Clinical Review

An 80-year-old Mandarin-speaking Chinese woman was referred to a mental health outpatient clinic for evaluation and treatment. The patient had a history of mild depression, for which she had been treated for many years with sertraline.

Five years earlier at age 75, the patient had been evaluated by a psychiatrist after she began to experience psychotic symptoms, including frequent repetitive auditory hallucinations of people counting, alternating with music from her childhood. At that time, she also had persecutory paranoid thoughts and delusional thinking that she was receiving messages in Mandarin while watching American TV programs. Initially, her only cognitive disturbance was an inability to differentiate among numbers on a calendar or a telephone keypad. No reports of memory problems were noted. Although the patient acknowledged auditory hallucinations, she denied experiencing command auditory hallucinations or hallucinations of other forms. The patient had no history of suicide attempts and denied suicidal or homicidal ideation. She had no history of psychiatric hospitalization.

The psychiatrist made a diagnosis of major depressive disorder with psychotic features, not otherwise specified¹ and prescribed sertraline 50 mg/d. The patient was also started on risperidone 0.25 mg/d for management of her psychotic symptoms, with the dosage gradually increased to 2.0 mg/d over five years. While taking this combination, the patient experienced stable mood and fewer paranoid thoughts, although her auditory hallucinations continued.

Two months before the current visit, the patient moved into a retirement living facility, and she reported having adapted well to the new setting. She was sleeping well and had a good appetite. Her BMI was within normal range.

The patient described herself as a single parent for nearly 40 years, raising one daughter. Formerly high functioning, she had held a full-time clerical job until age 70. She appeared well-groomed, polite but anxious, and oriented to time, person, and place. Her speech was normal, her thought processes were coherent, and her mood was stable. However, her affect was constricted; she acknowledged auditory hallucinations, which impaired her thought content. The patient reported feeling increased anxiety prior to any nonroutine activity, such as a doctor’s appointment; this, she said, would cause insomnia, leaving her to pace in her room.

During the examination, fine tremors on upper and lower extremities were noted. The patient’s Abnormal Involuntary Movement Scale (AIMS) score² was 13, which placed her in the highest risk category for antipsychotic-induced dopamine-blockade extrapyramidal symptoms (EPS). The patient was found to be negative for tardive dyskinesia, with no abnormal facial movements. She was aware of the tremors in her limbs and said she felt bothered by them.

The patient had an unsteady gait and used a four-point walker. Her Mini-Mental State Exam (MMSE) score³ was 28/30, which was normal for her age and education level (high school completed).

Apart from the described symptoms, the patient was healthy for her age and had no other medical diagnosis. Her vital signs were within normal range. The medical work-up to rule out other causes of dementia yielded negative results. Lab values were normal, including electrolyte levels and thyroid tests. The patient’s hearing test showed age-related hearing loss of full range, not limited to high pitch. She was able to engage in a meaningful conversation at a normal volume. Clinically, however, it was concerning to observe the possible signs of EPS and the relatively high risperidone dosage, considering the patient’s advanced age.

After the meeting with the patient, a treatment plan was created to 1) gradually reduce the dosage of antipsychotic medication, and 2) refer her to a neurologist for a complete work-up to rule out underlying neurologic disorders, such as dementia. Risperidone was tapered by increments of 0.25 mg/d every three to four weeks; throughout this process, the patient was closely monitored by the nursing staff at the retirement living facility. Monthly appointments were scheduled at the outpatient mental health clinic for evaluation and medication management.

Two months after the initial mental health clinic visit, the patient’s condition was pronounced stable on the current regimen of sertraline 50 mg/d and risperidone 1.0 mg/d. She was later seen by a neurologist, who made a diagnosis of Parkinson’s disease and placed her on carbidopa-­levodopa (1 1/2 tablets, 25/100 mg, tid). The patient’s auditory hallucinations continued with the same intensity as at baseline, but fewer tremors were noted in her extremities. By six months into the tapering process (with risperidone reduced at that time to 0.25 mg/d and carbidopa-levodopa to 25/100 mg tid), the patient had begun to experience dissipation of the tremors, and her AIMS score² was 0. She was able to replace her four-point walker with a cane.

