MSGM Case Presentation August 2025

Title: More than meets the eye

Prepared by: Dr Navena Sharma

Supervised by: Dr Toh Zeng Yan

Madam A, is a 66 year old lady with underlying childhood bronchial asthma (no recent asthma attacks, not on inhaler), type 2 diabetes mellitus (not on medications), hypertension (not compliant to medications) and hypothyroidism on thyroxine replacement therapy.

She was referred to a local rehabilitation facility for further evaluation and rehabilitation for generalised weakness and lethargy after recurrent falls. She was reviewed in the clinic and a decision was made for admission for inpatient rehabilitation in April 2025.

Background history

She was reportedly well with CFS 4 prior to her falls in November 2024. The clinical course was progressive and she started to have recurrent injurious falls which were all unwitnessed. She denied associated giddiness, chest pain or sudden limb weakness contributing to her falls. Since the beginning of 2025, she has had 7 falls and in April 2025 itself, she had 5 falls due to unsteadiness. Despite multiple falls, her bADLs were still independent in 2024. She then stopped going out due to physical limitation and multiple falls. She started using a single point walking stick during ambulation and subsequently was mainly in a wheelchair.

In January 2025, she had her first medical check-up following another unwitnessed fall. She was admitted to a private hospital and a battery of tests done which revealed no major pathology. Over the course of 4 months, she was mostly confined to a wheelchair. She gradually declined in basic daily functions where she needed more assistance and used diapers for functional urinary incontinence. By this time, she had low mood with passive death wishes but had no means to end her life. She had a psychiatric consult where medications

were started (Sertraline 25mg ON) for Major Depressive Disorder. She became unwell requiring hospitalisation again in April 2025. She presented then to a private hospital with respiratory symptoms and changes in behavior. She had a battery of work up done again and was treated with antibiotics for interstitial pneumonia.

Investigation	Date	Findings
CT Brain	13/4/2025	No ICB, small vessel disease
MRI Brain	13/4/2025	Small vessel disease
EEG	14/4/2025	Normal
Echocardiogram	14/4/2025	LVEF 65%, No RWMA, No vegetation
HRCT Thorax	14/4/2025	Features could represent non-specific interstitial pneumonia (NSIP)
USG Abdomen and Pelvis	14/4/2025	Fatty liver
USG Abdomen and Pelvis	14/4/2025	Septated gallbladder with gall stones and changes of adenomyomatosis
CT Abdomen and Pelvis	15/4/2025	Apparent mural thickening at the ascending colon and cecum. DDx collapsed state, colitis, acute diverticulitis, suggest correlation with scope findings
CT Abdomen and Pelvis	15/4/2025	Cholelithiasis with septated gallbladder showing changes of adenomyomatosis
CT Abdomen and Pelvis	15/4/2025	Mildly thickened and enhanced bilateral renal pelvis urothelium and urinary bladder, suggestive of infection (pyelitis and cystitis)
CT Abdomen and Pelvis	15/4/2025	Apparent diffuse mural thickening of the ascending and descending colon, DDx colitis, spurious appearance due to collapsed state. Suggest correlation with colonoscopy findings.
CT Abdomen and Pelvis	15/4/2025	Bilateral basal lung ground glass opacities. DDx infection, interstitial pneumonia
VEP	15/4/2025	Normal VEP study of both eyes

Madam A was reviewed in a rehabilitation center upon discharge from hospital.

On her first visit, she was noted to be cachexic and she weighed 46kg. She was lethargic. However, she could still answer simple questions and remained oriented to time and place. MMSE 19/30, recall 3, GDS 9/15. No peripheral edema.

Although her blood pressure and pulse were normal, it was noted that she had postural hypotension. Saturation was normal on room air. On lung examination, it was noted she had poor inspiratory effort but clear on auscultation. Heart sounds were normal. Neurological examination did not reveal any localising signs. On all 4 limbs, tone was normal and power was 4/5.

Madam A was accompanied by her sister who describes her to have an introverted personality but she is opinionated and seemed difficult to get along with others at home and usually gets into arguments with the rest. She is religious and keeps herself busy with religious activities. She is conservative with her dressing but had 2 episodes of walking around naked in December 2024 with no reason given which was out of character. She is a strict vegetarian and is very particular about food and utensils used but was told by the doctor to eat meat in

view of anemia, she disregarded her own beliefs recently and started consuming meat (this was perceived to be odd as patient is very staunch in her beliefs).

