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APRIL 2014–VOL. 62, NO. 4
Crusted scabies is another important differential in any elderly adult with an itchy, psoriasiform scalp eruption. Individuals at higher risks include those who are bedbound with multiple medical comorbidities and poor mobility. The prognosis in MF is worse in men, older adults, at a higher stage of disease, and with the folliculotropic variant of MF.2 This woman had at least T3N1M0B0 disease, compatible with Stage IIB, which is advanced.4 Overall survival at this stage is 37.8% to 63.2% at 5 years after diagnosis and 19.8% to 53.2% at 10 years.2 Systemic therapy is indicated because of extensive skin and lymph node involvement. Choices include retinoid (bexarotene), interferon, histone deacetylase inhibitors (e.g., romidepsin, vorinostat), chemotherapy (e.g., methotrexate, doxorubicin, gemcitabine, cyclophosphamide, chlorambucil, fludarabine, etoposide), and biologic agents (e.g., bortezomib, alemtuzumab).5,6 Because these treatments are expensive and not readily available, this woman was fortunate to receive the biological treatment and chemotherapy free of charge and had a good outcome. William Ngan, MBBS Department of Medicine, Queen Mary Hospital, Pokfulam, Hong Kong Johnny C.Y. Chan, MBBS Division of Dermatology, Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong Gloria Y.Y. Hwang, MBBS Division of Hematology, Queen Mary Hospital, Pokfulam, Hong Kong James K. H. Luk, MBBS Department of Medicine and Geriatrics, Fung Yiu King Hospital, Pokfulam, Hong Kong
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: Ngan: acquisition of patient information, analysis and interpretation of data, preparation of manuscript. Chan: preparation of manuscript and dermatological discussion of case. Hwang: preparation of manuscript and hematological discussion of case. Luk: preparation of manuscript, revision of draft, and geriatric discussion of case. Sponsor’s Role: No sponsor was involved.
LETTERS TO THE EDITOR
787
International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood 2007;110:1713–1722. 5. Weberschock T, Strametz R, Lorenz M et al. Interventions for mycosis fungoides. Cochrane Database Syst Rev 2012;9:CD008946. 6. Wollina U. Cutaneous T cell lymphoma: Update on treatment. Int J Dermatol 2012;51:1019–1036.
PANTOPRAZOLE SODIUM–INDUCED HYPONATREMIA IN A FRAIL ELDERLY ADULT To the Editor: Hyponatremia due to proton pump inhibitors (PPIs) is a rare electrolyte imbalance in elderly people.1,2 A frail elderly adult with hyponatremia caused by pantoprazole is presented here. A frail elderly adult, Mr. T, aged 80, was admitted with nausea, weakness, and vertigo to the outpatient clinic. He had used pantoprazole for 3 years for gastroesophageal reflux and dyspeptic symptoms, as well as levodopa 125 mg, benserazide 25 mg thrice daily, and rasagiline 1 mg daily for Parkinson’s disease; clopidogrel 75 mg daily for coronary artery disease; tamsulosin 0.4 mg daily for benign prostatic hyperplasia; and trospium 30 mg twice daily for urinary incontinence. His wife indicated that he did not use any other medications. Before he started pantoprazole (3 years before), his blood sodium level had been 137 mEq/dL. After pantoprazole treatment, his sodium level decreased to 133 mEq/dL (after 8 months). During this period, he had not had any symptoms of hyponatremia. On admission, his blood sodium level was 129 mEq/dL (normal range 135–145 mEq/dL). Other laboratory data were serum glucose 89 mg/dL (normal range 65– 107 mg/dL), serum creatinine 0.7 mg/dL (normal range 0.4–1.2 mg/dL), blood urea nitrogen 29 mg/dL (normal range 15–44 mg/dL), serum potassium 4.3 mEq/dL (normal range 3.5–5.5 mEq/dL), sedimentation rate 25 mm/h, serum osmolality 273 mOsm/L, and urine sodium 52.8 mmol/L. Complete blood count, liver enzymes, and thyroid function test results were within reference range. Vital signs were body temperature 36.6°C, blood pressure 160/80 mm/Hg, and pulse rate 80 beats per minute. On physical examination, he had mild gynecomastia, and his first heart sound was loud. Neurological examination was normal. It was thought that pantoprazole–induced hyponatremia was causing his weakness. Pantoprazole treatment was stopped, and antacid treatment was recommended for dyspepsia. After 3 months, his blood sodium level increased to 131 mEq/dL. His condition improved partially. At 6 months, has blood sodium level had improved to 136 mEq/dL. His complaints stopped completely, with normal serum sodium levels.
