Is presentation of bacteremia in the elderly the same as in younger patients?

OBJECTIVE: To compare the presentation of bacteremia in young and elderly patients. PATIENTS AND METHODS: Seventy-one elderly (mean age 80.4 years) and 34 younger inpatients (mean age 45.7 years) with bacteremia were prospectively studied. These were compared with a control group of 187 geriatric patients (mean age 81.3 years) with clinical signs of bacteremia but in whom blood cultures were negative. Bacteremia was defined as one or more positive blood cultures showing a pathogenic bacteria in patients with clinical signs of bacteremia. In all 105 patients with bacteremia, 16 common clinical or biological signs of the disease were immediately investigated after blood culture. Patients were classified into three groups: elder patients and young patients with bacteremia and elderly patients without bacteremia. RESULTS: Only three clinical findings of the 16 studied were found in at least 70% of the bacteremic elderly patients: fever, increased erythrocyte sedimentation rate, and a clinical indication of the source of infection. These three signs were found statistically more often in bacteremic elderly compared with nonbacteremic elderly patients (P < 0.01). Seven other signs (hypothermia, altered mental state, leukopenia, and lymphopenia) had a specificity above 80%. On a logistic regression analysis, four variables were significantly and independently associated with bacteremia in the elderly: rapid onset of infection (defined as a period < or = 48 hours between the earliest manifestation of bacteremia and the time of blood blood sample), fever, altered general state, and clinical indication of the source of infection. Younger infected patients had more chills, sweating, alter general state, altered mental state or lymphopenia than did the bacteremic elderly patients. Bacteremic elderly patients had statistically few symptoms than the young infected patients (P < 0.001). CONCLUSIONS: In elderly patients with early stage bacteremia, most of the signs or symptoms that are considered typical in the literature appear irregularly. None appeared pathognomonic. Elderly patients with bacteremia had fewer signs or symptoms than younger infected patients.

Does age play a role in clinical presentation of hypothyroidism?

OBJECTIVE: To determine if aging modifies the clinical presentation of hypothyroidism. DESIGN: Comparison of 24 clinical signs of hypothyroidism between elderly patients (> or = 70 years of age) and younger patients (< or = 55 years of age). SETTING: Prospective study of patients with chemically confirmed overt hypothyroidism. PATIENTS: Sixty seven elderly patients (79.3 +/- 6.7 years) and 54 younger patients (40.8 +/- 9 years) were included in the study. RESULTS: Neither mean duration of evolution nor mean thyroid-stimulating hormone (TSH) level were different between the 2 groups. Two signs were found in more than 50% of the elderly patients (fatigue and weakness). Four signs were significantly less frequent in elderly patients (chilliness, paresthesiae, weight gain, and cramps). Mean number of clinical signs in the elderly (6.6 +/- 4) was significantly smaller than in young patients (9.3 +/- 4.7) (P < 0.01). CONCLUSIONS: Our results suggest that the presentation of hypothyroidism is altered in the elderly in comparison with young patients in that there are (1) fewer signs or symptoms and (2) diminished frequency of some classical signs. Our results underline the importance of TSH measurement in the elderly.

[Can the protein concentration of the ascitic fluid in ascites predict the occurrence of an infection?]. / La concentration des protides dans l'ascite permet-elle de prévoir la survenue d'une infection du liquide d'ascite?

In cirrhotic patients, spontaneous bacterial peritonitis is frequent and severe. This study was performed to determine if low protein concentration in ascitic fluid on admission could predict the occurrence of spontaneous bacterial peritonitis during hospitalization. Ninety-two cirrhotic patients with ascites, without spontaneous bacterial peritonitis were studied. Bacteriologic study and cultures of ascitic fluid were performed on admission and repeated every 5 days, and if any suspicion of infection occurred; 11 patients developed spontaneous bacterial peritonitis during hospitalization. Among the 92 patients in the study, protein concentration in ascitic fluid was initially less than 10 g/l in 45 and 10 of these 45 patients (22 p. 100) developed spontaneous bacterial peritonitis during hospitalization; protein concentration in ascitic fluid was initially greater than 10 g/l in 47 patients; only one of these 47 patients (2.1 p. 100) developed spontaneous bacterial peritonitis during hospitalization. This difference (22 p. 100 vs 2.1 p. 100) was significant (p less than 0.01). Ascitic fluid protein concentration (6.9 +/- 2.3 g/l) was significantly lower (p less than 0.01) in the spontaneous bacterial peritonitis group than in patients without peritonitis (13.8 +/- 10.5 g/l). These results suggest that: 1) ascitic fluid protein concentration on admission is lower in patients who will develop spontaneous bacterial peritonitis during hospitalization than in patients without infection and 2) patients with ascitic fluid protein concentration under 10 g/l on admission represent an high risk group for spontaneous bacterial peritonitis.

