findings of lumbar spine magnetic resonance imaging showed substantial nerve compression. These patients had been treated for lumbar radiculopathy, but localized symptoms became conspicuous and femoral radiographs revealed complete AFF. The initial radiographs were reviewed retrospectively and revealed slight lateral cortical thickening in the affected femur, denoting a missed incomplete AFF. Internal fixation with intramedullary nails was performed.ConclusionsAFF may mimic lumbar radiculopathy. Therefore, clinicians should consider AFF as a differential diagnosis in older patients with lumbar canal stenosis who are undergoing long-term bisphosphonate therapy and present with thigh pain.

Jackstone Calculus

A 75-year-old man presented with a 3-year history of poor urinary flow, recent hematuria, and urgency. He had been taking α-blockers for more than 10 years for lower urinary tract symptoms. He was a nonsmoker. Computed tomography revealed normal kidneys and ureters but a large intravesical extension of the prostate gland and calculi with a spiculated pattern (Figure 1A and B), characteristic of jackstone calculi. Cystoscopic examination revealed calculi with multiple spicules and characteristic dark bands (Figure 2). He underwent cystoscopy-guided laser lithotripsy, with complete fragmentation via holmium laser. He also had concurrent transurethral resection of the prostate gland. Postoperatively, he voided with a good stream.Figure 2Cystoscopic image showing jackstone calculi in the bladder.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Jackstone calculi are bladder calculi composed of calcium oxalate dihydrate, which gives them their irregular shape.1Singh K.J. Tiwari A. Goyal A. Jackstone: a rare entity of vesical calculus.Indian J Urol. 2011; 27: 543-544Google Scholar They get their name from their resemblance to toy “jacks” with multiple spicules. Bladder calculi are an important consideration in the differential diagnosis in older patients with hematuria and are often secondary to prostatic obstruction.2Douenias R. Rich M. Badlani G. Mazor D. Smith A. Predisposing factors in bladder calculi: review of 100 cases.Urology. 1991; 37: 240-243Google Scholar Primary care physicians should be aware of their characteristic appearance on plain radiography. It is imperative, however, to perform contrast-enhanced computed tomography of the abdomen and pelvis and a thorough cystoscopic examination to rule out malignancy as cause of the hematuria.

Late age onset of amyotrophic lateral sclerosis is often not considered in elderly people.

Amyotrophic lateral sclerosis (ALS) is a fatal neurodegenerative disease causing an upper and lower motor neuron loss. It is neurology textbook knowledge that the mean age of onset is about 60years. However, recent investigations show an increasing incidence in older persons. We therefore evaluated whether ALS is potentially not considered in elderly people with ALS symptoms, respectively, not recognized. We included retrospectively all patients with ALS diagnoses after work-up that were admitted to our neurological and geriatric departments from 2007 to 2010 and collected their clinical data. The diagnosis of ALS was based on the El Escorial criteria. Patients were grouped into three categories according to age (<50, between 50 and 70, >70), and differences in clinical and/ or biographical factors were investigated. We identified 35 patients (18 men and 17 women) with a median age at onset of 71.5years (range: 36-87years). When establishing the diagnosis, 51% were older than 70years, 40% (14/35) between 50 and 70, and only 9% younger than 50. Only in 46 per cent of patients who were sent to our departments with ALS symptoms ALS was considered by the referring physician. Late age onset of ALS seems to be more common than formerly assumed and is presumably under-recognized in elderly patients. ALS needs to be considered as a differential diagnosis in older patients. Potential factors accounting for older people being underdiagnosed with ALS relate to frequent presentation with symptoms like dysphagia, frailty or general weakness for other reasons.

Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment

So, you want to enter the lucrative world of dementia evaluations, but it has been a long time since you saw anyone under 65? Then this 2013 contribution by Glenn Smith and Mark Bondi might just be the ticket to get you headed in the right direction. Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment is another volume in the American Academy of Clinical Neuropsychology series that follows a strong tradition of authoritative texts that appeal to graduate students and seasoned professionals and all neuropsychologists in between. Smith and Bondi are so extensively published and widely known for their work in aging and dementia that you could not find more qualified experts to guide you through the literature and offer their views on the late life continuum of cognitive disorders. As evident in the introductory chapter, the labels and criteria used to identify various stages of cognitive decline in the elderly have undergone dramatic shifts over the past three decades, with the speed of these changes rapidly increasing. For example, in just the past few years, major revisions have been made to the diagnostic criteria for various cognitive disorders from groups like the National Institute of Aging—Alzheimer's Association and the American Psychiatric Association. Smith and Bondi nicely summarize these changes and expound on future directions. In the second chapter, they also offer us glimpses into the future by identifying five expected roles for neuropsychology in this brave new world of “preclinical” dementia, including using neuropsychological measures as biomarkers and proxy outcomes in clinical trials. But as much as they praise the potential contribution of neuropsychology, they also encourage us to continue to advance our role in this ever-changing niche to remain competitive with neuroimaging and other biomarkers. The following chapters on normal cognitive aging and Mild Cognitive Impairment are excellent summaries of the existing literature on the non-demented side of the continuum. These chapters review a number of their own studies (and their colleagues at Mayo Clinics and University of California San Diego system), which might seem somewhat biased if they were not so germane. Chapters 5–8 cover the “big four” in dementias: Alzheimer's disease, vascular dementia, Dementia with Lewy bodies, and frontotemporal dementia. These are my bread and butter; the cases I see week in and week out. Despite this, I thoroughly enjoyed Smith and Bondi's approach to these chapters. Each chapter starts with a case presentation or two that makes the disorder more concrete. They also address the latest diagnostic criteria, neuropathology associated with the specific etiology, and typical neuropsychology findings from the literature (as well as their own decades of experience with these patients). Tanis Ferman guest authors a delightfully erudite chapter in this section on Dementia with Lewy bodies, which should make anyone feel more comfortable identifying these types of patients. Mild Cognitive Impairment and Dementia ends with chapters on the atypical dementias and interventions for behavioral difficulties in dementias. Under the atypical dementias, guest author David Salmon reviews progressive supranuclear palsy, corticobasal degeneration, posterior cortical atrophy, and other lesser common conditions. The last chapter offers practical recommendations that can be added to most neuropsychological reports to assist patients, families, and other care staff who encounter these non-cognitive symptoms of dementia. As with any book, some readers may be disappointed with certain decisions made by the authors. In this text, very few came to mind for me. In one, the authors review most of the main hypotheses of the neuropathology of Alzheimer's disease (e.g., choline hypothesis, vascular hypothesis, and amyloid cascade hypothesis), but seem to neglect others (e.g., tau and neuroinflammation). Similarly, a sizeable minority of my patients referred for a dementia evaluation do not end up having one of the “big four,” but some other reversible (e.g., autoimmune and metabolic) or non-dementia condition (e.g., depression and delirium). Readers new to this area would have benefitted from a chapter devoted to these conditions, which are frequently considered in the differential diagnosis in older patients with cognitive complaints. Perhaps this will be another volume in this series? Despite these limited concerns, Mild Cognitive Impairment and Dementia: Definitions, Diagnosis, and Treatment kept this informed reader underlining text, tabbing pages, and making notes in the margins. Whether you are a trainee learning about dementia for the first time, preparing for your board certification examination, brushing up on the literature for an upcoming case, or trying to confirm (or refute) what you thought you knew about dementia, this book has much to offer. Finally, what you might lose in reimbursement rates from seeing dementia referrals will surely be made up for in the volume of these cases in the coming years, so be prepared.

Very late-onset Friedreich ataxia: later than life expectancy?

