Clinical Case Presentation December 2023

Prepared by: Dr Mohd Zaquan Arif

Dr Aimy Abdullah

Dr Noor Azleen Tarmizi

Case Scenario

Mr R is a 69 year old gentleman, previously fit and independent.

His only comorbidities were dyslipidaemia and hypertension. He was an ex smoker (stopped 20 years ago, 40 pack year history).

He was on Simvastatin 40mg ON and Amlodipine 5mg OD.

Geriatric referral

• Family members noticed change in behaviour and progressive decline in memory since early 2020.

• But only sought medical attention recently.

• Mr R was first seen in the geriatric clinic in May 2023.

Change in behaviour

• This was the first noticeable symptom which started in January 2020.

• He was easily irritable and angry over small matters.

• This worsened and he became verbally abusive.

Cognitive decline

• Around July 2020, he started to forget his normal driving route and took longer to find his way home. Eventually his wife had to accompany him on all road trips.

• Shopping then was affected as he could not remember what items to buy. He had to bring pictures and notes to the grocery store to aid him. He was still able to manage money but was very slow in transactions.

• He struggled with names of nieces and nephews but was still able to name close family members.

• He would also tell the same stories repeatedly.

Tactile hallucinations

• He complained of a constant sensation of something crawling over his face despite nothing to suggest this in reality.

• There were no skin changes.

• He consumed numerous creams and ointments, to no avail.

• He denied any visual or auditory hallucinations.

Weight loss

• Mr R’s family noticed a significant drop in his weight over the last few years.

• His poor appetite was poor.

• He had no respiratory or urinary symptoms, and no change in bowel habit.

Activities of daily living

• iADL: Difficulty in driving, shopping and monetary transactions as described. Still able to operate smart phone and TV. Wife helps with medication.

• bADL: Remains independent for bathing dressing, personal hygiene and feeding. Fully continent.

• Mobility: No issues with mobility, no falls.

Clinical examination

​Vitals were all within normal limits	GCS was 15/15
No clubbing or conjunctival pallor	No focal neurological deficits
Thin built, cachectic. Abdomen was soft, non tender and no organomegaly. Lungs and cardiovascular exam was unremarkable	Reflexes were normal
No lymph nodes palpable	No parkinsonism or gaze palsy
​No facial skin changes	MMSE was 14/30 (orientation 7, registration 1, attention 1, recall 0, language 4, pentagon 1)

Blood investigations

• FBC: WCC 8.1, Hb 15.6, Plt 341

• Renal profile: Na 141, K 4.8, Ur 2.3, Cr 73

• Electrolytes: Ca 2.25 (corrected), Phos 1.13

• Liver function: Bil 5.9, ALP 104, ALT 14, GGT 22, Albumin 41

• Haematinics: Iron 14.7, TIBC 66.7, Ferritin 159, Folate 12, Vit B12 221

• TFT: T4 11.9, T3 1.69

MRI brain

• Ventricular dilatation with narrow Callosal angle, crowding at the vertex and peri-Sylvian atrophy.

• Bilateral medial temporal atrophy.

• Multifocal old lacunar infarcts (bilateral thalamus and right putamen) with small vessel ischaemia and cerebral atrophy.

• Incidental finding of left corona radiata cavernoma.

CT TAP

Lower rectal mass involving the internal sphincter, T3b N2. No evidence of mesorectal fascia involvement or extramural vascular invasion.
No evidence of distant metastatic disease.

Tumour markers

• Alpha-1-Fetoprotein 3.3

• CA 19-9 <0.8

• CEA 5.9 (elevated)

Paraneoplastic antigen

• AmphiAb negative

• CVA2Ab negative

• PNMa2Ab negative

• RiAb negative

• YoAb negative

• HuAb negative

• RecovAb negative

• SOX1Ab negative

• TitinAb negative

EEG

There are bilaterally synchronous intermittent abnormalities of doubtful clinical significance.

Discussion

• What are the possible differential diagnoses?

• Unfortunately, Mr R’s family did not give consent for a lumbar puncture to be done. What is the clinical significance of doing a lumbar puncture in this scenario?

• How would you manage older adults presenting with weight loss?