REFERENCES 1. Ku LS, Lo KK. Mycosis fungoides—a retrospective study of 40 cases in Hong Kong. Int J Dermatol 2005;44:215–220. 2. Benton EC, Crichton S, Talpur R et al. A cutaneous lymphoma international prognostic index (CLIPi) for mycosis fungoides and Sezary syndrome. Eur J Cancer 2013;49:2859–2868. 3. Zackheim HS. Treatment of patch-stage mycosis fungoides with topical corticosteroids. Dermatol Ther 2003;16:283–287. 4. Olsen E, Vonderheid E, Pimpinelli N et al. Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: A proposal of the
DISCUSSION Pantoprazole inhibits proton pumps on gastric parietal cells and prevents acid secretion. It is used safely in the treatment of gastric and duodenal ulcers from Helicobacter pylori and moderate to severe esophageal reflux and prevents recurrence of ulcers for years. The most-common side effects are indigestion, constipation, itching, skin
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eruption, hypomagnesemia, and osteoporosis with longterm use. The causal relationship between pantoprazole and hyponatremia was assessed using the Naranjo criteria3 and rated “possible.” The syndrome of inappropriate antidiuretic hormone secretion (SIADH) might explain the mechanism of hyponatremia related to pantoprazole. No signs of dehydration, low serum osmolarity, high urine sodium excretion, normal serum potassium, and absence of other causes of hyponatremia were an indication of SIADH. He was also frail and had Parkinson’s disease, which are risk factors for SIADH.4,5 To the best of the knowledge of the authors, this is the first report of hyponatremia induced by pantoprazole in a frail elderly adult. Physicians must be careful when prescribing pantoprazole to elderly adults. Periodic blood sodium monitoring might be recommended, especially in elderly adults who are frail and have Parkinson’s disease, which are risk factors for hyponatremia. Mehmet Ilkin Naharc y, MD Umit Cintosun, MD Ahmet Ozturk, MD Ergun Bozoglu, MD Huseyin Doruk, MD Division of Geriatrics, Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
ACKNOWLEDGMENTS Conflict of Interest: The authors have no financial or any other personal conflicts with this letter. Author Contributions: All authors participated in analysis and interpretation of subject’s data, and preparation of the letter. Sponsor’s Role: None.
REFERENCES 1. Brewster UC, Perazella MA. Proton pump inhibitors and the kidney: Critical review. Clin Nephrol 2007;68:65–72. 2. Hamilton DV, Lewis HW. A rare cause of hyponatraemia? Br J Hosp Med 2009;70:663. 3. Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239–245. 4. Walston JMD, Hadley EC, Ferrucci L et al. Research agenda for frailty in older adults: Toward a better understanding of physiology and etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc 2006;54:991–1001. 5. Bartter FC, Schwartz WB. The syndrome of inappropriate secretion of antidiuretic hormone. Am J Med 1967;42:790–806.
COMMENTS/RESPONSES THE EFFECT OF SHORT, UNPLANNED HOSPITALIZATIONS ON OLDER ADULT FUNCTIONAL STATUS To the Editor: The functional decline of older adults over acute care hospital stays has been well studied,1 showing
APRIL 2014–VOL. 62, NO. 4
JAGS
that older adults become less mobile and able to care for themselves. However, these studies generally exclude individuals who are admitted to the hospital for fewer than 3 days. Meanwhile, as medical protocols and insurers encourage ever-shorter hospitalizations to reduce costs and iatrogenic illness, the average length of hospitalization for patients aged 65 and older decreased from 10.7 days in 1980 to 5.6 in 2007.2 One-day stays made up 10.3% of Medicare inpatient days during 2013,3 up from 6.8% in 1990.4 A strong understanding of these short stays is becoming increasingly important given Medicare’s new two-midnight rule, which will presumptively classify many short stays as outpatient observation. It will be critical to understand how these individuals are affected as hospitals learn to manage their care as outpatients.
