Elderly Woman Presenting Research Articles

Bizarre Bilateral Adrenal Metastasis: A Sinister of Internal Malignancy

Abstract The ability to produce secondary metastatic deposits at a distant site is the single most essential biological process that symbolizes a malignant tumor. Metastasis to adrenal glands is known to spread from the primaries of the lungs, breast, melanoma, Gatro Intestinal Tract (GIT), pancreas, and kidneys. Here, we report a case of an elderly woman presenting with features of metastasis to subcutaneous tissue, lungs, liver, lymph nodes, and bilateral adrenal gland with symptomatic adrenal insufficiency and primary being in left kidney-renal cell carcinoma-clear cell type. The presence of bilateral synchronous adrenal metastasis with symptomatic adrenal insufficiency with evidence of metastasis to subcutaneous tissue is catastrophic since it marks disseminated cancer.

Hypothyroidism Complicated by Vitamin C and Thiamin Deficiency in Surgical Patients.

Multiple vitamin deficiencies together with endocrinopathy may be encountered in individuals presenting with critical illness. Following the surprise postmortem diagnosis of concomitant scurvy, Wernicke, and hypothyroidism in an elderly woman presenting with a mix of atypical symptoms, patients considered at risk were tested for TSH, vitamin C, and thiamin levels. Between September 1, 2018, and December 31, 2022, 801 vitamin C levels in 679 patients were measured in our rural hospital and 309 (39%) were found <0.4mg/dL. In this population, 39% of 626 thiamin levels were found to be low. Twenty-two patients with vitamin C and/or thiamin deficiency and elevated TSH levels were identified. Two patients died from scurvy; one also had myxedema. The incidence of vitamin C and thiamin deficiency in our patient population was higher than expected. Further studies should determine if this is unique to our rural setting or part of a bigger trend associated with poor dietary choices.

Late-onset psychose: een diagnostische en therapeutische uitdaging voor de clinicus

Late-onset psychosis: a diagnostic and therapeutic challenge for the clinician In clinical practice, doctors are frequently confronted with psychosis in the elderly (above 60 years). This symptomatology presents a diagnostic and therapeutic challenge for the clinician. Its cause may be primarily psychiatric or secondary to a somatic or neurological disorder. In this article, the case of an elderly woman presenting with typical partition delusions (the belief that something or someone exerts influence through impermeable structures) is described. This case illustrates the difficult differential diagnosis between primary psychiatric disorders and neurocognitive disorders with late-onset psychotic symptoms, as well as the discussion concerning the nosological classification of schizophrenia in the elderly population. At the end of the 20th century, the term ‘very late-onset schizophrenia-like psychosis’ was introduced for schizophrenia-like psychotic symptoms developing after the age of 60. To this day, the validity of the existence and the etiology of this subgroup of schizophrenia remain a matter of debate. Psychosocial interventions are the first step in the treatment of late-onset psychotic symptoms. The use of antipsychotics is reserved for persistent, severe and debilitating symptoms because of the many side effects in the elderly population. However, the symptoms are often intrusive and have a negative impact on general functioning, so that drug treatment is regularly used in clinical practice.

Non‐fluent/agrammatic variant of primary progressive aphasia with progressive supranuclear palsy

AbstractBackgroundNon‐fluent/agrammatic variante of primary progressive aphasia (nfvPPA) is a neurodegenerative disorder characterized by speech production impairment (1). The overlap of nfvPPA and progressive supranuclear palsy (PSP) and corticobasal syndrome cases have been reported (2). As nfvPPA progresses, a parkinsonian disorder often co‐occurs (3). There are different kinds of language impairment including articulatory deficits, agrammatism, reduced speech rate, and anomia (1). Here we present a Peruvian woman with nfvPPA with single‐photon emission computed tomography (SPECT) and parkinsonian syndrome.MethodWe describe a 73‐year‐old woman with progressive speech production impairment and parkinsonian syndrome. She completed standard neurological, neuropsychological, and speech‐language evaluations, as well as brain MRI and SPECT scan.ResultThe patient is a right‐handed woman with 16 years of education. No family history of dementia, parkinsonism or motor neuron disease was reported. At age 71, she presented progressive difficulty in speaking, anomia and verbal hesitancy; but she can understand conversations, send and read text messages. She also had depressive symptoms. MRI showed mild left frontal and perisylvian &gt; right atrophy (fig 1).By age 73, she developed a prominent reduction in spontaneous speech, mild difficulties in reading and writing, occasional paraphasia, less empathy, dietary change, moria and, mild parkinsonism (she expresses less emotion, tremor, slowly walk and falls). Her episodic memory starts to decline thereafter.On examination, she had mild‐moderate telegraphic speech, imitation behavior, mild facial masking, bradykinesia and mild postural instability but no abnormal extraocular movement. Speech‐language assessment showed non‐fluent aphasia and apraxia of speech. Impaired comprehension of syntactically complex sentences. Naming was mildly impaired. Syntactic errors were present. Executive function was also impaired, but visuoperceptual skills were preserved.Serological analyses were unrevealing. Brain SPECT scan showed left frontal and perisylvian &gt; right cortical hypoperfusion (fig 2).ConclusionWe report a Peruvian case of an elderly woman presenting with a 3‐year history of nfvPPA features and PSP. Her SPECT scan showed left frontal and perisylvian &gt; right cortical hypoperfusion. Consider early evaluating motor function in nfvPPA patients in light of the possibility of CBS or PSP overlap.