One year after her initial visit to the mental health clinic, the patient’s neurologist suggested replacing risperidone with quetia­pine (12.5 mg/d) for its improved tolerability and lower adverse effect profile.⁴ She continued to take sertraline and carbidopa-levodopa.

Improvement of symptoms was noted following the switch. After one month on the revised regimen, the patient reported that the number of auditory hallucinations persisted, but that their intensity had decreased dramatically. She had a brighter affect and appeared to feel uplifted and more energetic. She became involved in the social activities offered at the retirement living facility and the mental health clinic. She also maintained a steady gait without her cane. According to the patient’s daughter, her mother was at her best psychological state since the onset of psychotic symptoms six years earlier. The pharmacologic regimen had reached its maximum benefit.

At a mental health appointment at the outpatient clinic 18 months after her initial visit there, it was evident that the patient’s auditory hallucinations persisted as a major stressor. She began to complain about other residents in her facility. She said she disliked the resident with whom she shared meals, and she claimed that other residents often spit on the floor in front of her room. The nursing staff did not confirm these incidents, which they considered a delusion despite the patient’s “evidence” (the tissues she said she had used to clean up).

Additionally, a new theme had emerged in the patient’s auditory hallucinations. She reported hearing a male voice that announced changes in meal times. Although she knew there was no public address system in her room or in the hallway, the “announcement” was so convincing that she would go to the dining room and once there, realize that nothing had changed. She seemed to drift between reality and her hallucinations/delusions. According to her daughter, the patient’s independent and reserved personality forced her to internalize her stressors—in this case, her frustration about the other residents—which fed into her hallucinations and delusions.

In response to her worsening psychotic symptoms, the patient’s provider increased her quetia­pine dosage from 12.5 mg/d to 25 mg/d. Her MMSE score³ at this visit was 25/30.

Two months later, the patient exhibited increasing symptoms of paranoia, delusions, and auditory hallucinations. She continued to respond to the “broadcast” messages about meal times, and she voiced her frustrations to others who spoke Mandarin. She became agitated in response to out-of-the-ordinary events. When her alarm clock battery ran out, for example, she insisted that “a man’s voice” kept reminding her to replace the battery; in response, she placed the alarm clock in the refrigerator, later explaining, “Now I don’t need to worry about it.”

Her cognitive status began to show obvious, progressive deterioration, with an MMSE score³ of 22/30 at this visit—a significant reduction from previous scores. Worsening of her short-term memory became apparent when she had difficulty playing bingo and was unable to remember her appointment or the current date. She became upset when others corrected her.

In a review of the trends in this patient’s clinical presentation, it became increasingly evident to the patient’s mental health care providers that she had Lewy body dementia.

DISCUSSION
Dementia with Lewy bodies (DLB), a progressive disease, is the second most common cause of neurodegenerative dementia after Alzheimer’s disease.^5-7 It is estimated that DLB accounts for 20% of US cases of dementia (ie, about 800,000 patients).^8,9 Although public awareness of DLB is on the rise, the disorder is still underrecognized and underdiagnosed because its clinical manifestations so closely resemble those of Alzheimer’s disease, Parkinson’s disease, and psychosis.^10,11

Clinical symptoms of DLB include progressive cognitive decline, cognitive fluctuation, EPS, and parkinsonism; hallucinations involving all five senses, particularly sight; delusions; REM sleep disturbance, with or without vivid and frightening dreams; changes in mood and behavior; impaired judgment and insight; and autonomic dysfunction, such as orthostatic hypotension and carotid-sinus hypersensitivity.^5,11-15

The symptoms of DLB are caused by the accumulations of Lewy bodies, that is, deposits of alpha-synuclein protein in the nuclei of neurons. Lewy bodies destroy neurons over time, resulting in the destruction of dopaminergic and acetylcholinergic pathways from the brain stem to areas of the cerebral cortex associated with cognition and motor functions.^4,5,16

DLB is a spectrum disorder; it often coexists with Parkinson’s disease or Alzheimer’s disease, as Lewy bodies are also found in patients with these illnesses.⁷ This poses a challenge for formulating a differential diagnosis, particularly in patients with fluctuating cognition,¹⁰ and for attempting to establish disease prevalence.