DESIGN, SETTING, AND PARTICIPANTS Seventy-five adults aged 65 and older were interviewed an average of 22.8 days after discharge from 1- to 2-day unplanned hospitalizations at Mount Sinai Hospital. Two hundred eighty-two individuals met the inclusion criteria, 27% of whom were interviewed. It was not possible to interview 16% of potential subjects who spoke Spanish only and 30% who could not be reached after three attempts. Ten percent declined to enroll in the study. Potential subjects were administered the oral components of the Mini-Mental State Examination; the interview was conducted if the individuals scored at least 13 of 19 points. Subjects were asked about their ability to perform 11 activities of daily living (ADLs) based on the Duke Activity Status Index (DASI),5 which assigns a weighted number of points to each activity according to its difficulty. Subjects were given two aggregate scores based on their ability to perform the ADLs before hospitalization and at the time of interview. Subjects were also asked whether they required the help of family, friends, or professional aides for care at the same two time points.
RESULTS Interviewed individuals were on average 76.9 years old; 57% were male, 48% were white, and 20% black, similar to all individuals who met the inclusion criteria. The Case Mix Index (CMI), the average of a group of diagnosis-related group weights and a measure of disease severity and expected resource use, was 0.96 for the 75 interviewed individuals, compared to 2.01 for all Mount Sinai Hospital Medicare patients during the study period. Major results are presented in Table 1. Subjects had an average change in ADL score of 19.3%. Decline correlated strongly with increases in need for help from family, friends, and professional aides, and needing help before admission was strongly correlated with very low (11.2) ADL scores after discharge. Decline did not correlate with age. Participants who stayed for 2 days declined significantly less between admission and interview than those who stayed for 1 day, despite no statistically significant difference in CMI (0.93 and 0.98, respectively; P = .61).
APRIL 2014–VOL. 62, NO. 4
Crusted scabies is another important differential in any elderly adult with an itchy, psoriasiform scalp eruption. Individuals at higher risks include those who are bedbound with multiple medical comorbidities and poor mobility. The prognosis in MF is worse in men, older adults, at a higher stage of disease, and with the folliculotropic variant of MF.2 This woman had at least T3N1M0B0 disease, compatible with Stage IIB, which is advanced.4 Overall survival at this stage is 37.8% to 63.2% at 5 years after diagnosis and 19.8% to 53.2% at 10 years.2 Systemic therapy is indicated because of extensive skin and lymph node involvement. Choices include retinoid (bexarotene), interferon, histone deacetylase inhibitors (e.g., romidepsin, vorinostat), chemotherapy (e.g., methotrexate, doxorubicin, gemcitabine, cyclophosphamide, chlorambucil, fludarabine, etoposide), and biologic agents (e.g., bortezomib, alemtuzumab).5,6 Because these treatments are expensive and not readily available, this woman was fortunate to receive the biological treatment and chemotherapy free of charge and had a good outcome. William Ngan, MBBS Department of Medicine, Queen Mary Hospital, Pokfulam, Hong Kong Johnny C.Y. Chan, MBBS Division of Dermatology, Department of Medicine, University of Hong Kong, Pokfulam, Hong Kong Gloria Y.Y. Hwang, MBBS Division of Hematology, Queen Mary Hospital, Pokfulam, Hong Kong James K. H. Luk, MBBS Department of Medicine and Geriatrics, Fung Yiu King Hospital, Pokfulam, Hong Kong
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: Ngan: acquisition of patient information, analysis and interpretation of data, preparation of manuscript. Chan: preparation of manuscript and dermatological discussion of case. Hwang: preparation of manuscript and hematological discussion of case. Luk: preparation of manuscript, revision of draft, and geriatric discussion of case. Sponsor’s Role: No sponsor was involved.
LETTERS TO THE EDITOR
787
International Society for Cutaneous Lymphomas (ISCL) and the cutaneous lymphoma task force of the European Organization of Research and Treatment of Cancer (EORTC). Blood 2007;110:1713–1722. 5. Weberschock T, Strametz R, Lorenz M et al. Interventions for mycosis fungoides. Cochrane Database Syst Rev 2012;9:CD008946. 6. Wollina U. Cutaneous T cell lymphoma: Update on treatment. Int J Dermatol 2012;51:1019–1036.