An unusual case of Escherichia coli meningitis and bacteremia in an elderly woman presenting with intractable low back pain

An unusual case of Escherichia coli meningitis and bacteremia in an elderly woman presenting with intractable low back pain

Low Oxygen Affinity Variant Haemoglobin in an elderly woman presenting with low oxygen saturation

An asymptomatic 81-year-old woman was referred by her general practitioner regarding a pulse-oximetry oxygen saturation (SpO2) of 74%. An arterial blood gas analysis (ABG) on air showed PaO2 12.9 kPa, oxygen saturation 80%, with normal pH, PaCO2, methaemoglobin and carboxyhaemoglobin levels. After a normal chest x-ray, tinzaparin was administered empirically for possible occult pulmonary embolus. This diagnosis was subsequently excluded with an unremarkable computed tomography pulmonary angiogram (CTPA). She was further investigated as an out patient. DNA globin-gene analysis identified a variant haemoglobin revealed to be haemoglobin Saint Mande (HbSM). Following reassurance regarding the benign nature of her condition, she has remained well.

Refractory atrioventricular nodal re-entrant tachycardia: A rare manifestation of acute massive pulmonary embolism

With a wide array of manifestations ranging from mild dyspnea to fatal cardiogenic shock, acute pulmonary embolism (PE) remains an enigmatic clinical entity. Vivid electrocardiography (ECG) patterns portrayed in different clinical instances of acute PE have always remained an interesting, yet debatable subject since the classic S1Q3T3 pattern on ECG secondary to PE was first described in 1935. Atrial fibrillation, atrial flutter and atrial tachycardia are commonly described supraventricular tachycardias in association with PE; however, there is scant description of PE in the literature presenting as atrioventricular nodal re-entrant tachycardia (AVNRT). The present report describes the clinical course of an elderly woman presenting with refractory typical AVNRT who was subsequently found to have bilateral multilobar acute PE. To the authors’ knowledge, the present report is the first to describe a case involving acute PE presenting as hemodynamically unstable AVNRT requiring cardioversion.

Treatment of a Basilar Trunk Perforator Aneurysm With the Pipeline Embolization Device

Basilar trunk perforator (BTP) aneurysms are rare lesions that pose significant challenges to microsurgical clipping and endovascular coiling. We present the intriguing case of a ruptured BTP aneurysm that was successfully treated with the Pipeline Embolization Device (PED). An elderly woman presenting with subarachnoid hemorrhage was found to have a 1.5-mm aneurysm arising from the proximal portion of a thin midbasilar perforator. The decision was made to treat this aneurysm with flow diversion in an attempt to preserve the patency of the perforator and to avoid the hazards associated with parent vessel trapping. A 3 × 12-mm PED was successfully deployed in the basilar trunk across the neck of the aneurysm, causing stasis in the aneurysm, with continuous flow through the parent vessel. The procedure and postoperative course were uneventful. A follow-up angiogram 2 weeks later showed complete disappearance of the aneurysm with preservation of the patency of the perforator. At the 6-month follow-up, the patient was asymptomatic and remained neurologically intact. We present the first case of a BTP aneurysm treated with the PED. The aneurysm was successfully occluded, and the patency of the feeding vessel was preserved. In light of the limitations of coiling and the hazards associated with microsurgery and parent vessel trapping, the PED may be a valuable option for BTP aneurysms.