Diagnosis
Currently, a conclusive diagnosis of DLB can be confirmed only through postmortem autopsy, although use of medial temporal lobe volume (via structural MRI) and regional blood flow (via single photon emission CT [SPECT] tracers) is being investigated.¹⁷

The diagnosis of DLB is currently based on the presenting clinical symptoms and the exclusion of other medical conditions whose symptoms mimic those of DLB.⁷ The screening assessment may include a neurologic/psychiatric assessment (MMSE, psychiatric evaluation, and interviews with family members or caretakers), neuroimaging such as MRI to rule out other organic causes, and laboratory evaluation to rule out potentially reversible causes of dementia, including electrolyte imbalance, vitamin deficiency (specifically vitamin B12), anemia, thyroid dysfunction, and kidney or liver impairment.¹⁸

The American Psychiatric Assocation¹ categorizes DLB under “Dementia Due to Other General Medical Conditions” (294.1x). The World Health Organization¹⁹ includes it among “Other specified degenerative diseases of the nervous system” (G31.8).

Treatment
Lewy body dementia is an irreversible neurologic degenerative disorder. Treatment for DLB comprises symptom management, primarily through pharmacology; however, the response to medication is highly individualized. Treatment includes management of the following symptoms:

Cognitive impairment. Cholinesterase inhibitors, such as rivastigmine (3 to 12 mg/d), donepezil (10 mg/d), or galantamine (titrated up to 12 mg bid),^20-23 improve attention and behavior and reduce apathy, anxiety, delusions, and hallucinations. As cognitive impairment worsens, memantine (10 mg bid) may be effective.²⁴ The potential for anticholinergic adverse effects requires close monitoring in patients taking these agents.

Parkinsonian symptoms. Medications indicated for Parkinson’s disease and syndrome, such as carbidopa-levodopa (25/100 mg tid), can be effective; dosage may be slowly titrated upward as tolerated and if needed for symptom management.^25,26 The dopaminergic effect of antiparkinson medications may intensify the psychotic symptoms and worsen the REM sleep pattern. In this case, a low-dose atypical antipsychotic is suggested^27,28 (see below).

Psychotic symptoms. An atypical antipsychotic agent, such as quetiapine (12.5 mg), risperidone (0.25 mg), olanzapine (2.5 mg), ziprasidone (20 mg), aripiprazole (2 mg), or paliperidone (1.5 mg), may be used. Because of the DLB-associated risk of neuroleptic sensitivity, atypical antipsychotic agents should be initiated at a low dose with slow upward titration^17,26,29; quetiapine appears less likely than risperidone or olanzapine to cause neuroleptic sensitivity or to trigger EPS.⁴ For Asian patients, who often respond to lower doses of these medications (and are more easily affected by associated adverse effects), Chen et al³⁰ recommend a starting dose of about one-half the recommended dose.

Depression. An SSRI antidepressant with relatively simple pharmacologic properties and moderate half-life may be used to manage symptoms of depression.^26,31,32 Long–half-life SSRIs (eg, fluoxetine) should be avoided in elderly patients; in response to SNRIs (serotonin-norepinephrine reuptake inhibitors), these patients may experience elevated blood pressures and pulses, with subsequent morbidity.³³

REM sleep disturbances. Clo­nazepam (0.25 mg), melatonin (3.0 mg), or quetiapine (12.5 mg) may be administered at bedtime.³⁴

Important Lessons
In general, providers should consider the benefits and risks of any pharmacologic treatment and avoid polypharmacy, if possible. Family and caretakers should be included in the treatment planning, with a focus on prioritizing and managing the most debilitating symptoms or dysfunctions that prompt concerns for safety.

For optimal homeostasis, some DLB patients may require joint pharmacologic modalities that appear counterintuitive—for example, an antiparkinsonism (dopaminergic) agent for parkinsonian symptoms or neuroleptic-induced EPS, versus an antipsychotic (eg, a dopamine antagonist) to treat profound hallucinations.²⁶

As the response to treatment for DLB is highly individualized, it is essential to titrate and augment with care.

