JAGS
FEBRUARY 2014–VOL. 62, NO. 2
of treating pyogenic hepatic abscesses are antibiotics and drainage. If multiple abscesses are present, the larger lesions should be drained percutaneously.3 Older adults with pyogenic liver abscess generally have outcomes similar to those of younger adults. Their hospital stay may be longer, and they are more likely to have multiple comorbidities. Older adults with pyogenic liver abscesses are more likely to have a biliary disorders or an underlying malignancy, whereas younger adults with pyogenic liver abscesses are more likely to be male and to have right upper quadrant tenderness, alcoholism, and a cryptogenic etiology. The diagnosis of pyogenic liver abscess is challenging because of its vague presenting symptoms and signs and nonspecific laboratory findings. Intraabdominal infections such as diverticulitis and appendicitis can also cause liver abscesses. Right upper quadrant tenderness occurs less frequently in older than in the young adults with pyogenic liver abscesses despite the higher frequency of biliary disorders in older adults.4 This man’s presentation with hypotension, leukocytosis, and delirium and his ineffective, prolonged course of antibiotics were important additional features that were noted. John Lung, MD Ariba Khan, MB, BS MPH Michael L. Malone, MD Aurora Health Care, School of Medicine and Public Health, University of Wisconsin, Milwaukee, Wisconsin
ACKNOWLEDGMENTS The authors would like to thank John Plummer, Aurora Sinai Librarian, for his bibliographic search. 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: Lung, Khan: acquisition of subject, study concept, bibliographic search and preparation of manuscript. Malone: preparation and revision of manuscript. Sponsor’s Role: No sponsor.
LETTERS TO THE EDITOR
409
management decisions for patients and clinicians.1 Renal replacement therapy in the form of dialysis is often considered, and complications from hemodialysis or peritoneal dialysis should be part of the decision-making process.2 Herein is presented a case of “sweet syndrome” in an individual undergoing continuous ambulatory peritoneal dialysis (CAPD). The subject was an 84-year-old woman with a history significant for pacemaker implantation for sick-sinus syndrome, diet-controlled diabetes mellitus, and CAPD for ESRD. She had been a member of a Program of Allinclusive Care for the Elderly (PACE) for 3 years and had been managing her CAPD independently since switching from hemodialysis in January 2013. She was cognitively intact and lived independently. She presented to the PACE clinic with 1 day of increasing dyspnea, nonproductive cough, and wheezing. She denied missing any recent CAPD exchanges. On examination, she was afebrile, with a heart rate of 84 beats per minute, a respiratory rate of 26 breaths per minute, oxygen saturation of 98% on 2 L of oxygen, and blood pressure of 161/61 mmHg. She had bilateral wheezing but no evidence of pulmonary edema on lung examination. Although she had gained 20 pounds, there were no peripheral signs of volume overload (no peripheral edema, hepatojugular reflux, or rales). An electrocardiogram was unchanged from baseline and demonstrated no new ST changes or tachydysrhythmia. Because patients can be seen daily in PACE, she was treated with nebulizers and azithromycin for presumed communityacquired pneumonia, and a follow-up telephone call was scheduled for the next day. Because her symptoms improved with the nebulizer, she was already on antibiotics, and she had close follow-up, no chest X-ray was obtained. She had no oxygen requirement when she left the clinic. Her wheezing and shortness of breath initially improved and then rapidly deteriorated 48 hours later during her CAPD. She presented to the emergency department
REFERENCES 1. Cohen JL, Martin FM, Rossi RL, et al. Liver abscess. The need for complete gastrointestinal evaluation. Arch Surg 1989;124:561–564. 2. Zibari GB, Maguire S, Aultman DF, et al. Pyogenic liver abscess. Surg Infect (Larchmt) 2000;1:15–21. 3. Sridharan GV, Wilkinson SP, Primrose WR. Pyogenic liver abscess in the elderly. Age Ageing 1990;19:199–203. 4. Chen SC, Lee YT, Yen CH, et al. Pyogenic liver abscess in the elderly: Clinical features, outcomes and prognostic factors. Age Ageing 2009;38: 271–276; discussion.
