Elderly Lady Research Articles

Disseminated tuberculosis masquerading as a psychiatric illness—A case report

ABSTRACT Tuberculosis (TB) can affect any organ, and at times more than one organ in any sequence, in which case it is referred to as disseminated tuberculosis (DTB). We report a patient who presented primarily for psychiatric symptoms of three months’ duration, which later turned out to be a case of DTB involving the central nervous system as well as the spine and lungs. Case Presentation: An elderly lady with subacute onset and worsening behavioural changes of three months’ duration was referred for exclusion of organic brain disease. The neurological and respiratory examination, chest X-ray, electroencephalogram (EEG), and MRI of the brain were normal. She, however, had elevated C-reactive protein, ESR, and raised CSF opening pressure on lumbar puncture. The CSF cell counts, biochemistry, and cultures were within normal limits. Unable to detect a neurological cause for her illness, she was advised to consult a psychiatrist. Two months later she reported to us again, this time essentially for back pain. Investigations for the back pain (including CT spine) revealed a T12 compression fracture with irregularity of the left T12 pedicle and a para-spinal fluid collection. Pus drained from the collection showed mycobacterium tuberculosis bacteria on staining with ZN stain. The CT scan thorax also showed left lower lobe consolidation and a pleural effusion. Contrast CT scan brain revealed subtle meningeal enhancement at the right parietal region. With standard treatment with a four-drug anti-TB regimen (along with a short course of dexamethasone), she improved well. This case report indicates that the initial clinical presentation of TB in general, as well as DTB, can be misleading, resulting in delay in diagnosis and in initiating treatment.

Jaw Subluxation as a Complication of Tardive Dyskinesia

Tardive Dyskinesia (TD) is an iatrogenic complication caused by antipsychotic agents and rarely by other anti-depressive/antiepileptic or anti-nausea medication. It is mostly a benign condition with implications regarding esthetic issues but it can also impact social and emotional well-being. We are reporting a case in which severe TD ensued in an elderly lady with newly diagnosed dementia, who presented to the psychiatric ER with a Capgras syndrome and paranoia accompanied by behavioral disturbances. She was treated with 4 consecutive antipsychotic agents (haloperidol, brexiprazole, risperidone, and olanzapine) due to unresponsive psychosis in conjunction with biperiden and developed a severe case of TD, which was complicated by two successive episodes of jaw subluxation. In spite of the good outcome following the reduction of the subluxation, we emphasize the danger of this rare painful, and bothersome side-effect and recommend how to pharmacologically deal with the TD setting in which it occurred.

An Elderly Lady with Tetany and Brain Calcification

We present the case of a 59-year-old Bangladeshi lady who presented in Intensive Care Unit with tetany and altered level of consciousness. Tetany resolved after giving IV calcium injection. Initial laboratory investigations showed hypocalcemia. Non-contrast CT brain showed irregular bilateral symmetrical calcifications in basal ganglia, thalami, cerebellum and corona radiata. Subsequent laboratory test revealed low parathyroid hormone level. So, she was diagnosed as Fahr’s syndrome due to secondary hypoparathyroidism. This is a rare neurological disorder characterized by metabolic, biochemical, neuroradiological and neuropsychiatric abnormalities due to symmetrical and bilateral intracranial calcifications. Bangladesh Crit Care J September 2024; 12 (2): 160-162

Digital Gangrene and Cutaneous Infarct in an Elderly Lady: A Diagnostic Conundrum

Digital Gangrene and Cutaneous Infarct in an Elderly Lady: A Diagnostic Conundrum

Post-intubation tracheal injury during esophagectomy

Post-intubation tracheal injuries are rare complications with serious consequences. Several factors increase the risk of tracheal injuries which may be attributed to patient, or procedure related. Majority of the tracheal injuries are managed surgically, however, role of less invasive and conservative treatment are also emerging. Case: we report a case of an elderly lady who underwent minimally invasive esophagectomy for esophageal carcinoma. She developed significant surgical emphysema within hours after surgery and massive air leak through underwater seal chest drainage tube. She was taken for emergency re-exploration. On table bronchoscopy confirmed 5 cm longitudinal tear of membranous part of cervical and upper thoracic trachea. Thoracoscopic repair along with transcervical-transtracheal repair of membranous wall of trachea and a tracheostomy was performed. She made significant recovery with few complications which were managed successfully.