CONCLUSION
In DLB, as with other dementing illnesses, the onset of symptoms can be gradual and insidious, posing a great challenge to the clinician who seeks to confirm the diagnosis. In the illness’s early stages, the clinician may have to treat targeted symptoms and adjust the treatment plan once signs of the pathologic origins emerge.

It is critical to understand the mechanisms of psychotropic medications and targeted neurotransmitters when evaluating treatment for DLB. Titrating or augmenting these medications in elderly patients requires the clinician to follow a principle of start low and go slow, making only one change at a time.

It is always helpful to include family members in the patient’s care and to gather information on previous history, personality traits, family history, and cultural components. It is also important to communicate with other specialists to implement collaborative care.

An 80-year-old Mandarin-speaking Chinese woman was referred to a mental health outpatient clinic for evaluation and treatment. The patient had a history of mild depression, for which she had been treated for many years with sertraline.

Five years earlier at age 75, the patient had been evaluated by a psychiatrist after she began to experience psychotic symptoms, including frequent repetitive auditory hallucinations of people counting, alternating with music from her childhood. At that time, she also had persecutory paranoid thoughts and delusional thinking that she was receiving messages in Mandarin while watching American TV programs. Initially, her only cognitive disturbance was an inability to differentiate among numbers on a calendar or a telephone keypad. No reports of memory problems were noted. Although the patient acknowledged auditory hallucinations, she denied experiencing command auditory hallucinations or hallucinations of other forms. The patient had no history of suicide attempts and denied suicidal or homicidal ideation. She had no history of psychiatric hospitalization.

The psychiatrist made a diagnosis of major depressive disorder with psychotic features, not otherwise specified¹ and prescribed sertraline 50 mg/d. The patient was also started on risperidone 0.25 mg/d for management of her psychotic symptoms, with the dosage gradually increased to 2.0 mg/d over five years. While taking this combination, the patient experienced stable mood and fewer paranoid thoughts, although her auditory hallucinations continued.

Two months before the current visit, the patient moved into a retirement living facility, and she reported having adapted well to the new setting. She was sleeping well and had a good appetite. Her BMI was within normal range.

The patient described herself as a single parent for nearly 40 years, raising one daughter. Formerly high functioning, she had held a full-time clerical job until age 70. She appeared well-groomed, polite but anxious, and oriented to time, person, and place. Her speech was normal, her thought processes were coherent, and her mood was stable. However, her affect was constricted; she acknowledged auditory hallucinations, which impaired her thought content. The patient reported feeling increased anxiety prior to any nonroutine activity, such as a doctor’s appointment; this, she said, would cause insomnia, leaving her to pace in her room.

During the examination, fine tremors on upper and lower extremities were noted. The patient’s Abnormal Involuntary Movement Scale (AIMS) score² was 13, which placed her in the highest risk category for antipsychotic-induced dopamine-blockade extrapyramidal symptoms (EPS). The patient was found to be negative for tardive dyskinesia, with no abnormal facial movements. She was aware of the tremors in her limbs and said she felt bothered by them.

The patient had an unsteady gait and used a four-point walker. Her Mini-Mental State Exam (MMSE) score³ was 28/30, which was normal for her age and education level (high school completed).

Apart from the described symptoms, the patient was healthy for her age and had no other medical diagnosis. Her vital signs were within normal range. The medical work-up to rule out other causes of dementia yielded negative results. Lab values were normal, including electrolyte levels and thyroid tests. The patient’s hearing test showed age-related hearing loss of full range, not limited to high pitch. She was able to engage in a meaningful conversation at a normal volume. Clinically, however, it was concerning to observe the possible signs of EPS and the relatively high risperidone dosage, considering the patient’s advanced age.

After the meeting with the patient, a treatment plan was created to 1) gradually reduce the dosage of antipsychotic medication, and 2) refer her to a neurologist for a complete work-up to rule out underlying neurologic disorders, such as dementia. Risperidone was tapered by increments of 0.25 mg/d every three to four weeks; throughout this process, the patient was closely monitored by the nursing staff at the retirement living facility. Monthly appointments were scheduled at the outpatient mental health clinic for evaluation and medication management.