PANTOPRAZOLE SODIUM–INDUCED HYPONATREMIA IN A FRAIL ELDERLY ADULT To the Editor: Hyponatremia due to proton pump inhibitors (PPIs) is a rare electrolyte imbalance in elderly people.1,2 A frail elderly adult with hyponatremia caused by pantoprazole is presented here. A frail elderly adult, Mr. T, aged 80, was admitted with nausea, weakness, and vertigo to the outpatient clinic. He had used pantoprazole for 3 years for gastroesophageal reflux and dyspeptic symptoms, as well as levodopa 125 mg, benserazide 25 mg thrice daily, and rasagiline 1 mg daily for Parkinson’s disease; clopidogrel 75 mg daily for coronary artery disease; tamsulosin 0.4 mg daily for benign prostatic hyperplasia; and trospium 30 mg twice daily for urinary incontinence. His wife indicated that he did not use any other medications. Before he started pantoprazole (3 years before), his blood sodium level had been 137 mEq/dL. After pantoprazole treatment, his sodium level decreased to 133 mEq/dL (after 8 months). During this period, he had not had any symptoms of hyponatremia. On admission, his blood sodium level was 129 mEq/dL (normal range 135–145 mEq/dL). Other laboratory data were serum glucose 89 mg/dL (normal range 65– 107 mg/dL), serum creatinine 0.7 mg/dL (normal range 0.4–1.2 mg/dL), blood urea nitrogen 29 mg/dL (normal range 15–44 mg/dL), serum potassium 4.3 mEq/dL (normal range 3.5–5.5 mEq/dL), sedimentation rate 25 mm/h, serum osmolality 273 mOsm/L, and urine sodium 52.8 mmol/L. Complete blood count, liver enzymes, and thyroid function test results were within reference range. Vital signs were body temperature 36.6°C, blood pressure 160/80 mm/Hg, and pulse rate 80 beats per minute. On physical examination, he had mild gynecomastia, and his first heart sound was loud. Neurological examination was normal. It was thought that pantoprazole–induced hyponatremia was causing his weakness. Pantoprazole treatment was stopped, and antacid treatment was recommended for dyspepsia. After 3 months, his blood sodium level increased to 131 mEq/dL. His condition improved partially. At 6 months, has blood sodium level had improved to 136 mEq/dL. His complaints stopped completely, with normal serum sodium levels.
REFERENCES 1. Ku LS, Lo KK. Mycosis fungoides—a retrospective study of 40 cases in Hong Kong. Int J Dermatol 2005;44:215–220. 2. Benton EC, Crichton S, Talpur R et al. A cutaneous lymphoma international prognostic index (CLIPi) for mycosis fungoides and Sezary syndrome. Eur J Cancer 2013;49:2859–2868. 3. Zackheim HS. Treatment of patch-stage mycosis fungoides with topical corticosteroids. Dermatol Ther 2003;16:283–287. 4. Olsen E, Vonderheid E, Pimpinelli N et al. Revisions to the staging and classification of mycosis fungoides and Sezary syndrome: A proposal of the
DISCUSSION Pantoprazole inhibits proton pumps on gastric parietal cells and prevents acid secretion. It is used safely in the treatment of gastric and duodenal ulcers from Helicobacter pylori and moderate to severe esophageal reflux and prevents recurrence of ulcers for years. The most-common side effects are indigestion, constipation, itching, skin
788
LETTERS TO THE EDITOR
eruption, hypomagnesemia, and osteoporosis with longterm use. The causal relationship between pantoprazole and hyponatremia was assessed using the Naranjo criteria3 and rated “possible.” The syndrome of inappropriate antidiuretic hormone secretion (SIADH) might explain the mechanism of hyponatremia related to pantoprazole. No signs of dehydration, low serum osmolarity, high urine sodium excretion, normal serum potassium, and absence of other causes of hyponatremia were an indication of SIADH. He was also frail and had Parkinson’s disease, which are risk factors for SIADH.4,5 To the best of the knowledge of the authors, this is the first report of hyponatremia induced by pantoprazole in a frail elderly adult. Physicians must be careful when prescribing pantoprazole to elderly adults. Periodic blood sodium monitoring might be recommended, especially in elderly adults who are frail and have Parkinson’s disease, which are risk factors for hyponatremia. Mehmet Ilkin Naharc y, MD Umit Cintosun, MD Ahmet Ozturk, MD Ergun Bozoglu, MD Huseyin Doruk, MD Division of Geriatrics, Department of Internal Medicine, Gulhane School of Medicine, Ankara, Turkey
ACKNOWLEDGMENTS Conflict of Interest: The authors have no financial or any other personal conflicts with this letter. Author Contributions: All authors participated in analysis and interpretation of subject’s data, and preparation of the letter. Sponsor’s Role: None.