[Liver lipogranulomas with log-term fever caused by paraffin oil]. / Lipogranulomes hépatiques à l'huile de paraffine responsables d'une fièvre au long cours.

In hepatic granuloma, identification of lipogranulomas generally leads to etiological diagnosis. The case reported here was granulomatosis due to mineral oil ingestion, revealed by prolonged fever. In the literature lipogranulomas are generally asymptomatic and diagnosed at autopsy.

[Neuroma of the common bile duct: a rare cause of jaundice]. / Névrome de la voie biliaire principale: une cause rare d'ictère.

We report a case of neuroma of the main bile duct arising twenty years after cholecystectomy. The patient, a 82-year-old woman, was admitted for jaundice. Endoscopic retrograde cholangiography showed a regular stenosis of the main bile duct. Histologic examination demonstrated neuroma. Based on the analysis of this and 15 other previously published cases, the following features of bile duct neuroma were outlined: a) variable interval between cholecystectomy and the onset of jaundice (6 months to 35 years); b) the generally complicated postoperative course, c) the various localizations on the biliary tree (cystic, main bile duct, intrahepatic bile duct) and, d) the circumstances of onset.

[A case of primary osteosarcoma of the liver]. / Un cas d'ostéosarcome primitif du foie.

The authors report a case of primary osteosarcoma of the liver in a 75 year-old man with post hepatitic B cirrhosis. The hepatic tumor was discovered on ultrasound and computed tomography. Angiography showed a hypervascularized tumor. The patient died rapidly. Diagnosis of primary osteosarcoma of the liver was established through histopathological examination of post mortem specimens and was confirmed by immunohistochemical study. From this and two other previously reported cases the authors describe the different primary hepatic tumors mimicking osteosarcoma.

[Pyogenic osteomyelitis in Gaucher's disease]. / Ostéomyélite à pyogène au cours de la maladie de Gaucher.

Gaucher's disease is a sphingolipidosis which may be accompanied by severe pain in the bones. We report a case of Bacteroides fragilis osteomyelitis consecutive to surgical biopsy. The bone pain may be due to ischaemia of the bone or to a pyogenic osteomyelitis which is iatrogenic in most cases. The clinical and paraclinical features of these two entities are described after a review of the literature, and the main complementary examinations leading to their diagnosis are presented.

[Incidence and severity of drug interactions in the elderly: a prospective study of 639 patients]. / Fréquence et gravité des interactions médicamenteuses dans une population âgée: étude prospective concernant 639 malades.

The medicinal treatments of 639 patients aged over 65 were recorded on admission to hospital. The mean number of drugs consumed was 4.4 +/- 2.8 per patient. Drug interaction was found in 37 p. 100 of the patients on the basis of data published in the Vidal dictionary. The prevalence of interactions increased with the number of drugs prescribed. The medicinal families most frequently involved were digitalis derivatives, antiarrythmic agents, diuretics, anticoagulants and psychotropic drugs. Thirty patients (4.7 p. 100) presented with a side-effect that was directly ascribable to an interaction. Among the iatrogenic adverse reactions 11 were life-threatening, including 8 cases of severe dysrhythmia and 3 cases of gastrointestinal haemorrhages. Altogether, one-third of all iatrogenic disorders were consecutive to a drug interaction. Simple precautions would have considerably reduced the frequency of such side-effects.

[Increase of aminotransferases]. / Elévation des aminotransférases.