NOT SO “SWEET”: AN UNUSUAL CASE OF DYSPNEA IN AN OLDER WOMAN ON PERITONEAL DIALYSIS To the Editor: End-stage renal disease (ESRD) is a common condition in older adults and poses difficult
Figure 1. Anterior-posterior, semi-upright, portable X-ray demonstrating large right plural effusion.
chest
410
LETTERS TO THE EDITOR
with significant shortness of breath and wheezing, which required biphasic positive airway pressure support. She denied all retrosternal or pleuritic chest pain, palpitations, or calf pain. Her physical examination revealed rales and decreased breath sounds on the right and bilateral expiratory wheezes. Her laboratory test results were remarkable for a creatinine of 7.2 mg/dL (her baseline), blood glucose of 95 mg/dL, and white blood cell count of 12,300 cells/ mL. Her electrocardiogram was unchanged, troponin I was 0.02 mg/dL, and chest X-ray demonstrated a 50%, right pleural effusion (Figure 1). She was admitted to the medical intensive care unit for respiratory support and started on moxifloxacin for a presumed infectious process. The diagnostic and therapeutic thoracentesis produced 1.6 L of clear fluid, white blood cells of 35/mL, red blood cells 45/mL, total protein of 0.3 g/dL, lactate dehydrogenase of 20 U/L, and glucose of 302 mg/dL, consistent with a transudate. Pleural fluid glucose was significantly greater than blood glucose, which is consistent with dialysate fluid.3 Her respiratory status improved after the thoracentesis, and she was discharged on hospital day 3. Her CAPD was discontinued, and she was started on hemodialysis. As an outpatient, she will remain on hemodialysis until imaging and treatment of a possible pleuroperitoneal communication is complete. A “sweet” hydrothorax is the result of pleuroperitoneal communications in an individual undergoing CAPD. This is a rare cause of a pleural effusion, and it is has been infrequently reported.4,5 The dialysate migrates into the pleural space and can cause life-threatening respiratory distress from the resulting effusion. A review of one case series found the incidence of “sweet” hydrothoraxes to be 1.9% of individuals undergoing CAPD.6 The diagnosis is confirmed through analysis of the pleural fluid, which will have a glucose measurement significantly greater than the blood glucose. A difference of more than 50 mg/dL was found to be 100% specific and sensitive for identifying a “sweet” hydrothorax.3 Acute treatment is thoracentesis and conversion to hemodialysis. For individuals who wish to return to CAPD, pleuroperitoneal communication can sometimes be visualized using technetium-99 m peritoneal scintigraphy or video-assisted thoracic surgery, and the opening can be closed using pleurodesis.3,7,8 In one series, talc pleurodesis was successful in six of seven individuals.7 Some older adults with ESRD choose CAPD for longterm management because it allows greater personal autonomy. Acute presentation with respiratory symptoms in these individuals should prompt clinicians to consider sweet syndrome (effusion due to pleuroperitoneal communications) as a possible etiology. Eben Clattenburg, MPH School of Medicine, Johns Hopkins University, Baltimore, Maryland Anuj Bhatnagar, MD Carol Perfetto, NP Matthew McNabney, MD Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
FEBRUARY 2014–VOL. 62, NO. 2
JAGS
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: All authors: conception, writing, and editing letter. Sponsor’s Role: There was no sponsorship of this work.