Two months after the initial mental health clinic visit, the patient’s condition was pronounced stable on the current regimen of sertraline 50 mg/d and risperidone 1.0 mg/d. She was later seen by a neurologist, who made a diagnosis of Parkinson’s disease and placed her on carbidopa-­levodopa (1 1/2 tablets, 25/100 mg, tid). The patient’s auditory hallucinations continued with the same intensity as at baseline, but fewer tremors were noted in her extremities. By six months into the tapering process (with risperidone reduced at that time to 0.25 mg/d and carbidopa-levodopa to 25/100 mg tid), the patient had begun to experience dissipation of the tremors, and her AIMS score² was 0. She was able to replace her four-point walker with a cane.

One year after her initial visit to the mental health clinic, the patient’s neurologist suggested replacing risperidone with quetia­pine (12.5 mg/d) for its improved tolerability and lower adverse effect profile.⁴ She continued to take sertraline and carbidopa-levodopa.

Improvement of symptoms was noted following the switch. After one month on the revised regimen, the patient reported that the number of auditory hallucinations persisted, but that their intensity had decreased dramatically. She had a brighter affect and appeared to feel uplifted and more energetic. She became involved in the social activities offered at the retirement living facility and the mental health clinic. She also maintained a steady gait without her cane. According to the patient’s daughter, her mother was at her best psychological state since the onset of psychotic symptoms six years earlier. The pharmacologic regimen had reached its maximum benefit.

At a mental health appointment at the outpatient clinic 18 months after her initial visit there, it was evident that the patient’s auditory hallucinations persisted as a major stressor. She began to complain about other residents in her facility. She said she disliked the resident with whom she shared meals, and she claimed that other residents often spit on the floor in front of her room. The nursing staff did not confirm these incidents, which they considered a delusion despite the patient’s “evidence” (the tissues she said she had used to clean up).

Additionally, a new theme had emerged in the patient’s auditory hallucinations. She reported hearing a male voice that announced changes in meal times. Although she knew there was no public address system in her room or in the hallway, the “announcement” was so convincing that she would go to the dining room and once there, realize that nothing had changed. She seemed to drift between reality and her hallucinations/delusions. According to her daughter, the patient’s independent and reserved personality forced her to internalize her stressors—in this case, her frustration about the other residents—which fed into her hallucinations and delusions.

In response to her worsening psychotic symptoms, the patient’s provider increased her quetia­pine dosage from 12.5 mg/d to 25 mg/d. Her MMSE score³ at this visit was 25/30.

Two months later, the patient exhibited increasing symptoms of paranoia, delusions, and auditory hallucinations. She continued to respond to the “broadcast” messages about meal times, and she voiced her frustrations to others who spoke Mandarin. She became agitated in response to out-of-the-ordinary events. When her alarm clock battery ran out, for example, she insisted that “a man’s voice” kept reminding her to replace the battery; in response, she placed the alarm clock in the refrigerator, later explaining, “Now I don’t need to worry about it.”

Her cognitive status began to show obvious, progressive deterioration, with an MMSE score³ of 22/30 at this visit—a significant reduction from previous scores. Worsening of her short-term memory became apparent when she had difficulty playing bingo and was unable to remember her appointment or the current date. She became upset when others corrected her.

In a review of the trends in this patient’s clinical presentation, it became increasingly evident to the patient’s mental health care providers that she had Lewy body dementia.