Her education level is Secondary 5. She worked as a technician and she was retrenched at the age of 46 years old. She later worked as a clerk and stopped working at the age of 55 years old.

She is a widow with 2 marriages in the past; Her 1st marriage ended in a divorce as her husband was abusive and in her 2nd marriage, she was widowed in her late 30s after her husband committed suicide. She has no children. She has 10 siblings. Following her recent decline, she currently stays with her younger sister in a double-storey house.

She was admitted for rehabilitation and issues identified were:

1. Recurrent Falls with Sarcopenia

Progressive functional decline with recent hospital associated deconditioning

 Ambulation: wheelchair with occasional walking stick

 bADLs: 1 person assist

 iADL: decline in all aspects

 Intrinsic falls risk factor: sarcopenia, anemia, gait instability, postural hypotension

2. Major Depressive Disorder

Other medical diagnoses:

3. Vitamin D deficiency

4. Osteoporosis with T12 compression fracture (incidental finding on CT abdomen)

5. Normochromic normocytic anemia with TSAT 16%

6. Hypothyroidism (clinically euthyroid)

She was admitted for gait and bADL retraining. Rehabilitation was initiated.

Multi-disciplinary team input is as stated.

Transfer : min to max assist (inconsistent)

Bathing : commode (needs prompting)

Feeding : independent

Toileting : diapers (indicated inconsistently)

Sleep : able to sleep

Mood : psychomotor retardation

EMS	12/20 (borderline)
5x Sit to Stand	37 sec (independent)
Berg Balance Scale	23/56 (high risk of fall)
TUG	36 sec (walking stick)
10 MWT	0.35 m/sec (household ambulator)
6 MWT	82 m
Grip Strength	Right - 5kgF / Left - 4kgF
MBI	51% (Moderate dependency level)
MMSE	19/30 (recall 3/3) > 14/30 (Recall: 1/3)
GDS	9/15 > 10/15

Her updated medication list:

 T Sangobion 1 tab OD ()

 T Atorvastatin 40mg ON

 T Mirtazapine 15mg ON

 T L Thyroxine 25mcg OD

 T Esomeprazole 40mg OD

 Sy Lactulose 15mls BD

 D Cure 50000iu Weekly

During rehabilitation, she was noted to have psychomotor retardation with lack of motivation. Her attention span was also short. She was lethargic with chills. However, there was no documented fever throughout her stay. Subsequently, she was found to have urinary retention with pyuria. She was treated for urinary tract infection. My 4AT score then was 0+2+1+4 (7). In addition, she made no progress during rehabilitation and instead was noted to have oxygen desaturation during therapy sessions. She was relatively stable in the ward but over the course of 2 days she developed progressively worsening breathlessness even at rest and

subsequently requiring oxygen supplementation.

Despite on broad spectrum antibiotics, she worsened over the course of 5 days requiring mechanical ventilation with severe sepsis requiring inotropic support. She also developed acute kidney injury.

She was treated for:

1. Hospital Acquired Pneumonia

2. ESBL E.coli urosepsis complicated with Hypoactive Delirium and Acute Kidney Injury

Her progress remained poor despite cardio-respiratory support. As part of the AMS (anti- microbial stewardship programme), she was reviewed by the Infectious Disease Consultant

and Microbiology team. It was by chance that the microbiologist involved was working on the confirmatory test of her HIV test sent a week prior. It was later confirmed positive with high titres.

Impression was revised to:

1. RVD with opportunistic infection: PJP (Pneumocystic jirovecii pneumonia) TRO PTB.

Additional investigations sent:

 Tracheal sampling was negative for TB (AFB direct smear)

 CT brain 9/5/25: No ICB and no focal brain lesion

 USG KUB 8/5/25: No evidence of obstructive uropathy

 CD4 count was 11

 Lumbar Puncture 9/5/2025: Opening pressure of 13cm H2O and clear CSF,

glucose 10.5 (CBS 14.7) (glucose CSF to serum ratio 0.7), protein 0.29

Summary of sampling results did not suggest any specific pathology

o Cryptococcal antigen: Negative

o JC virus PCR: Non-reactive

o CSF culture no growth

She did not make any positive progress throughout her stay in the high dependency unit. She succumbed to her illness after being on a ventilator for 13 days (a total of 25 days admission). Her sister was informed regarding the diagnosis of RVD in the course of her stay in high- dependency unit.