REFERENCES 1. Rosansky SJ, Clark WF. Has the yearly increase in the renal replacement therapy population ended? J Am Soc Nephrol 2013;24:1367–1370. 2. Brunori G, Viola BF, Maiorca P et al. How to manage elderly patients with chronic renal failure: Conservative management versus dialysis. Blood Purif 2008;26:36–40. 3. Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Curr Opin Pulm Med 2004;10: 315–319. 4. Smolin B, Henig I, Levy Y. “Sweet” hydrothorax complicating chronic peritoneal dialysis. Eur J Intern Med 2006;17:583–584. 5. Michel C, Devy A, Lavaud F et al. A “sweet” hydrothorax. Presse Med 2001;30:1401–1403. 6. Chow KM, Szeto CC, Li PK. Management options for hydrothorax complicating peritoneal dialysis. Semin Dial 2003;16:389–394. 7. Tang S, Chui WH, Tang AW et al. Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003;18: 804–808. 8. Yang PJ, Liu TH. Massive “sweet” hydrothorax. Can Med Assoc J 2010;182:1883.
COMMENTS/RESPONSES MEDICINAL USE OF CANNABIS AND CANNABINOIDS IN OLDER ADULTS: WHERE IS THE EVIDENCE? To the Editor: Marijuana (Cannabis sativa) has been used medicinally for centuries for the management of different conditions and diseases.1 The cannabis plant contains a number of cannabinoids, which are responsible for its physiological and psychoactive effects. They act primarily through CB1 (brain) and CB2 (peripheral organs and tissues) receptors.
WHAT IS THE PROBLEM? The use of medicinal cannabis is increasing in older adults, but the exact prevalence of cannabis use is not known. A recent survey by the International Association for Cannabinoid Medicines on the medicinal use of herbal cannabis (marijuana) and cannabinoid-based medicine, completed by 953 participants from 31 countries (e.g., United States, Germany, Canada, France, the Netherlands), showed that 6.5% of medicinal cannabis users were aged 61 to 76.2 In the Netherlands, between 2003 and 2010, 37% of 5,540 patients who used prescription herbal cannabis were aged 61 to 93.3 Although the medicinal use of cannabis and cannabinoids in the general
FEBRUARY 2014–VOL. 62, NO. 2
of treating pyogenic hepatic abscesses are antibiotics and drainage. If multiple abscesses are present, the larger lesions should be drained percutaneously.3 Older adults with pyogenic liver abscess generally have outcomes similar to those of younger adults. Their hospital stay may be longer, and they are more likely to have multiple comorbidities. Older adults with pyogenic liver abscesses are more likely to have a biliary disorders or an underlying malignancy, whereas younger adults with pyogenic liver abscesses are more likely to be male and to have right upper quadrant tenderness, alcoholism, and a cryptogenic etiology. The diagnosis of pyogenic liver abscess is challenging because of its vague presenting symptoms and signs and nonspecific laboratory findings. Intraabdominal infections such as diverticulitis and appendicitis can also cause liver abscesses. Right upper quadrant tenderness occurs less frequently in older than in the young adults with pyogenic liver abscesses despite the higher frequency of biliary disorders in older adults.4 This man’s presentation with hypotension, leukocytosis, and delirium and his ineffective, prolonged course of antibiotics were important additional features that were noted. John Lung, MD Ariba Khan, MB, BS MPH Michael L. Malone, MD Aurora Health Care, School of Medicine and Public Health, University of Wisconsin, Milwaukee, Wisconsin
ACKNOWLEDGMENTS The authors would like to thank John Plummer, Aurora Sinai Librarian, for his bibliographic search. 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: Lung, Khan: acquisition of subject, study concept, bibliographic search and preparation of manuscript. Malone: preparation and revision of manuscript. Sponsor’s Role: No sponsor.