Friedreich ataxia (FA) is an autosomal-recessive hereditary ataxia with a prevalence of around 1 case per 30,000. It is a severely debilitating disease characterized by progressive gait and limb ataxia, dysarthria, lower-limb areflexia, muscular weakness and pyramidal signs, and is due to GAA triplet expansion in the frataxin (FXN) gene located on chromosome 9q13 [1]. Patients usually begin the disorder at puberty or before the age of 25 years in most studies, but rare cases of ‘Late-Onset Friedreich ataxia’ (LOFA) have been described. LOFA patients were recognized to have a median age of onset of 28.8 years (range of 25.5–48), have a milder phenotype and often retained lower limb reflexes [2, 3]. Very late–Onset Friedreich ataxia (VLOFA) has also been reported [4, 5], with the first manifestations appearing in the seventies. Here we report an 82-year-old lady who presented with balance difficulties that led to some loss of independence. Symptoms began at about age 80 with subsequent mild dysarthria. She denied any similar familial history, rending autosomal dominant disease unlikely. On examination, cognition was normal, but she had hypometric ocular saccades, dysarthria, generally brisk deep tendon reflexes except for bilateral absent ankle jerks and a bilateral Babinski sign. There was also reduced ability for rapid, alternating motor tasks. There was no loss of sensations, including proprioception. The patient also showed important gait ataxia. The Scale for the Assessment and Rating of Ataxia (SARA) was rated 15 (gait: 3; stance: 1; sitting: 1; speech disturbance: 2; finger chase: 1; nose-finger test: 2; fast altering hand movements: 2; heel-sheen slide: 3). There was no pes cavus, scoliosis, deafness or diabetes. The nerve conduction study was normal, including amplitude of the sural nerve action potentials. Cardiac echography and EKG were normal. Friedreich ataxia was considered as a diagnosis based on ataxia with a bilateral Babinski sign and absent Achilles reflexes and normal blood vitamin E levels with undetectable serum antinuclear auto-antibodies (against Hu, Yo, Ma2, CV2/CRMP5, Ri, Tr, and GAD). The diagnosis was confirmed when an unstable GAA triplet expansion was demonstrated on both alleles of the FXN gene, with 170 and 1,300 tri-nucleotides, respectively. The small GAA expansion probably explains why the patient developed FA in her eighties, as other studies suggest a correlation between the size of the expanded tri-nucleotide repeats and severity of the disease and an inverse correlation with the age of onset [6, 7]. To our knowledge (excluding one possible but not proven case) [8], this lady represents the highest age of onset for a diagnosed FA patient. Even though FA is typically encountered in young patients, this report confirms that it cannot be excluded based on the advanced age of the patient, and should remain a possible differential diagnosis of older patients with ataxia, along with other genetic causes, such as SCA6 [9].

Diagnosis of Meckelʼs Diverticula via Double Balloon Enteroscopy

Purpose: Meckel's diverticula (MD) are typically found in the ileum and > 50% contain heterotopic gastric or pancreatic mucosa. MD may present with gastrointestinal hemorrhage, intussusception, obstruction, diverticulitis, or perforation. Most MD are diagnosed via technetium-99 scintigraphy or at surgical exploration. Double balloon enteroscopy (DBE) permits direct endoscopic visualization and therapy for lesions in the distal small bowel. We sought to characterize our experience with the diagnosis of MD via DBE. Methods: We retrospectively reviewed DBE performed at two tertiary care centers from 2004-2012 for the diagnosis of MD. Results: We report 8 cases of MD diagnosed via retrograde DBE at two tertiary referral centers (Table 1). All 8 patients had prior negative endoscopic and/or radiologic evaluation and were subsequently referred for device-assisted enteroscopy.Table 1: No Caption available.Conclusion: Retrograde DBE readily detects the presence of MD. While prior series have emphasized MD in the differential diagnosis of obscure bleeding in the young, the median age in our series was 57 years. MD should remain in the differential diagnosis in older patients with bleeding. The endoscopic identification of ectopic gastric mucosa and adjacent ulceration presumably increase the likelihood that MD is the source of obscure bleeding. Further, the ability to tattoo the site facilitates laparoscopic surgical intervention. These cases illustrate that MD can be easily identified via retrograde DBE and should be considered in the differential diagnosis of obscure bleeding in adult patients. Disclosure: Dr. Oleh Haluszka - Consultant Fujinon.Figure: Mucosal ulceration within a MD.Figure: Heterotopic mucosa in the base of a MD.

OCULAR SARCOIDOSIS MISDIAGNOSED AS PRIMARY INTRAOCULAR LYMPHOMA

The purpose of this study was to describe patients initially carrying a diagnosis of primary intraocular lymphoma who were ultimately diagnosed with ocular sarcoidosis. The medical records of patients evaluated between 1995 and 2007 fitting the criteria described earlier were identified, and pertinent clinical findings allowing for the diagnosis of sarcoidosis are described. Nine patients between the ages of 52 and 83 were referred with a diagnosis of primary intraocular lymphoma but were ultimately diagnosed with sarcoidosis. The most common clinical signs found in these patients that are atypical for primary intraocular lymphoma but common in sarcoidosis were multifocal choroiditis (n = 7) and cystoid macular edema (n = 6). Additional findings included keratic precipitates, posterior synechiae, and Koeppe nodules. Chest computerized tomography was consistent with sarcoidosis in seven of eight tested patients, and five of these patients had normal chest x-rays. Other findings included elevated angiotensin-converting enzyme and/or lysozyme, and biopsy revealing noncaseating granulomas. Although primary intraocular lymphoma should always be in the differential diagnosis of older patients who present with signs of ocular inflammation, ophthalmologists must also consider other etiologies, including sarcoidosis. A chest computerized tomography may be helpful in the diagnosis, particularly when laboratory findings are supportive of sarcoidosis.