REFERENCES 1. Brewster UC, Perazella MA. Proton pump inhibitors and the kidney: Critical review. Clin Nephrol 2007;68:65–72. 2. Hamilton DV, Lewis HW. A rare cause of hyponatraemia? Br J Hosp Med 2009;70:663. 3. Naranjo CA, Busto U, Sellers EM et al. A method for estimating the probability of adverse drug reactions. Clin Pharmacol Ther 1981;30:239–245. 4. Walston JMD, Hadley EC, Ferrucci L et al. Research agenda for frailty in older adults: Toward a better understanding of physiology and etiology: Summary from the American Geriatrics Society/National Institute on Aging Research Conference on Frailty in Older Adults. J Am Geriatr Soc 2006;54:991–1001. 5. Bartter FC, Schwartz WB. The syndrome of inappropriate secretion of antidiuretic hormone. Am J Med 1967;42:790–806.
COMMENTS/RESPONSES THE EFFECT OF SHORT, UNPLANNED HOSPITALIZATIONS ON OLDER ADULT FUNCTIONAL STATUS To the Editor: The functional decline of older adults over acute care hospital stays has been well studied,1 showing
APRIL 2014–VOL. 62, NO. 4
JAGS
that older adults become less mobile and able to care for themselves. However, these studies generally exclude individuals who are admitted to the hospital for fewer than 3 days. Meanwhile, as medical protocols and insurers encourage ever-shorter hospitalizations to reduce costs and iatrogenic illness, the average length of hospitalization for patients aged 65 and older decreased from 10.7 days in 1980 to 5.6 in 2007.2 One-day stays made up 10.3% of Medicare inpatient days during 2013,3 up from 6.8% in 1990.4 A strong understanding of these short stays is becoming increasingly important given Medicare’s new two-midnight rule, which will presumptively classify many short stays as outpatient observation. It will be critical to understand how these individuals are affected as hospitals learn to manage their care as outpatients.
DESIGN, SETTING, AND PARTICIPANTS Seventy-five adults aged 65 and older were interviewed an average of 22.8 days after discharge from 1- to 2-day unplanned hospitalizations at Mount Sinai Hospital. Two hundred eighty-two individuals met the inclusion criteria, 27% of whom were interviewed. It was not possible to interview 16% of potential subjects who spoke Spanish only and 30% who could not be reached after three attempts. Ten percent declined to enroll in the study. Potential subjects were administered the oral components of the Mini-Mental State Examination; the interview was conducted if the individuals scored at least 13 of 19 points. Subjects were asked about their ability to perform 11 activities of daily living (ADLs) based on the Duke Activity Status Index (DASI),5 which assigns a weighted number of points to each activity according to its difficulty. Subjects were given two aggregate scores based on their ability to perform the ADLs before hospitalization and at the time of interview. Subjects were also asked whether they required the help of family, friends, or professional aides for care at the same two time points.
RESULTS Interviewed individuals were on average 76.9 years old; 57% were male, 48% were white, and 20% black, similar to all individuals who met the inclusion criteria. The Case Mix Index (CMI), the average of a group of diagnosis-related group weights and a measure of disease severity and expected resource use, was 0.96 for the 75 interviewed individuals, compared to 2.01 for all Mount Sinai Hospital Medicare patients during the study period. Major results are presented in Table 1. Subjects had an average change in ADL score of 19.3%. Decline correlated strongly with increases in need for help from family, friends, and professional aides, and needing help before admission was strongly correlated with very low (11.2) ADL scores after discharge. Decline did not correlate with age. Participants who stayed for 2 days declined significantly less between admission and interview than those who stayed for 1 day, despite no statistically significant difference in CMI (0.93 and 0.98, respectively; P = .61).