Apathetic Thyrotoxicosis Presenting with Hemoptysis

Introduction: Apathetic thyrotoxicosis is an uncommon manifestation of hyperthyroidism. We report a case of apathetic thyrotoxicosis in an elderly Nigerian woman presenting with hemoptysis. Case Presentation: An 85 year old woman with past medical history of hypertension and euthyroid goiter presented with a two-week-history of subjective weight loss, cough, hemoptysis and progressively worsening dyspnea. Examination findings included dyspnea, pallor, goiter, an irregularly irregular pulse, tachypnea, jugular venous distension, a third heart sound and rales in both lung bases. Thyroid function tests revealed elevated free triiodothyronine and free thyroxine with a suppressed thyroid stimulating hormone. Her brain natriuretic peptide was 980pg/L and her electrocardiogram revealed atrial fibrillation with rapid ventricular response. Findings on trans-thoracic echocardiogram included a dilated left atrium, mild concentric left ventricular hypertrophy with grade 1 diastolic dysfunction, but preserved left ventricular systolic function, without any significant valvular abnormalities. A diagnosis of apathetic throtoxicosis presenting with heart failure with preserved ejection fraction, precipitated by atrial fibrillation was made and treatment was instituted. The patient reverted to sinus rhythm with resolution of her hemoptysis and heart failure symptoms within one week of admission. Discussion: Apathetic thyrotoxicosis is an atypical manifestation of hyperthyroidism more commonly found in the elderly. It presents with cardiac disease, wasting or depression with only a few of the more typical clinical manifestations of thyrotoxicosis. The hemoptysis found in our patient is most likely due to pulmonary edema from left ventricular failure. Conclusion: A diagnosis of apathetic thyrotoxicosis should be considered in the elderly patient presenting with heart failure in the absence of the usual risk factors for heart failure. Early recognition and treatment can reduce the morbidity and mortality associated with this condition.

Gastric antral vascular ectasia with aortic stenosis: Heydes syndrome

Gastric antral vascular ectasia (GAVE) is a well-recognized albeit rare cause of gastro-intestinal (GI) bleeding. It classically presents in an elderly female as iron-deficiency anemia due to chronic blood loss. The association of GI blood loss with aortic stenosis (AS) has been popularized as Heydes syndrome (HS). We report a case of an elderly woman presenting as iron-deficiency anemia subsequently diagnosed with HS.

A rare cause of haematemesis and chest pain

This article discusses an elderly woman presenting with haematemesis and chest pain who underwent urgent oesophago-gastroduodenoscopy. This revealed a large dissecting intramural oesophageal haematoma, initially mistaken for a varix. This is a rare cause of haematemesis and chest pain but has characteristic endoscopic findings. It is a benign condition that may be managed conservatively and both clinicians and endoscopists should be aware of its classical presentation. Misdiagnosis of the chest pain as cardiac ischaemia may have an adverse outcome if antiplatelet or anticoagulation therapy is commenced. Follow up endoscopy a week later showed complete resolution of the lesion leaving a linear mucosal defect.

Obturator Hernia in an Elderly Woman Presenting with Aspiration Pneumonia and Respiratory Failure

Obturator hernia is a rare but important cause of intestinal obstruction. The mortality rate is high if the diagnosis is not made early and surgical intervention is delayed. We report an 88-year-old female patient who presented with aspiration pneumonia and respiratory failure. She did not have nausea/vomiting and physical examination was unremarkable. She was fed through a nasogastric tube, but no gastric emptying was noted. An abdominal/pelvic computed tomograpy (CT) scan performed 5 days after the presentation revealed a left incarcerated obturator hernia. Emergency laparotomy was performed and the patient eventually recovered. This case reminds us that aspiration pneumonia may be the presenting feature of obturator hernia and a clue to its early diagnosis.

Primary progressive aphasia in a bilingual speaker: a single-case study

We report on the case of an elderly bilingual woman presenting with a diagnosis of primary progressive aphasia. The participant's native language was Friulian (L1), a predominantly oral Romance language, and her second language was Italian (L2), formally learned at primary school in oral and written forms. We investigated her linguistic abilities by means of the Bilingual Aphasia Test ( . The assessment of bilingual aphasia. Hillsdale, NJ: Lawrence Erlbaum Associates), which is specifically devised for studying language levels and skills in bilingual/polyglot individuals with aphasia. Specifically, we focused on different tasks extracted from the Bilingual Aphasia Test, targeting phonology, morphology, syntax and lexical semantics. Results show that both languages were affected to a clinically significant degree, but with different profiles in terms of linguistic levels, suggesting the presence of greater phonological, morphological, grammatical and syntactic impairments in L2. Results are discussed in terms of possible dissociations both within the language system of each language and between languages, within the Procedural/Declarative theoretical framework of language acquisition in bilinguals.