Kikuchi-Fujimoto disease as a rare cause of fever of unknown origin in a septuagenarian

We report the case of a 72-year patient presented with fever of unknown origin. Initial clinical and radiological findings suggested a diagnosis of lymphoma. However, subsequent histology revealed Kikuchi-Fujimoto disease (KFD). KFD is predominantly a self-limiting disease of the young, but should be considered in the differential diagnosis of older patients presenting with fever of unknown origin or features suggestive of lymphoma.

Co-Occurring Depressive Symptoms in the Older Patient with Schizophrenia

Clinicians treating older patients with schizophrenia are often challenged by patients presenting with both depressive and psychotic features. The presence of co-morbid depression impacts negatively on quality of life, functioning, overall psychopathology and the severity of co-morbid medical conditions. Depressive symptoms in patients with schizophrenia include major depressive episodes (MDEs) that do not meet criteria for schizoaffective disorder, MDEs that occur in the context of schizoaffective disorder and subthreshold depressive symptoms that do not meet criteria for MDE. Pharmacological treatment of patients with schizophrenia and depression involves augmenting antipsychotic medications with antidepressants. Recent surveys suggest that clinicians prescribe antidepressants to 30% of inpatients and 43% of outpatients with schizophrenia and depression at all ages. Recent trials addressing the efficacy of this practice have evaluated selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, fluvoxamine and citalopram. These trials have included only a small number of subjects and few older subjects participated; furthermore, the efficacy results have been mixed. Although no published controlled psychotherapeutic studies have specifically targeted major depression or depressive symptoms in older patients with schizophrenia, psychosocial interventions likely play a role in any comprehensive management plan in this population of patients.Our recommendations for treating the older patient with schizophrenia and major depression involve a stepwise approach. First, a careful diagnostic assessment to rule out medical or medication causes is important as well as checking whether patients are adherent to treatments. Clinicians should also consider switching patients to an atypical antipsychotic if they are not taking one already. In addition, dose optimization needs to be targeted towards depressive as well as positive and negative psychotic symptoms. If major depression persists, adding an SSRI is a reasonable next step; one needs to start with a low dose and then cautiously titrate upward to reduce depressive symptoms. If remission is not achieved after an adequate treatment duration (8-12 weeks) or with an adequate dose (similar to that used for major depression without schizophrenia), switching to another agent or adding augmenting therapy is recommended.We recommend treating an acute first episode of depression for at least 6-9 months and consideration of longer treatment for patients with residual symptoms, very severe or highly co-morbid major depression, ongoing episodes or recurrent episodes. Psychosocial interventions aimed at improving adherence, quality of life and function are also recommended. For patients with schizophrenia and subsyndromal depression, a similar approach is recommended.Psychosis accompanying major depression in patients without schizophrenia is common in elderly patients and is considered a primary mood disorder; for these reasons, it is an important syndrome to consider in the differential diagnosis of older patients with mood and thought disturbance. Treatment for this condition has involved electroconvulsive therapy (ECT) as well as combinations of antidepressant and antipsychotic medications. Recent evidence suggests that combination treatment may not be any more effective than antidepressant treatment alone and ECT may be more efficacious overall.

Synovial sarcoma of the larynx in a 79-year-old woman, confirmed by karyotyping and fluorescence in situ hybridization analysis

Synovial sarcoma is an uncommon tumor of the head and neck and is an exceedingly rare finding in the larynx. Generally, it afflicts younger patients and most often occurs in the hypopharynx. We report a case of a biphasic synovial sarcoma arising in the arytenoid fold of a 79-year-old woman. The diagnosis was confirmed by an extensive immunohistochemical panel, karyotyping, and fluorescence in situ hybridization (FISH). The patient was treated with total laryngectomy, and she did well postoperatively. To our knowledge, our patient is the oldest ever to be reported in the literature, concluding that although this entity is considered a disease of young patients, it still has to be included in the differential diagnosis in older patients. Second, our report is only the third to describe t(X;18) (p11.2;q11.2) by karyotyping and the first ever by using FISH analysis, thus adding more cytogenetic data to the literature in this rare location and confirming the use of FISH in making the accurate diagnosis.