Medication reconciliation to minimise medication errors: Iatrogenic hypercalcaemia as a case report

Hypercalcaemia is a relatively less common yet life-threatening electrolyte disorder and is caused by parathyroid-dependent and independent factors. This case report describes an elderly lady, a known patient of stable hypothyroidism, hypertension, type 2 diabetes mellitus and non-oliguric chronic kidney disease-IV who presented with complaints of gradually worsening drowsiness. Investigations revealed a hypercalcemic crisis; all other contributory investigations were unremarkable. She was put on intravenous saline rehydration, furosemide, pamidronate, and calcitonin. However, due to new-onset haemodynamic instability, cardiomyopathy, and worsening renal parameters, haemodialysis was initiated to reduce the serum calcium levels rapidly. The patient remained asymptomatic after that, and her renal parameters improved to near baseline levels, though cardiac function improvement was not obtained at the end of one month. History elicited from the patient after her neurological improvement revealed that failing to interpret the prescription of three orthopaedics she had visited lately, she followed all simultaneously and had thus consumed toxic levels of calcium and Vitamin D. Medication reconciliatory measures such as e-prescribing, computerised drug dispensing system, automated patient drug dispensing boxes and ‘brown-bagging’ all ongoing medications during the physician visits would ensure reduction in medication errors, thus avoiding adverse events, reducing uncalled for mortalities and morbidities and healthcare cost.

A new meaning to 'picking your nose': the first use of N-acetylcysteine to successfully treat trigeminal trophicsyndrome.

Trigeminal trophic syndrome (TTS) is a rare neurological condition characterized by self-induced injury to the face in the distribution of the trigeminal nerve. Chronic scratching or picking cause ulceration, scarring, and tissue loss. TTS typically occurs following damage to the trigeminal nerve, often from surgical procedures, trauma, or stroke. We present a case of trigeminal trophic syndrome in an elderly lady who successfully responded to oral N-acetylcysteine. An increased awareness of this rare syndrome and potential treatment options will encourage a prompt diagnosis and possibly prevent permanent disfiguration.

Coinfection with SARS-CoV-2 and parainfluenza virus in an elderly patient: a case report

COVID-19 was declared a pandemic by the WHO on 11th March 2020. Influenza usually occurs in winters, and the burden of the disease is determined by several factors, including the effectiveness of the vaccine that season, the characteristics of the circulating viruses, and how long the season lasts. Host factors and comorbidities also play an integral role in determining the outcome of the disease. Both the viral diseases present with an acute influenza like illness which may progress in certain individuals to Acute Respiratory Distress Syndrome. It is essential to understand that coinfection with viruses may occur and it is important to diagnose them as some require antivirals and some supportive and symptomatic management. Here, we present the case of an elderly lady with bilateral bronchiectasis who was infected with both SARS-CoV2 virus and parainfluenza 3.

Chronic Neck Swelling: A Case Report of Migrating Fish Bone

Background: Foreign bodies in the upper aerodigestive tract are frequently seen in otolaryngological practice, but migration of foreign body and oesophageal penetration are rare occurrences. Most reported cases of migration in literature involve fish bones, which are usually found in the lateral neck soft tissue or thyroid lobule. This can cause serious complications if left untreated. In most cases, fish bones can be removed safely by endoscopy, but they may migrate extraluminally to the skin in rare cases. Computed tomography (CT) neck with contrast is the investigation of choice to confirm migration. Case presentation: We present a case of an elderly lady with fish bone ingestion which migrated and embedded itself over the right thyroid cartilage region that required open surgery for removal. In this case, the patient underwent two open surgeries to locate the presence of the foreign body despite the CT neck done to aid in mapping intraoperatively. We used surgical clips in the first unsuccessful operation in locating the foreign body, and later performed a repeat CT scan and the clips were used to pinpoint the exact location of the foreign body during second surgery. By doing so, we successfully managed to remove the foreign body and patient was discharged well. Conclusion: This case has illustrated how versatile surgical clips are in helping us to locate the position of the foreign body rather than blindly exploring and causing further iatrogenic injury. With supplementation from a thorough repeat CT scan, we do think that in a presenting case of foreign body migration with difficulty locating the exact foreign body location, imaging adjunct such as C arm fluoroscopy and ultrasound guidance as reported in the literature can be used to avoid unnecessary iatrogenic injury and cause more harm to the patient.

Periprosthetic metastases in carcinoma of unknown primary: A rare association.

Septic or aseptic loosening may cause bone loss around artificial prosthesis leading to prosthesis failure. This occurrence due to metastatic infiltration of bone or surrounding soft tissues is rare but has been occasionally reported. We report a case of an elderly lady presenting with swelling and pain at the site of previous hemiarthroplasty performed for traumatic injury. On evaluation, she was found to have a lytic femur lesion with a large soft-tissue component around the prosthetic joint. Biopsy suggested a metastatic carcinoma of renal origin, but screening of kidneys did not reveal any primary lesion. She had additional skeletal metastatic lesions but no other primary site was detected either. She was given palliative radiotherapy and systemic therapy (sunitinib) based on the histologic diagnosis of renal cell origin but did not tolerate it. Thereafter, she is continuing on zoledronate every 4 weeks and best supportive management since 4 months from diagnosis.