Elevated aminotransferases activities are frequent in medical practice. In acute elevations, the mains causes are generally easily found (viral, drug-induced, toxic, ischemic). In moderate or prolonged elevations, the most frequent causes are steatosis (alcoholic, diabetes, obesity) and chronic hepatitis (viral B, D, C, drug-induced and auto-immune diseases.

[Diagnostic value of a distinct rise in sedimentation rate]. / Valeur diagnostique d'une augmentation franche de la vitesse de sédimentation.

Among the 931 patients who were admitted, over a 9-month period, to an internal medicine department, a group of 84 patients (9 p. 100) whose erythrocyte sedimentation rate (ESR) was 70 mm or more at 1 hour was selected and compared to the remaining 847 patients whose ESR was below 70 mm at 1 hour. In most cases, a pathology likely to account for the distinct rise observed in ESR was found (infection in 42 p. 100 of the cases, malignant disease in 27 p. 100, inflammation in 20 p. 100), and only 5 p. 100 of these rises remained unexplained. This makes an ESR of 70 mm or more a good index of morbidity generally, without pointing at any specific disease. An ESR of 70 mm or more has very low sensitivity (always below 30 p. 100), so that no disease whatsoever can be excluded when the ESR is only slightly elevated. Moreover, in all but infectious diseases a distinctly high ESR is not an index of severity.

[Changes in arterial pressure in the postprandial period in the elderly]. / Etude des variations de la pression artérielle en période post-prandiale chez les sujets âgés.

The repercussions of food intake on blood pressure may account for certain malaises which occur after meals in elderly people. In this study, blood pressure and heart rate were measured during and after a meal in 39 elderly hospital patients divided into two groups depending on whether or not they were taking drugs likely to act on arterial blood pressure. The patients were compared with two groups of controls: 29 young adults examined after a meal and 16 elderly subjects examined at a distance from meals. A significant fall in blood pressure starting 18 minutes after the meal and without concomitant increase in heart rate, was observed in the 2 groups of elderly patients. No significant changes in blood pressure and heart rate were observed in the 2 control groups. In elderly people, food intake might act on blood pressure through entrapment of blood in splanchnic territories and/or through alteration of baroreceptors.

[Inter-alpha-trypsin inhibitor and its derivatives in inflammatory syndromes]. / Inter-alpha-trypsine inhibiteur et ses dérivés dans les syndromes inflammatoires.

Modifications of inter-alpha-trypsin inhibitor (ITI) in inflammatory syndromes were determined by studying its serum components: ITI 80 (the native form) and serum derivatives (SD), as well as urinary ITI derivatives (UID) excretion in 31 controls and 128 patients with inflammatory of various origins. The patients were divided into 4 groups: Group I bacterial infections (n = 29); Group II cancers (n = 50); Group III inflammatory diseases (n = 14); Group IV inflammatory syndromes due to other causes (n = 35). Other markers of inflammation were also studied. In bacterial infections and cancers ITI 80 concentrations were significantly decreased, with values of 0.55 +/- 0.15 g/l and 0.54 +/- 0.15 g/l respectively vs 0.65 +/- 0.11 g/l in controls. SD concentrations were significantly increased in all 4 groups: Gr I: 0.31 +/- 0.12 g/l; Gr II: 0.30 +/- 0.11 g/l; Gr III: 0.25 +/- 0.08 g/l; Gr IV: 0.24 +/- 0.10 g/l, as compared with 0.16 +/- 0.09 in controls. UID excretion was increased in all cases, particularly in bacterial infections and cancers (10.8 +/- 13.4 and 6.0 +/- 8.8 mg/mmol of creatinine vs 1.5 +/- 1.7 g/mmol). A significant correlation was observed between CRP levels and SD levels. In bacterial infections and cancers, a fall in ITI associated with a rise in SD and an increase in UID excretion is suggestive of degradation of the native form. In inflammatory diseases and inflammatory syndromes of other causes, the rise in SD without significant variations in ITI 80 suggests and increase in SD synthesis. The correlation between CRP and SD seems to indicate that SD are produced in the early stage of inflammatory syndromes.