LETTERS TO THE EDITOR
409
management decisions for patients and clinicians.1 Renal replacement therapy in the form of dialysis is often considered, and complications from hemodialysis or peritoneal dialysis should be part of the decision-making process.2 Herein is presented a case of “sweet syndrome” in an individual undergoing continuous ambulatory peritoneal dialysis (CAPD). The subject was an 84-year-old woman with a history significant for pacemaker implantation for sick-sinus syndrome, diet-controlled diabetes mellitus, and CAPD for ESRD. She had been a member of a Program of Allinclusive Care for the Elderly (PACE) for 3 years and had been managing her CAPD independently since switching from hemodialysis in January 2013. She was cognitively intact and lived independently. She presented to the PACE clinic with 1 day of increasing dyspnea, nonproductive cough, and wheezing. She denied missing any recent CAPD exchanges. On examination, she was afebrile, with a heart rate of 84 beats per minute, a respiratory rate of 26 breaths per minute, oxygen saturation of 98% on 2 L of oxygen, and blood pressure of 161/61 mmHg. She had bilateral wheezing but no evidence of pulmonary edema on lung examination. Although she had gained 20 pounds, there were no peripheral signs of volume overload (no peripheral edema, hepatojugular reflux, or rales). An electrocardiogram was unchanged from baseline and demonstrated no new ST changes or tachydysrhythmia. Because patients can be seen daily in PACE, she was treated with nebulizers and azithromycin for presumed communityacquired pneumonia, and a follow-up telephone call was scheduled for the next day. Because her symptoms improved with the nebulizer, she was already on antibiotics, and she had close follow-up, no chest X-ray was obtained. She had no oxygen requirement when she left the clinic. Her wheezing and shortness of breath initially improved and then rapidly deteriorated 48 hours later during her CAPD. She presented to the emergency department
REFERENCES 1. Cohen JL, Martin FM, Rossi RL, et al. Liver abscess. The need for complete gastrointestinal evaluation. Arch Surg 1989;124:561–564. 2. Zibari GB, Maguire S, Aultman DF, et al. Pyogenic liver abscess. Surg Infect (Larchmt) 2000;1:15–21. 3. Sridharan GV, Wilkinson SP, Primrose WR. Pyogenic liver abscess in the elderly. Age Ageing 1990;19:199–203. 4. Chen SC, Lee YT, Yen CH, et al. Pyogenic liver abscess in the elderly: Clinical features, outcomes and prognostic factors. Age Ageing 2009;38: 271–276; discussion.
NOT SO “SWEET”: AN UNUSUAL CASE OF DYSPNEA IN AN OLDER WOMAN ON PERITONEAL DIALYSIS To the Editor: End-stage renal disease (ESRD) is a common condition in older adults and poses difficult
Figure 1. Anterior-posterior, semi-upright, portable X-ray demonstrating large right plural effusion.
chest
410
LETTERS TO THE EDITOR
with significant shortness of breath and wheezing, which required biphasic positive airway pressure support. She denied all retrosternal or pleuritic chest pain, palpitations, or calf pain. Her physical examination revealed rales and decreased breath sounds on the right and bilateral expiratory wheezes. Her laboratory test results were remarkable for a creatinine of 7.2 mg/dL (her baseline), blood glucose of 95 mg/dL, and white blood cell count of 12,300 cells/ mL. Her electrocardiogram was unchanged, troponin I was 0.02 mg/dL, and chest X-ray demonstrated a 50%, right pleural effusion (Figure 1). She was admitted to the medical intensive care unit for respiratory support and started on moxifloxacin for a presumed infectious process. The diagnostic and therapeutic thoracentesis produced 1.6 L of clear fluid, white blood cells of 35/mL, red blood cells 45/mL, total protein of 0.3 g/dL, lactate dehydrogenase of 20 U/L, and glucose of 302 mg/dL, consistent with a transudate. Pleural fluid glucose was significantly greater than blood glucose, which is consistent with dialysate fluid.3 Her respiratory status improved after the thoracentesis, and she was discharged on hospital day 3. Her CAPD was discontinued, and