DISCUSSION
Dementia with Lewy bodies (DLB), a progressive disease, is the second most common cause of neurodegenerative dementia after Alzheimer’s disease.^5-7 It is estimated that DLB accounts for 20% of US cases of dementia (ie, about 800,000 patients).^8,9 Although public awareness of DLB is on the rise, the disorder is still underrecognized and underdiagnosed because its clinical manifestations so closely resemble those of Alzheimer’s disease, Parkinson’s disease, and psychosis.^10,11

Clinical symptoms of DLB include progressive cognitive decline, cognitive fluctuation, EPS, and parkinsonism; hallucinations involving all five senses, particularly sight; delusions; REM sleep disturbance, with or without vivid and frightening dreams; changes in mood and behavior; impaired judgment and insight; and autonomic dysfunction, such as orthostatic hypotension and carotid-sinus hypersensitivity.^5,11-15

The symptoms of DLB are caused by the accumulations of Lewy bodies, that is, deposits of alpha-synuclein protein in the nuclei of neurons. Lewy bodies destroy neurons over time, resulting in the destruction of dopaminergic and acetylcholinergic pathways from the brain stem to areas of the cerebral cortex associated with cognition and motor functions.^4,5,16

DLB is a spectrum disorder; it often coexists with Parkinson’s disease or Alzheimer’s disease, as Lewy bodies are also found in patients with these illnesses.⁷ This poses a challenge for formulating a differential diagnosis, particularly in patients with fluctuating cognition,¹⁰ and for attempting to establish disease prevalence.

Diagnosis
Currently, a conclusive diagnosis of DLB can be confirmed only through postmortem autopsy, although use of medial temporal lobe volume (via structural MRI) and regional blood flow (via single photon emission CT [SPECT] tracers) is being investigated.¹⁷

The diagnosis of DLB is currently based on the presenting clinical symptoms and the exclusion of other medical conditions whose symptoms mimic those of DLB.⁷ The screening assessment may include a neurologic/psychiatric assessment (MMSE, psychiatric evaluation, and interviews with family members or caretakers), neuroimaging such as MRI to rule out other organic causes, and laboratory evaluation to rule out potentially reversible causes of dementia, including electrolyte imbalance, vitamin deficiency (specifically vitamin B12), anemia, thyroid dysfunction, and kidney or liver impairment.¹⁸

The American Psychiatric Assocation¹ categorizes DLB under “Dementia Due to Other General Medical Conditions” (294.1x). The World Health Organization¹⁹ includes it among “Other specified degenerative diseases of the nervous system” (G31.8).

Treatment
Lewy body dementia is an irreversible neurologic degenerative disorder. Treatment for DLB comprises symptom management, primarily through pharmacology; however, the response to medication is highly individualized. Treatment includes management of the following symptoms:

Cognitive impairment. Cholinesterase inhibitors, such as rivastigmine (3 to 12 mg/d), donepezil (10 mg/d), or galantamine (titrated up to 12 mg bid),^20-23 improve attention and behavior and reduce apathy, anxiety, delusions, and hallucinations. As cognitive impairment worsens, memantine (10 mg bid) may be effective.²⁴ The potential for anticholinergic adverse effects requires close monitoring in patients taking these agents.

Parkinsonian symptoms. Medications indicated for Parkinson’s disease and syndrome, such as carbidopa-levodopa (25/100 mg tid), can be effective; dosage may be slowly titrated upward as tolerated and if needed for symptom management.^25,26 The dopaminergic effect of antiparkinson medications may intensify the psychotic symptoms and worsen the REM sleep pattern. In this case, a low-dose atypical antipsychotic is suggested^27,28 (see below).

Psychotic symptoms. An atypical antipsychotic agent, such as quetiapine (12.5 mg), risperidone (0.25 mg), olanzapine (2.5 mg), ziprasidone (20 mg), aripiprazole (2 mg), or paliperidone (1.5 mg), may be used. Because of the DLB-associated risk of neuroleptic sensitivity, atypical antipsychotic agents should be initiated at a low dose with slow upward titration^17,26,29; quetiapine appears less likely than risperidone or olanzapine to cause neuroleptic sensitivity or to trigger EPS.⁴ For Asian patients, who often respond to lower doses of these medications (and are more easily affected by associated adverse effects), Chen et al³⁰ recommend a starting dose of about one-half the recommended dose.