HbA1c 5.7%

Iron 2.5

Tsat 16%

B12 220

Folate 43

Learning Questions

1. The HIV serology test in this circumstance has been invaluable in the diagnostic course and trajectory of her disease. The request for this lab test raises a common clinical dilemma of screening for immunocompromised state in the elderly especially in the context of an Asian culture.

When should we test for HIV in our geriatric patients?

- A study was conducted in Uganda in 2020 (Mbalinda, S.N., Lusota, D.A., Muddu, M. et al. 2024) highlighting the management challenges of patients who fell sick often and would get help but not get any better. They were then tested positive for HIV. The study proposed that there is a need to normalise HIV testing at treatment centres for all ages so that no one is missed.

- Having recorded 9% of individuals above the age of 50 and the increasing number of PLHIV who are inevitably ageing, can immunosenescence still be enough to account for falling sick frequently with poor recovery?

- How reliable is social history taking from the aspects of patient’s willingness to

provide detailed information and the comfort level of treating doctors to gather

detailed sexual history in our Asian culture?

2. Sexual Health discussions is still a taboo in our culture. With increasing life span,

increased number of new partners, higher divorce rates, older adults frequently

excluded from STI prevention and health promotion, widespread use of erectile

dysfunction medication, ease of foreign travel and lack of awareness among health-care professionals about old-age sexual health leads to inadequate communication with older people regarding sexual health and HIV risks (Fu, Leiwen et al. 2019).

How can we create a more conducive healthcare environment to support the

older population in sexual health issues?

How do we reduce the stigma towards HIV infection amongst our elderly

population?

3. Madam A has reported lethargy, progressive weight loss, progressive endurance

decline despite still coping independently in the community back in 2024.

Could her physical decline with a slow recovery after a minor insult in 2024/2025 signal a more common issue of frailty and sarcopenia?

HIV has been associated with earlier onset age-associated medical related conditions.

Is HIV just a red herring in this case or did HIV contribute to a more rapid and

negative frailty and sarcopenia trajectory (accelerated ageing)?

Would the outcome have been better with earlier medical/geriatric intervention during the initial days of decline in 2024 (which would include a CGA) or would the outcome be better just with earlier HIV diagnosis?

Would that then highlight the importance of sexual health in comprehensive geriatric assessments in all cases?

4. Madam A has gone through much to have led her to develop Major Depressive

Disorder (MDD). Learning from her strong and independent personality, having to

depend on her sibling for daily activities and having mobility loss would have made a profound impact to her self-esteem and self-worth.

Is there a link between MDD and HIV infection in general?

Several studies noted, patients with HIV infection were two to seven times more likely to meet the diagnostic criteria for MDD while it was also noted that many had the previous diagnosis of MDD prior to the infection with HIV.

Could HIV be the cause or causal to the development of MDD?

In summary, HIV infection in the older population is a hidden but growing concern. A modelling study estimated that the proportion of adults with HIV infection aged 50 years or older in the Netherlands would increase from 28% in 2010 to 73% in 2030. These statistics should bring awareness to health-care providers regarding the effects of ageing societies and other societal factors on the risk of HIV and other STIs in our geriatric population and we should develop age-appropriate interventions.

References

Mbalinda, S.N., Lusota, D.A., Muddu, M. et al. Ageing with HIV: challenges and coping mechanisms of older adults 50 years and above living with HIV in Uganda. BMC Geriatr 24, 95 (2024). https://doi.org/10.1186/s12877-024-04704-z

Fu, Leiwen et al. Global, regional, and national burden of HIV and other sexually transmitted infections in older adults aged 60– 89 years from 1990 to 2019: results from the Global Burden of Disease Study 2019. The Lancet Healthy Longevity, Volume 5, Issue 1, e17 - e30

Hinkin CH, Castellon SA, Atkinson JH, Goodkin K. Neuropsychiatric aspects of HIV infection among older adults. J Clin Epidemiol. 2001 Dec; 54 Suppl 1(Suppl 1):S44-52. doi: 10.1016/s0895-4356(01)00446-2. PMID: 11750209; PMCID: PMC2864032.

Luther VP, Wilkin AM. HIV infection in older adults. Clin Geriatr Med. 2007 Aug;23(3):567-83, vii. doi: 10.1016/j.cger.2007.02.004. PMID: 17631234.

2023 Global AIDS Monitoring, Country Progress Report – Malaysia, Ministry of Health Malaysia Disease Control Division.