Unmasking the mitochondrial mystery: febrile illness exposing a rare cause of refractory epilepsy with unique imaging features: a case report

BackgroundMitochondrial DNA polymerase, which is encoded by the POLG (polymerase gamma) gene, is responsible for the replication of the mitochondrial genome. Around 300 pathogenic variants have been identified in this gene and the clinical impact of POLG mutations is highly variable in both severity and phenotype. Our case had a clinical presentation distinct from the known mitochondrial syndromes associated with POLG gene, in the form of refractory focal seizures against a background of progressive ataxia, late symptom onset and rapid progression. In addition, our patient had signal changes in the pons with a unique radiological feature not previously described in this disease.Case presentationWe describe a 46-year-old lady with adult onset refractory focal seizures against a background of progressive cognitive impairment and ataxia preceded by a febrile illness. MRI brain showed T2/FLAIR hyperintensities involving right frontal and parietal cortex, bilateral thalamus, pons and cerebellum. Clinical exome and mitochondrial genome sequencing identified homozygous missense variation in exon 13 of the POLG gene. Among these above radiological features, a novel radiological finding in a case of POLG mutation was the transverse pontine signal change, which has not been described till date to our knowledge. She was being treated and given increasing doses and combinations of anti-seizure medications, but succumbed to the illness after two months.ConclusionsThis case highlights a unique radiological finding in the form of transverse T2/FLAIR signal change in pons, in a case of genetically proven case of POLG mutation along with other common radiological features. The triad of clinical features, which were characterised by progressive ataxia, cognitive impairment and refractory focal seizures occurring in combination, were unusual in a middle aged lady with POLG mutation.

Severe gastrointestinal cytomegalovirus infection with underlying common variable immunodeficiency in a middle aged lady

Cytomegalovirus is a common herpes virus infection found worldwide and by adulthood majority become seropositive. In immunosuppressed state it may reactivate to cause tissue invasive disease in gastro intestinal tract, liver, lungs, brain and retina with or without viremia. It is commonly seen in bone marrow transplant, organ transplant, AIDS and autoimmune disease requiring intense immunosuppressive therapy. Common variable immunodeficiency is a condition that affects both arms of the immune system and can lead to opportunistic infections. Chance is more when CD4 counts falls below 50 cells/microlt.

Isolated hepatic tuberculosis in a middle aged diabetic lady: a rare case report

Isolated hepatic tuberculosis is a rare clinical entity with non-specific clinical and imaging features that can result in a diagnostic challenge. A high index of suspicion is required and a definitive diagnosis can be very difficult. Here, we report a case of a 55-year-old Bangladeshi lady with type 2 diabetes mellitus and hypertension presenting with prolonged fever and tender hepatomegaly. After initial evaluation she was found to have raised alkaline phosphatase and γ-glutamyl transferase levels. A diagnosis of hepatic tuberculosis was confirmed from histopathology of liver tissue. Anti-tuberculosis therapy was started. Although rare, hepatic tuberculosis should be considered in any case of unexplained hepatomegaly or hepatosplenomegaly with prolonged fever. A liver biopsy should be performed, as this condition responds well to anti-tuberculosis therapy. BIRDEM Med J 2023; 13(3): 155-159

Hazards Of Monopolar Diathermy Plate In Surgery.

Respected Madam, I would like to draw attention to the hazard of severe skin burns from the using the monopolar diathermy plate electrode during surgical procedures. Diathermy operates in two modes. The monopolar mode where the current enters the patient’s body through an active electrode and exits via a grounding pad attached to the patient.(1) During a recent total abdominal hysterectomy with bilateral salpingo-oophorectomy of a 30-year-old lady with a complex mass, the grounding pad for the electro-cautery had been applied to the left foot, which was found to have third degree burns after completion of the procedure. Similarly, an elderly diabetic lady presented to our outpatient department with the history of a 32 days old non-healing lesion on her left thigh and a Pfannenstiel incision on her abdomen. She had undergone a complete abdominal hysterectomy in another health care centre. During the surgery, the grounding pad was placed on her left thigh which suffered partial thickness burns. According to the patient’s history, the lesion was coin sized at the beginning, but due to poor glycemic control, it continued to involve the surrounding healthy tissue, including the bone. She had previously undergone multiple debridements for the lesion and was advised hip disarticulation after a thorough assessment by the senior management at our department. Even though the procedure was carried out, she, unfortunately, could not survive a few days following the disarticulation. The reason for the burns was a loose application of the grounding pad to the skin of the patient resulting in heat generation and sparking at the site preventing the current to pass safely causing skin burns. To prevent this, the grounding pad should be firmly applied to the skin preferably with crepe bandage. Some other ways to help prevent such complications are adhesive grounding pads and utilization of diathermy machines alarm system.(1)Surgical briefing with the entire perioperative team is necessary so that each individual understands their role in preventing electrosurgical hazards.(2) In addition to this, case reporting of surgical burns to the national database is necessary for implementation of such preventive measures.(3)

Pisa syndrome secondary to donepezil

Pisa syndrome is characterised by a tonic flexion of the trunk to one side and a slight axial rotation in the sagittal plane. Recently more cases have been reported in Alzheimer's dementia and in patients treated with acetylcholinesterase inhibitor medication. Here the authors present a case of Pisa syndrome in an elderly lady treated with donepezil and highlight the importance of monitoring patients for side‐effects.

