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increase in the 70s and a decline at advanced ages.2 Colorectal cancer can spread by lymphatic and hematogenous dissemination, as well as through contiguous and transperitoneal routes. Approximately 20% of individuals with colorectal cancer have distant metastatic disease at the time of presentation,3 the most common metastatic sites being regional lymph nodes, liver, lungs, and peritoneum but rarely in the bones.4 Although infrequent, there are several reports in literature of colorectal cancer diffusely involving bone marrow, in the case of primary presentation5,6 or even infectious complications of unknown underlying disease (e.g., paravertebral abscess).7 In the course of neoplastic diseases, back pain is frequently associated with marked abnormalities of blood count and coagulation, such as disseminated intravascular coagulation.8 A substantial proportion of deaths in older persons with colorectal cancer may be attributed to comorbidity, especially congestive heart failure, diabetes mellitus, and chronic obstructive pulmonary disease,9 but in this case, the cause of death was a fungal infection. Candida species can be life threatening in elderly people, in particular when they are immunocompromised, and rank fourth among the most common nosocomial pathogens.10 Low back pain is extremely frequent in people referred to the hospital, and contrary to common belief, it does not always derive from a benign cause. Thus, the large number of individuals presenting for this symptom may be misdiagnosed. Although infrequent, the hypothesis of spinal bone marrow involvement could also be taken into consideration in elderly adults with severe back pain. Cecilia Soavi, MD Claudia Parisi, MD Ruana Tiseo, MD Elisa Misurati, MD Alfredo De Giorgi, MD Christian Molino, MD Fabio Fabbian, MD Roberto Manfredini, MD Department of Medicine, Azienda OspedalieroUniversitaria, Ferrara, Italy

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REFERENCES 1. Makris UE, Fraenkel L, Han L et al. Epidemiology of restricting back pain in community-living older persons. J Am Geriatr Soc 2011;59:610– 614. 2. Akushevich I, Kravchenko J, Ukraintseva S et al. Age patterns of incidence of geriatric disease in the U.S. population: Medicare-based analysis. J Am Geriatr Soc 2012;60:323–327. 3. Siegel R, Ma J, Zou Z et al. Cancer statistics, 2014. CA Cancer J Clin 2014;64:9. 4. Vasic L. Osteolysis of hand bones due to metastatic deposits from colon cancer—a case report. Med Pregl 2010;63:719–722. 5. Padhi P, Mackey C. Spine and scapular pain: An unusual presentation of colon adenocarcinoma. BMJ Case Rep 2013 pii: bcr2013010239. doi: 10.1136/bcr2013010239. 6. Isozaki Y, Yamanishi M, Utsunomiya S et al. A case of disseminated carcinomatosis of bone marrow with disseminated intravascular coagulation caused by advanced colon cancer treated by mFOLFOX6. Gan To Kagaku Ryoho 2011;38:1705–1708. 7. Ballardini P, Incasa E, Gamberini S et al. Not all lower back pain is benign—paravertebral abscess and colonic cancer. Am J Emerg Med 2008;26:513.e3–513.e4. 8. Suzuki H, Matsuoka N, Ushimaru Y et al. A case of disseminated carcinomatosis of the bone marrow with disseminated intravascular coagulation caused by advanced colon cancer successfully treated with SOX/bevacizumab. Gan To Kagaku Ryoho 2014;41:1013–1016. 9. Gross CP, Guo Z, MaAvay GJ et al. Multimorbidity and survival in older persons with colorectal cancer. J Am Geriatr Soc 2006;54:1898– 1904. 10. Fabbian F, De Giorgi A, Pala M et al. Severe acute leukopenia due to Candida parapsilosis in an old comorbid woman: A case report. J Am Geriatr Soc 2013;61:836–837.

NONCONVULSIVE STATUS EPILEPTICUS: MASTER OF DISGUISE To the Editor: Nonconvulsive status epilepticus (NCSE) is an epileptic state in which there is some impairment of consciousness associated with ongoing seizure activity according to electroencephalography (EEG). Clinically it may be disguised as altered mental status. Antiepileptic drugs are the mainstay of seizure treatment, although they can sometimes paradoxically induce seizure when they are in the toxic range. We report a case of an 81-year-old woman who presented with altered mental status who was found to have NCSE with mildly supratherapeutic phenytoin level.

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: Soavi: original idea, acquisition of data, patient care, literature search, preparation of manuscript. Parisi, Molino: acquisition of data, patient care, draft review. Tiseo: acquisition of data, patient care (hematologic expertise), draft review. Misurati: acquisition of data, patient care (infectious diseases expertise), draft review. De Giorgi: acquisition of data, patient care, literature search. Fabbian: discussion of original idea, literature search, draft revision for intellectual content. Manfredini: original idea, acquisition of data, literature search, preparation of manuscript and revision for important intellectual content, final supervision. Sponsor’s Role: None.

CASE REPORT An 81-year-old woman from an assisted living facility presented with acute change in mental status. She had had an episode of confusion lasting a few minutes, with eyes rolled backward but no loss of consciousness. She had no memory of the event. The staff member present did not witness tonic-clonic seizure, tongue biting, or bowel or urinary incontinence. Her past medical history included mild cognitive impairment and epileptic disorder diagnosed at the age of 30, consisting of generalized tonic-clonic seizure associated with urinary incontinence, the last episode of which had been 5 months before admission. She was taking phenytoin and levetiracetam at the time of admission. On admission, her mental status returned to baseline. Initial laboratory tests, including comprehensive metabolic panel, liver function test, septic screen, and brain imaging, were normal. Her phenytoin level was supratherapeutic at

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24.2. During her hospitalization, she was disoriented and had difficulty following complex commands and answering questions. Out of concern about seizure, EEG was performed, revealing severely abnormal waveform characterized by disorganization, epileptiform discharges, and excessive slowing consistent with NCSE. She was loaded with sodium valproate immediately, with gradual improvement of her mental status. Her phenytoin dosage was reduced to avoid paradoxical seizure induced by phenytoin toxicity. Repeat EEG 24 hours later demonstrated improvement in waveforms. She was discharged shortly after with weaning regimen of phenytoin.

