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Journal of the American Academy of Physician Assistants:
Case Report

Occult infection in an elderly woman with a chief complaint of pain

Footracer, Katherine GeeBah MS, PA‐C, CMT

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Kaesa Footracer practices urgent care and family medicine in the greater Los Angeles, California, area. The author has indicated no relationships to disclose relating to the content of this article.

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Providing urgent care to elderly patients is challenging because even life‐threatening illnesses can manifest with nonspecific symptoms as a consequence of advanced age.

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A 78‐year‐old woman presented to an urgent care clinic on a Friday evening with a chief complaint of muscle and joint pain over her entire body for the previous 2 days. The pain had progressed after starting in her feet, was worse with movement, and was not responding to acetaminophen. She also reported that her hands seemed to have less strength than usual. Vital signs were temperature, 99.2°F; pulse, 66 beats per minute; respiration rate, 16 breaths per minute; and BP, 104/60 mm Hg; pulse oximetry was 98% on room air. Her purpose in coming to the clinic was to request pain medication to help her “get through the weekend” so she could follow up with her primary care provider (PCP), who was out of town and would be back on Monday.

History The patient's medical history included type 2 diabetes, hypertension, peripheral vascular disease (PVD), anemia, depression, peripheral neuropathy in her feet, steatorrhea, and osteoarthritis. Medications included verapamil; candesartan; citalopram; insulin glargine (Lantus), a combination of fast‐ and intermediate‐acting insulin on a sliding scale; vitamin D; acetaminophen for her arthritis, and pancrelipase. She received erythropoietin injections for her anemia, did physical therapy for the PVD, and used a walker. She stated that she checked her blood glucose level 3 times a day and maintained good control. The only recent medication change had occurred 1 week earlier when she had increased her vitamin D intake from 5,000 units to 10,000 units daily, as instructed by her PCP. Her surgical history consisted of a hysterectomy in 1980 for fibroids.

There had been no recent injury, fall, travel, or sick contacts. The patient did not smoke or use illicit drugs. She reported drinking 1 to 2 glasses of wine a week. She lived by herself but had family nearby. She had no known allergies. Family history was significant for diabetes mellitus in her father, who died of hepatitis at age 80 years, and pancreatic cancer in her mother, who died of an MI. The patient's daughter had rheumatoid arthritis.

Remaining results from the review of systems were normal. The patient denied fevers, chills, fatigue, and sweats. She reported no headaches, paresthesias, numbness, or vision change, and she had no ear, nose, or throat pain; rhinorrhea; or rash. She had no complaints of chest pain, palpitations, cough, or shortness of breath. There had been no abdominal pain, nausea, vomiting, diarrhea, or urinary symptoms.

Physical examination Both feet demonstrated mild erythema and edema, which the patient reported was her baseline because of the PVD. No other erythema, edema, or tenderness was noted, despite the complaint of muscle and joint pain. When the patient sat still, she did not appear to be in any distress, but she had obvious discomfort when she moved or shifted positions. No objective weakness was noted in the hands or any other area. Findings from examination of the head and neck and assessment of the cardiovascular, respiratory, GI, and neurologic systems were unremarkable.

Laboratory results The patient was unable to provide a urine specimen at the clinic, so urinalysis was not possible. Blood was drawn for a CBC, comprehensive metabolic panel, ESR, Lyme disease titers, rheumatoid factor (RF), antinuclear antibodies (ANAs), myoglobin, troponins, and creatine kinase (CK). Most of the studies were requested from an outside laboratory, but the CBC was done in the office. The results are presented in Table 1.

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Table 1
Table 1
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Elevated WBC and granulocyte counts were consistent with a bacterial infection. Given the patient's age and underlying medical conditions, an early, atypical manifestation of sepsis was suspected. The patient's condition was deemed to be beyond the scope of the urgent care center, and she was referred to the hospital for admission to identify and treat the source of infection. Despite some initial reluctance, she was eventually persuaded to go.