she was started on hemodialysis. As an outpatient, she will remain on hemodialysis until imaging and treatment of a possible pleuroperitoneal communication is complete. A “sweet” hydrothorax is the result of pleuroperitoneal communications in an individual undergoing CAPD. This is a rare cause of a pleural effusion, and it is has been infrequently reported.4,5 The dialysate migrates into the pleural space and can cause life-threatening respiratory distress from the resulting effusion. A review of one case series found the incidence of “sweet” hydrothoraxes to be 1.9% of individuals undergoing CAPD.6 The diagnosis is confirmed through analysis of the pleural fluid, which will have a glucose measurement significantly greater than the blood glucose. A difference of more than 50 mg/dL was found to be 100% specific and sensitive for identifying a “sweet” hydrothorax.3 Acute treatment is thoracentesis and conversion to hemodialysis. For individuals who wish to return to CAPD, pleuroperitoneal communication can sometimes be visualized using technetium-99 m peritoneal scintigraphy or video-assisted thoracic surgery, and the opening can be closed using pleurodesis.3,7,8 In one series, talc pleurodesis was successful in six of seven individuals.7 Some older adults with ESRD choose CAPD for longterm management because it allows greater personal autonomy. Acute presentation with respiratory symptoms in these individuals should prompt clinicians to consider sweet syndrome (effusion due to pleuroperitoneal communications) as a possible etiology. Eben Clattenburg, MPH School of Medicine, Johns Hopkins University, Baltimore, Maryland Anuj Bhatnagar, MD Carol Perfetto, NP Matthew McNabney, MD Division of Geriatric Medicine and Gerontology, School of Medicine, Johns Hopkins University, Baltimore, Maryland
FEBRUARY 2014–VOL. 62, NO. 2
JAGS
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: All authors: conception, writing, and editing letter. Sponsor’s Role: There was no sponsorship of this work.
REFERENCES 1. Rosansky SJ, Clark WF. Has the yearly increase in the renal replacement therapy population ended? J Am Soc Nephrol 2013;24:1367–1370. 2. Brunori G, Viola BF, Maiorca P et al. How to manage elderly patients with chronic renal failure: Conservative management versus dialysis. Blood Purif 2008;26:36–40. 3. Szeto CC, Chow KM. Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Curr Opin Pulm Med 2004;10: 315–319. 4. Smolin B, Henig I, Levy Y. “Sweet” hydrothorax complicating chronic peritoneal dialysis. Eur J Intern Med 2006;17:583–584. 5. Michel C, Devy A, Lavaud F et al. A “sweet” hydrothorax. Presse Med 2001;30:1401–1403. 6. Chow KM, Szeto CC, Li PK. Management options for hydrothorax complicating peritoneal dialysis. Semin Dial 2003;16:389–394. 7. Tang S, Chui WH, Tang AW et al. Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003;18: 804–808. 8. Yang PJ, Liu TH. Massive “sweet” hydrothorax. Can Med Assoc J 2010;182:1883.
COMMENTS/RESPONSES MEDICINAL USE OF CANNABIS AND CANNABINOIDS IN OLDER ADULTS: WHERE IS THE EVIDENCE? To the Editor: Marijuana (Cannabis sativa) has been used medicinally for centuries for the management of different conditions and diseases.1 The cannabis plant contains a number of cannabinoids, which are responsible for its physiological and psychoactive effects. They act primarily through CB1 (brain) and CB2 (peripheral organs and tissues) receptors.
WHAT IS THE PROBLEM? The use of medicinal cannabis is increasing in older adults, but the exact prevalence of cannabis use is not known. A recent survey by the International Association for Cannabinoid Medicines on the medicinal use of herbal cannabis (marijuana) and cannabinoid-based medicine, completed by 953 participants from 31 countries (e.g., United States, Germany, Canada, France, the Netherlands), showed that 6.5% of medicinal cannabis users were aged 61 to 76.2 In the Netherlands, between 2003 and 2010, 37% of 5,540 patients who used prescription herbal cannabis were aged 61 to 93.3 Although the medicinal use of cannabis and cannabinoids in the general