Radiologic prevalence of advanced lateral C1-C2 osteoarthritis.

The lateral C1-C2 (atlantoaxial) joints were evaluated retrospectively in 355 patients referred for radiographs of the paranasal sinuses. To determine the radiologic prevalence of advanced lateral atlantoaxial osteoarthritis. Previous studies have shown a relation between atlantoaxial osteoarthritis and referred pain in the suboccipital region. However, the radiologic prevalence of this degenerative disorder is unknown. Five hundred radiographs of the paranasal sinuses were evaluated retrospectively. Both lateral atlantoaxial joints were clearly visible on occipitofrontal projections in 355 examinations. Each lateral atlantoaxial joint was considered severely degenerated when advanced narrowing or obliteration of the joint space, subchondral sclerosis, and/or osteophytosis were present. Atlantoaxial osteoarthritis was found in 4.8% of the patients. The radiologic prevalence of advanced degenerative changes at the lateral atlantoaxial joint(s) was found to increase with age, ranging from 5.4% in the sixth decade to 18.2% in the ninth decade of life. Because advanced degenerative changes at the lateral atlantoaxial joints can cause suboccipital neck pain, these findings should be included in the differential diagnosis in older patients with this symptom.

Late-onset holocarboxylase synthetase deficiency.

We report a 21-month-old female patient whose urine organic acid profile suggested a biotin utilization abnormality consistent with multiple carboxylase deficiency. For most previously reported patients, holocarboxylase synthetase deficiency has correlated with the early-onset variant of multiple carboxylase deficiency; conversely, biotinidase deficiency has been characteristic of the late-onset form. In vitro enzyme studies revealed that our patient suffered from holocarboxylase synthetase deficiency. We suggest that holocarboxylase synthetase deficiency should be considered in the differential diagnosis of older patients in whom there is suspicion of a defect in biotin metabolism.

Ectopic ureters and ureteroceles in adults

Ectopic ureters and ureteroceles are typically diagnosed in childhood and rarely present in adults. Nevertheless, ureteral ectopia should be included in the differential diagnosis of older patients who present with urinary tract infections or urinary incontinence. Detection is often delayed because of inadequate evaluation and heightened awareness is necessary on the part of treating physicians. Earlier detection and proper diagnosis serves to minimize morbidity and, in some cases, may maximize the possibility of renal preservation. Case reports serve to highlight the spectrum of these uncommon but clinically important anomalies.

Mitral valve prolapse syndrome: Analysis of 62 patients aged 60 years and older

Sixty-two patients diagnosed as having mitral valve prolapse, 60 to 81 years old, presented with disabling chest pain (20), symptoms of arrhythmias including palpitations and syncope (16), or mitral regurgitation (MR) with symptoms of congestive heart failure (26). The diagnosis of MVP was made on the basis of a combination of classic auscultatory, echocardiographic and angiographic findings. Thirteen of the 20 patients with chest pain had normal coronary angiograms and 7 had significant coronary artery disease (CAD). Patients with CAD could not be differentiated by clinical presentation alone. Furthermore, the incidence and types of arrhythmias, the presence of a positive stress test, and hemodynamic findings were similar in all patients in this group whether or not CAD was present. The 16 patients with palpitations had a broad spectrum of rhythm disorders, including both supraventricular and ventricular arrhythmias. Two patients had prehospital “sudden death” and 2 others had systemic emboli. Twenty-one of the 26 patients with MR had valve surgery. Intraoperatively the valves were described as enlarged, floppy and with redundant leaflets. Histologie examination showed extensive “myxomatous” changes throughout the valve leaflets. Thus, mitral valve prolapse is a cause of symptomatic heart disease in the elderly. It has a predictable pattern of clinical presentation and should be considered in the differential diagnosis of older patients with disabling chest pain and arrhythmias and as the cause of progressive or severe MR.