Intravascular lymphoma presenting as a longitudinally-extensive myelitis: Diagnostic challenges and etiologic clues

Intravascular lymphoma is a rare disorder that commonly involves the central nervous system. Neurologic involvement may be the presenting and only manifestation. Identifying intravascular lymphoma as the cause of neurologic disease is diagnostically challenging. We report an elderly woman presenting with subacute onset paraparesis due to spinal cord involvement by an intravascular lymphoma. Progressive worsening was associated with extension of a longitudinally-extensive thoracic intramedullary spinal cord lesion. Extensive investigations failed to provide a diagnosis in life and repeated empiric therapeutic trials were unsuccessful. Diagnostic confirmation was postmortem. A longitudinally-extensive spinal cord lesion has a broad differential diagnosis. Intravascular lymphoma should be considered particularly in older individuals. The presence of coexisting hematologic abnormalities should prompt consideration of a bone marrow biopsy. Early diagnosis may direct therapy and lead to a more favorable prognosis.

A Successful Case of Repeat Thrombolysis in Acute Prosthetic Valve Thrombosis

Acute heart failure is an important presentation in the Acute Medical Unit. We describe a case of successful repeat thrombolysis in an elderly woman presenting as an emergency with severe pulmonary oedema, due to acute prosthetic mitral valve thrombosis. The diagnostic imaging and therapeutic modalities available are also described.This case highlights the need for acute physicians to consider prosthetic valve thrombosis in the differential for patients with metallic heart valves who present with acute heart failure or cardiogenic shock.

Osteoid Osteoma Invading the Posterior Labyrinth of the Petrous Bone

We report a painless osteoid osteoma of the inner ear in an elderly woman presenting with hearing loss, tinnitus, and vertigo. CT showed a heterogeneous mass containing calcifications involving the posterior labyrinth, which heterogeneously enhanced on postcontrast MR images. Osteoid osteoma should be included in the differential diagnosis of an osteolytic petrous bone lesion with central calcification and enhancement.

A case of primary biliary cirrhosis: First report from Bangladesh

Primary biliary cirrhosis (PBC) is a rare autoimmune liver disease, not infrequent in the West, but hardly reported from the East. We report a case of PBC for the first time from Bangladesh. The patient was an elderly woman presenting with vague complaints. The diagnosis was confirmed by antibody testing and histopathology, whereas other possible causes of cirrhosis were also excluded.

Splenic Cystic lymphangiomatosis presenting with massive splenomegaly

Cystic lymphangiomatosis of the spleen is an extremely rare pathologic entity. It is considered to be the result of a developmental malformation of the lymphatic system and can involve the spleen alone or may be a part of multiorgan disease. It is usually seen in children. We report a case of cystic lymphangiomatosis of the spleen occurring in an elderly woman presenting with massive splenomegaly with emphasis on the rarity of the case in old age and on the problems in the differential diagnosis.

Voiding dysfunction due to long-standing labial fusion in an elderly woman: a case report

Labial adhesions or fusion in the elderly are rare, and only few cases are described in the English literature. We describe a case of near-complete labial fusion in an elderly woman presenting with voiding difficulty, its management and literature review.

Syncope in a patient presenting to the emergency room with chest pain, shock, and neurological disorders

Transient left ventricular dysfunction associated with apical ballooning at echocardiography or angiography has been described in many overlapping clinical settings: neurological disorders, such as subarachnoid haemorrhage and stroke, pheochromocytoma, and the recent takotsubo syndrome. We describe the case of an elderly woman presenting with syncope, chest pain, electrocardiographic abnormalities, mild enzymatic release, and transient left ventricular apical ballooning, mimicking an anterior wall acute coronary syndrome with shock, following a subarachnoid haemorrhage that could not be detected upon admission.The pathophysiological mechanisms of myocardial damage during catecholamine surge cannot be completely explained by epicardial coronary vasoconstriction or microvascular spasm and subsequent ischaemia; also direct catecholamine-mediated myocyte injury may play a role in myocardial stunning.