[Pyoderma gangrenosum and hemopathies in older patients]

Pyoderma gangrenosum (PG) belongs to neutrophilic dermatoses. PG can have different clinical presentations (ulcerated, bullous, pustular), is often painful, and preferentially affects the lower limbs. The diagnosis can be challenging, and a cutaneous biopsy is often necessary, which shows an aseptic cutaneous infiltrate of neutrophils. The association with inflammatory or hematologic conditions is frequent, especially in older patients. The hematologic diseases the most frequently associated with PG are myelodysplastic syndrome, followed by monoclonal gammopathy of undetermined significance. Because of the strong impact of its treatment, recognition of PG is crucial. The treatment is based on first-line corticosteroids and topical or systemic immunosuppressive drugs and most often leads to a favourable outcome. The management of an acute hematologic disease would further improve the prognosis of PG. The singularity of geriatric patients encourages to thoroughly balance the risks and benefits of the recommended drugs and to consider associated non-drug measures. Here, we propose a review of the scientific literature about the association between PG and hematologic diseases, with a special focus on older patients, accompanied by the report of two cases in geriatric ward.

Corticosteroid therapy in COVID-19 associated with in-hospital mortality in geriatric patients: a propensity matched cohort study

Background

Few data are available on the prognosis of older patients who received corticosteroids for COVID-19. We aimed to compare the in-hospital mortality of geriatric patients hospitalized for COVID-19 who received corticosteroids or not.

Methods

We conducted a multicentric retrospective cohort study in 15 acute COVID-19 geriatric wards in the Paris area from March to April 2020 and November 2020 to May 2021. We included all consecutive patients aged 70 years and older who were hospitalized with confirmed COVID-19 in these wards. Propensity score and multivariate analyses were used.

Results

Of the 1 579 patients included (535 received corticosteroids), the median age was 86 (interquartile range 81–91) years, 56% of patients were female, the median Charlson Comorbidity Index (CCI) was 2.6 (interquartile range 1–4), and 64% of patients were frail (Clinical Frailty Score 5–9). The propensity score analysis paired 984 patients (492 with and without corticosteroids). The in-hospital mortality was 32.3% in the matched cohort. On multivariate analysis, the probability of in-hospital mortality was increased with corticosteroid use (odds ratio [OR] = 2.61 [95% confidence interval (CI) 1.63–4.20]). Other factors associated with in-hospital mortality were age (OR = 1.04 [1.01–1.07], CCI (OR = 1.18 [1.07–1.29], activities of daily living (OR = 0.85 [0.75–0.95], oxygen saturation < 90% on room air (OR = 2.15 [1.45–3.17], C-reactive protein level (OR = 2.06 [1.69–2.51], and lowest lymphocyte count (OR = 0.49 [0.38–0.63]). Among the 535 patients who received corticosteroids, 68.3% had at least one corticosteroid side effect, including delirium (32.9%), secondary infections (32.7%), and decompensated diabetes (14.4%).

Conclusions

In this multicentric matched-cohort study of geriatric patients hospitalized for COVID-19, the use of corticosteroids was significantly associated with in-hospital mortality.

Fecal impaction is associated with postoperative urinary retention after hip fracture surgery

BACKGROUND

Postoperative urinary retention (POUR) is a common hip fracture (HF) complication. Although fecal impaction (FI) is one of the oft-cited causes of POUR in clinical practice, evidence regarding this association is scarce.

OBJECTIVE

The aim of this study was to determine whether FI was associated with POUR after HF surgery in older patients.

METHODS

All patients consecutively admitted after a HF surgery in a geriatric perioperative unit were included in this cross-sectional study. FI was systematically assessed by a digital rectal exam at admission and according to clinical suspicion during the hospital stay. The dependent variable was POUR, systematically screened according to the department protocol and defined as a bladder volume > 400 ml requiring catheterization. The association between FI and POUR was assessed by multivariable analysis.