Hospital care The patient was admitted to the hospitalist service with a diagnosis of acute infection and started empirically on IV piperacillin and tazobactam until the source of infection could be identified. Blood chemistry, troponin levels, a repeat CBC, blood cultures, urinalysis, urine cultures, ECG, and a chest radiograph were obtained. The CBC results indicated anemia and included an elevated WBC count. Elevations were also noted in blood glucose (322 mg/dL [reference range, 70‐100 mg/dL]), BUN (64 mg/dL [reference range, 7‐18 mg/dL]), and serum creatinine (2.6 mg/dL [reference range, 0.6‐1.3 mg/dL]). The glomerular filtration rate (GFR) was decreased (19 mL/min/1.73 m2 [normal, greater than 60 mL/min/1.73 m2]). Urinalysis revealed 250 mg/dL glucose, 3+ protein, and leukocyte esterase, all of which are normally absent.

Three days later, the urine culture grew out Enterococcus faecalis (greater than 100,000 colony‐forming units/mL). Despite treatment with IV antibiotics, the patient decompensated and developed pneumonia, acute respiratory failure, acute congestive heart failure (CHF), and acute‐on‐chronic kidney disease. She was eventually stabilized and discharged 11 days later to a rehabilitation facility.

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As demonstrated by this case, elderly patients may present with nonspecific symptoms, even in the presence of life‐threatening conditions, such as pneumonia, MI, or sepsis. Vague or constitutional symptoms—including fatigue, weakness, loss of appetite, nausea, headache, body aches, or mental status changes—in an elderly patient with several comorbid conditions require a more intensive investigation than they would in a normally healthy younger patient. Moreover, acute changes in the patient's mental status or the presence of dementia can make obtaining a thorough history difficult. Such a presentation is a challenge for all clinicians but especially so for those practicing in outpatient settings with limited resources who may be encountering a patient for the first time.1,2 While the extent of the workup performed is restricted by the laboratory and diagnostic imaging resources that are available, the clinician must always start with a thorough history and physical examination, including a review of all medications. Findings from the history and physical examination, any laboratory and imaging results, and the practitioner's clinical judgment will determine whether the patient is treated on an outpatient basis, referred for further testing, or admitted to the hospital.

The number of urgent care centers in the United States is increasing. Of the more than 8,700 centers operating in 2009‐2010, more than 300 were started during the previous year.3 These centers fill a niche by making treatment for acute, non‐life‐threatening medical conditions convenient and accessible. Moreover, urgent care centers help preserve emergency department (ED) resources for true emergencies.

As happens in an ED, patients arriving at an urgent care center are in various states of distress. More often than not, this is a first encounter with little previous medical history available, and clinicians may have no follow‐up visits with patients. Unlike an ED, urgent care center resources for further diagnostic testing are very limited, with only radiographs, ECGs, and basic blood and urine tests available. Most urgent care centers are not part of a hospital with access to specialists. For the majority of patients seeking treatment at an urgent care center, these resources are more than adequate and treatment fully meets standards of care. However, urgent care clinicians must maintain a degree of suspicion that a more complex process may be underlying the patients’ symptoms and refer them for additional workup accordingly.

Geriatric patients make up approximately 12% of the US population but account for 38% of ED visits, 35% of hospital stays, and 26% of clinician office visits. Elderly patients have physiologic and anatomic findings that are different from those of younger patients and present with more complex cases resulting from their comorbidities, polypharmacy, and atypical symptoms. Despite these complexities, training in geriatric medicine lags behind need. Approximately 50% of graduating internal medicine and family medicine residents report feeling very prepared to care for geriatric patients. As the population ages, practitioners need an increased under‐standing of age‐associated differences.1,4,5 The case presented illustrates the increased need for caution when working with geriatric patients, especially in outpatient settings.