Acute disseminated encephalomyelitis with optic neuritis and mononeuritis multiplex following COVID-19 vaccination: case report

BackgroundAcute disseminated encephalomyelitis (ADEM) is an extremely rare complication of COVID-19 vaccination with very few reports worldwide. Concomitant peripheral nervous tissue involvement in ADEM is very uncommon.Case presentationWe report the case of a 52 year aged lady who developed headache and focal neurological deficits after 10 days of COVID-19 vaccination. Her evaluation suggested ADEM with optic neuritis and mononeuritis multiplex. She responded to pulse methylprednisolone therapy.ConclusionsCOVID-19 vaccine may be associated with ADEM, optic neuritis and concurrent peripheral nervous system inflammation in rare instances.

Diagnostic and therapeutic dilemma due to new pattern electrocardiographic change in myocardial infarction: a case report from a remote island

Acute myocardial infarction results due to acute disruption of coronary blood flow, commonly presented with chest pain. Electrocardiogram showing ST-segment elevation in consecutive leads is a classical ST-elevation myocardial infarction; however, atypical ST-segment elevation also can occur. We report an elderly lady who presented to the island health centre with intractable central chest pain. Electrocardiogram showed ST-segment elevation in V1 and aVR; whereas ST-depression in V4-6. With primary management, she was referred to a regional hospital. Repeat electrocardiogram showed ST-segment elevation in V1, aVR, and III; whereas ST-depression in V4-6, aVL, and I. Therefore, considering Aslanger's pattern of ECG change myocardial infarction, she was referred to the cardiac centre where coronary angiography revealed severe diffuse triple vessel disease. Primary PCI was performed on the right coronary artery initially as it is the primary culprit vessel with stenosis of other vessels. Therefore, staged angioplasty was performed on the left coronary system. Uncommon and atypical electrocardiographic presentations may be encountered in daily practice, associated with severe multiple-vessel diseases. So, it can be challenging for a cardiologist as well during interventions.

Intraoral Endoscopic Approach to Excision of an Infratemporal Fossa Tumour

Introduction: The infratemporal fossa is an inverted pyramid shaped structure that lies at the skull base, posterior to the maxillary sinus. It has a complex anatomy due to its relationship to various important vascular and neural channels. Surgical approaches to this region, via the lateral skull base and access mandibulotomies, have high morbidity. By our minimally invasive intra-oral endoscopic technique, an external incision, bony osteotomies and cranial nerve palsies were avoided with an expedited road to recovery and shorter hospital stay. Case Report: A middle aged lady who presented with left sided facial swelling and numbness was evaluated for the same with a Diagnostic nasal endoscopy and imaging. MRI of the maxilla with contrast revealed a well-defined left infra-temporal fossa soft tissue signal intensity mass, which was subsequently planned for intra-oral endoscopic removal. The surgery was performed via a transvestibular-paramandibular incision through which the endoscope was passed, structures delineated and tumour removed piece meal. Immunohistochemical analysis confirmed that it was a Spindle cell Rhabdomyosarcoma. Hence, she was given post operative chemoradiotherapy and is currently one year post surgery, with good outcomes. Discussion The infratemporal fossa has a varied and complex anatomy, due to its interior location and multiple important neurovascular structures within it. This intra-oral endoscopic approach, although challenging for the novice surgeon, avoided an external scar, providing better cosmesis and also had lesser patient morbidity related to wound gaping and dehiscence. It also allowed a direct and magnified visualization of the neuro-vascular structures in that region, aiding in tumour removal.

Endoscopic Management of a Complex Biliary Problem

AbstractEndoscopic interventions have become increasingly popular in the management of obstructive jaundice. In this case study, we present a case of complex Bismuth type 4 hilar stricture in an elderly lady presenting with obstructive jaundice. Complete endoscopic biliary drainage was accomplished successfully by placement of three metal stents – two with ERCP and one with Endoscopic Ultrasound (EUS) guided hepatico-gastrostomy. She developed cholecystitis later, which was successfully addressed by EUS guided gallbladder drainage using a cautery enhanced lumen apposing metal stent. Thus, a complete internal biliary drainage was achieved with endoscopic interventions.

Para-choreo-ballism due to pinealoma in an elderly lady.

Para-choreo-ballism due to pinealoma in an elderly lady.