RESULTS

A total of 256 patients were included (mean [SD] age 86 [6] years), 76% women): 108 (42%) presented FI and 63 (25%) POUR. The frequency of FI was higher with than without POUR (73% vs 32%, P<0.001). On multivariable analysis, after adjusting for age, sex, Cumulative Illness Rating Scale score and anticholinergic load, FI was the only factor independently associated with POUR (odds ratio 4.78 [95% confidence interval 2.44-9.71], P<0.001.

CONCLUSIONS

FI was the only independent factor associated with POUR after HF surgery in older adults. Further studies are needed to optimize perioperative geriatric care including FI and POUR assessment and management.

A curable pseudo-dementia related to an atypical presentation of giant cell arteritis

A 70-year-old patient was admitted with rapidly progressive cognitive decline associated with limitations in activities of daily living, weight loss and cerebellar ataxia. The diagnosis of giant cell arteritis (GCA) with vascular involvement was made, based on the presence of a metabolically active vasculitis of the brachiocephalic trunk on 18FDG-PET imaging. Temporal artery biopsy also revealed pan-arteritis. A progressive regression of cognitive disorders occurred under corticosteroid treatment and immunosuppressive therapy. Previously published case reports concerning this atypical presentation of GCA are scarce. They suggest that numerous cognitive symptoms, such as impairment of short-term memory, disorientation, delirium, impaired attention or visual hallucinations might be related to GCA. Thus, this diagnosis should be considered as a curable cause of unexplained cognitive impairment associated with weight loss and systemic inflammation.

[Familial Mediterranean fever]

Familial Mediterranean Fever (FMF) is the most frequent monogenic auto-inflammatory disease. FMF is an autosomal recessive disease, which affects populations from Mediterranean origin and is associated with MEFV gene mutations encoding for the protein pyrin. Pyrin activation enhances the secretion of interleukin 1 by myelo-monocytic cells. Main features of the disease are acute attacks of serositis mainly located on the abdomen, less frequently on chest and joints, accompanied by fever and biological inflammatory markers elevation. Usually attacks last 1 to 3 days and spontaneously stop. A daily oral colchicine intake of 1 to 2mg/day is able to prevent attack's occurrence, frequency, intensity and duration among most patients. Colchicine is also able to prevent the development of inflammatory amyloidosis, the most severe complication of FMF. This state of the art article will focus on the diagnosis of FMF, the treatment and an update on the pathophysiology including the recent described dominant form of MEFV-associated new auto-inflammatory diseases.

Mastocytosis among elderly patients: A multicenter retrospective French study on 53 patients

Mastocytosis is a heterogeneous group of diseases with a young median age at diagnosis. Usually indolent and self-limited in childhood, the disease can exhibit aggressive progression in mid-adulthood. Our objectives were to describe the characteristics of the disease when diagnosed among elderly patients, for which rare data are available.The French Reference Center conducted a retrospective multicenter study on 53 patients with mastocytosis >69 years of age, to describe their clinical, biological, and genetic features.The median age of our cohort of patients was 75 years. Mastocytosis variants included were cutaneous (n = 1), indolent systemic (n = 5), aggressive systemic (n = 11), associated with a hematological non-mast cell disease (n = 34), and mast cell leukemia (n = 2). Clinical manifestations were predominantly mast cell activation symptoms (75.5%), poor performance status (50.9%), hepatosplenomegaly (50.9%), skin involvement (49.1%), osteoporosis (47.2%), and portal hypertension and ascites (26.4%). The main biological features were anemia (79.2%), thrombocytopenia (50.9%), leucopenia (20.8%), and liver enzyme abnormalities (32.1%). Of the 40 patients tested, 34 (85%), 2 (5%), and 4 (10%) exhibited the KIT D816V mutant, other KIT mutations and the wild-type form of the KIT gene, respectively. Additional sequencing detected significant genetic defects in 17 of 26 (65.3%) of the patients with associated hematological non-mast cell disease, including TET2, SRSF2, IDH2, and ASLX1 mutations. Death occurred in 19 (35.8%) patients, within a median delay of 9 months, despite the different treatment options available.Mastocytosis among elderly patients has a challenging early detection, rare skin involvement, and/or limited skin disease; it is heterogeneous and has often an aggressive presentation with nonfortuitous associated myeloid lineage malignant clones, and thus a poor overall prognosis.