The physiologic and anatomic changes that occur in patients aged 70 years and older affect all the body's systems. In the cardiovascular system, for example, left ventricular filling declines, while valves and vessels stiffen and calcify. The lungs lose some of their elastic recoil, the cough reflex diminishes, and the ability of alveoli to exchange gases decreases. The lower esophageal sphincter can lose contractile strength, gastric pH increases, gastric emptying can be delayed, and liver mass declines. The GFR decreases, and the kidneys lose some of their ability to compensate for changes in hydration and electrolytes. Urinary outflow can be impaired as urethral strictures, neoplasms, prostatic hyperplasia, and obstructed catheters become more common. Skin thins and becomes more susceptible to tears. Bones lose mass. Muscle mass decreases, while percentage of body fat increases. Immune system function decreases, resulting in less robust responses and declines in T‐cell counts. Dementias, such as Alzheimer disease and vascular dementia, become more common. These changes can lead to an increased risk for illness and injury; slower immunologic response; decreased ability of the body to compensate for changes to its homeostasis; development of atypical symptoms; and changes in drug absorption, distribution, and metabolism.1,2,6

Polypharmacy presents another challenge in the evaluation and treatment of geriatric patients because they are often taking multiple medications for comorbid conditions in addition to OTC supplements. Side effects from multiple medications, such as confusion from tricyclic antidepressants and benzodiazepines, can make obtaining a history difficult and interfere with diagnosis. Polypharmacy can also lead to drug‐drug or drug‐supplement/herb interactions that create new conditions, such as an increased risk of hemorrhagic stroke when warfarin is taken in combination with gingko and vitamin E supplements. Alterations in the body's response to changes in its homeostasis can occur; for example, beta blockers taken to control BP can mute a hypoglycemic response, and acetaminophen taken for arthritis pain can suppress fevers. Complications of polypharmacy are compounded when medications are not taken as directed; alcohol or substance abuse is present; and patients do not inform clinicians of all the drugs they are taking, including supplements and OTC medications.7 In addition to risks associated with medications, common comorbid diseases, such as hypertension and diabetes mellitus, increase risk for various additional conditions, including chronic kidney disease (CKD), stroke, and infection.

In sum, a high level of suspicion for infection and life‐threatening conditions must be maintained when working with geriatric patients because illnesses can manifest atypically and progress rapidly. In the case presented, the patient had no obvious focus of infection at her initial visit, but her elevated WBC count raised flags of an occult process at work. If she had been sent home on medications for pain as she requested, the infectious process would likely have accelerated and she could have decompensated while alone.

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- Compared with younger patients, geriatric patients can have physiologic and anatomic differences, more comorbidities, and a higher likelihood of polypharmacy.

- As a result of these differences, geriatric patients may present with nonspecific symptoms in the presence of life‐threatening conditions.

- Vague or constitutional symptoms in a geriatric patient with several comorbid conditions require a more intensive investigation than they would in a normally healthy younger patient.

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1. Eliopoulos C. Infections. In: Eliopoulos C. Gerontological Nursing. 6th ed. Lippincott Williams & Wilkins: Philadelphia, PA; 2005: chap 23.

2. Fletcher K. Geriatric emergencies, part 1. Vulnerability and primary prevention. Topics in Advanced Practice Nursing eJournal. Published June 1, 2004. Accessed June 1, 2012.

3. Urgent Care Association of America. Urgent care statistics & benchmarking. Accessed June 1, 2012.

4. Williams BC, Warshaw G, Fabiny AR, et al. Medicine in the 21st century: recommended essential geriatric competencies for internal medicine and family medicine residents. J Grad Med Educ. 2010;2(3):373-383.

5. Xu KT, Nelson BK, Berk S. The changing profile of patients who used emergency department services in the United States: 1996 to 2005. Ann Emerg Med. 2009;54(6):805-810

6. Minaker KL. Common clinical sequelae of aging. In: Goldman L, Ausiello D, Bennett JC, et al, eds. Cecil Textbook of Medicine. 22nd ed. Philadelphia, PA: WB Saunders; 2004: chap 23.

7. Somogyi, AA. Clinical pharmacokinetics and issues in therapeutics. In: Minneman KP, Wecker L, eds. Brody's Human Pharmacology. 4th ed. Philadelphia, PA: Elsevier Mosby; 2005: chap 4.

© 2012 Lippincott Williams & Wilkins, Inc.


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