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individuals taking more than one AED. An urgent EEG should be the next step of investigation. Early recognition and treatment may shorten length of stay and improve outcomes in these individuals. Eng Keong Tan, MD Department of Internal Medicine, Baystate Medical Center/Tufts University School of Medicine, Springfield, MA Kah Poh Loh, MD Department of Medicine, Baystate Medical Center/Tufts University School of Medicine, Springfield, MA

DISCUSSION The prevalence of epilepsy increases with age, doubling from the sixth to eighth decade. The clinical presentations of epilepsy may be challenging to differentiate from delirium in elderly adults, which affects approximately 14% to 56% of all hospitalized older people. Confusion may be the manifestation of ongoing seizure or postictal manifestation, resulting from transient brain dysfunction after seizure. Nonconvulsive status epilepticus is an epileptic state in which there is some impairment of consciousness associated with ongoing seizure activity on EEG.1,2 Classic cases of NCSE probably account for approximately 5% to 20% of all cases with status epilepticus. Diagnosis of NCSE is a challenge given the absence of motor manifestation. It can have protean symptoms associated with an alteration of mentation, which are often missed.3 NCSE may lead to neuronal injury and cytotoxic edema, which is caused by an abrupt increase in blood pressure and subsequent cerebral vasoconstriction leading to cerebral ischemia.4,5 In a retrospective study, EEG was performed in 56% of 177 elderly adults who presented to the emergency department with delirium; 84% of which were abnormal, with three revealing NCSE. These people had longer hospital stays and a rate of higher institutionalization. The study recommended that EEG be performed in all older adults with delirium,6 but given limited resources, urgent EEG may not be available, especially after office hours. Another study demonstrated that the presence of remote risk factors for seizures and eye movement abnormalities, as in the woman described above, has a sensitivity of 100% for NCSE, and EEG should be ordered urgently.7 Paradoxical intoxication has been described with most antiepileptic drugs (AEDs), including phenytoin, leading to confusion and, rarely, seizures.8 The level required to cause seizures has been reported to be much higher than 20 lg/dL. An increase in frequency of focal seizures secondary to phenytoin is due to anticonvulsant activity at the neuronal membrane.9 Seizures during intoxication are rare with monotherapy but with polytherapy, the therapeutic range of AEDs may change and can exert seizureinducing action or at least loss of their usual efficacy in suppressing seizure.10 Therefore, reduction of dosage of AEDs often decreases seizure frequency. In conclusion, geriatricians and internists should have a high index of suspicion of NCSE in individuals with epilepsy presenting with acute altered mental status, despite normal or supratherapeutic phenytoin levels, especially in

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: Tan E.K.: data analysis, developed image, literature review, writing manuscript. Loh K.P.: manuscript revision, critical review of manuscript for important intellectual content. Sponsor’s Role: No sponsor.

REFERENCES 1. Commission on Classification and Terminology. International League Against Epilepsy. Proposal for revised clinical electroencephalographic classification of epileptic seizures. Epilepsia 1981;22:489–501. 2. Kaplan PW. Nonconvulsive status epilepticus. Semin Neurol 1996;16:33–40. 3. Drislane FW. Presentation, evaluation, and treatment of nonconvulsive status epilepticus. Epilepsy Behav 2000;1:301–314. 4. Fountain NB, Lothman EW. Pathophysiology of status epilepticus. J Clin Neurophysiol 1995;12:326–342. 5. Stott VL, Hurrell MA, Anderson TJ. Reversible posterior leukoencephalopathy syndrome: A misnomer reviewed. Intern Med J 2005;35:83–90. 6. Gilles G, Bachir I, Gaspard N et al. Epileptic activities are common in older people with delirium. Geriatr Gerontol Int 2014;14:447–451. 7. Husain AM, Horn GJ, Jacobson MP. Non-convulsive status epilepticus: Usefulness of clinical feature in selecting patients for urgent EEG. J Neurol Neurosurg Psychiatry 2003;74:189–191. 8. Troupin AS, Ojemann LM. Paradoxical intoxication–a complication of anti-convulsive administration. Epilepsia 1975;16:753–758. 9. Dichter MA. Old and new mechanisms of antiepileptic drug actions. In: French JA, Dichter MA, Leppik IE, eds. New Antiepileptic Drug Development: Preclinical and Clinical Aspects, Vol. 10. Amsterdam, the Netherlands: Elsevier, 1993, pp 9–17. 10. Taylor DC, McKinlay I. When not to treat epilepsy with drugs. Dev Med Child Neurol 1984;26:822–827.

LATE-ONSET SARCOIDOSIS IN A 77-YEAR-OLD MAN To the Editor: Sarcoidosis is rare in elderly adults;1 we report here a case in an elderly adult hospitalized for confusion. A 77-year-old man, who had been independent until then, was hospitalized for deteriorated general health and confusion. His history included ischemic cardiopathy, hiatal hernia, and hypovitaminosis D. Over the previous 8 days, he had become totally dependent and confused, with inappropriate undressing and urination. His treatment consisted

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Nonconvulsive status epilepticus: master of disguise.

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