Depression. An SSRI antidepressant with relatively simple pharmacologic properties and moderate half-life may be used to manage symptoms of depression.^26,31,32 Long–half-life SSRIs (eg, fluoxetine) should be avoided in elderly patients; in response to SNRIs (serotonin-norepinephrine reuptake inhibitors), these patients may experience elevated blood pressures and pulses, with subsequent morbidity.³³

REM sleep disturbances. Clo­nazepam (0.25 mg), melatonin (3.0 mg), or quetiapine (12.5 mg) may be administered at bedtime.³⁴

Important Lessons
In general, providers should consider the benefits and risks of any pharmacologic treatment and avoid polypharmacy, if possible. Family and caretakers should be included in the treatment planning, with a focus on prioritizing and managing the most debilitating symptoms or dysfunctions that prompt concerns for safety.

For optimal homeostasis, some DLB patients may require joint pharmacologic modalities that appear counterintuitive—for example, an antiparkinsonism (dopaminergic) agent for parkinsonian symptoms or neuroleptic-induced EPS, versus an antipsychotic (eg, a dopamine antagonist) to treat profound hallucinations.²⁶

As the response to treatment for DLB is highly individualized, it is essential to titrate and augment with care.

CONCLUSION
In DLB, as with other dementing illnesses, the onset of symptoms can be gradual and insidious, posing a great challenge to the clinician who seeks to confirm the diagnosis. In the illness’s early stages, the clinician may have to treat targeted symptoms and adjust the treatment plan once signs of the pathologic origins emerge.

It is critical to understand the mechanisms of psychotropic medications and targeted neurotransmitters when evaluating treatment for DLB. Titrating or augmenting these medications in elderly patients requires the clinician to follow a principle of start low and go slow, making only one change at a time.

It is always helpful to include family members in the patient’s care and to gather information on previous history, personality traits, family history, and cultural components. It is also important to communicate with other specialists to implement collaborative care.

An 80-year-old Mandarin-speaking Chinese woman was referred to a mental health outpatient clinic for evaluation and treatment. The patient had a history of mild depression, for which she had been treated for many years with sertraline.

Five years earlier at age 75, the patient had been evaluated by a psychiatrist after she began to experience psychotic symptoms, including frequent repetitive auditory hallucinations of people counting, alternating with music from her childhood. At that time, she also had persecutory paranoid thoughts and delusional thinking that she was receiving messages in Mandarin while watching American TV programs. Initially, her only cognitive disturbance was an inability to differentiate among numbers on a calendar or a telephone keypad. No reports of memory problems were noted. Although the patient acknowledged auditory hallucinations, she denied experiencing command auditory hallucinations or hallucinations of other forms. The patient had no history of suicide attempts and denied suicidal or homicidal ideation. She had no history of psychiatric hospitalization.

The psychiatrist made a diagnosis of major depressive disorder with psychotic features, not otherwise specified¹ and prescribed sertraline 50 mg/d. The patient was also started on risperidone 0.25 mg/d for management of her psychotic symptoms, with the dosage gradually increased to 2.0 mg/d over five years. While taking this combination, the patient experienced stable mood and fewer paranoid thoughts, although her auditory hallucinations continued.

Two months before the current visit, the patient moved into a retirement living facility, and she reported having adapted well to the new setting. She was sleeping well and had a good appetite. Her BMI was within normal range.

The patient described herself as a single parent for nearly 40 years, raising one daughter. Formerly high functioning, she had held a full-time clerical job until age 70. She appeared well-groomed, polite but anxious, and oriented to time, person, and place. Her speech was normal, her thought processes were coherent, and her mood was stable. However, her affect was constricted; she acknowledged auditory hallucinations, which impaired her thought content. The patient reported feeling increased anxiety prior to any nonroutine activity, such as a doctor’s appointment; this, she said, would cause insomnia, leaving her to pace in her room.

During the examination, fine tremors on upper and lower extremities were noted. The patient’s Abnormal Involuntary Movement Scale (AIMS) score² was 13, which placed her in the highest risk category for antipsychotic-induced dopamine-blockade extrapyramidal symptoms (EPS). The patient was found to be negative for tardive dyskinesia, with no abnormal facial movements. She was aware of the tremors in her limbs and said she felt bothered by them.

The patient had an unsteady gait and used a four-point walker. Her Mini-Mental State Exam (MMSE) score³ was 28/30, which was normal for her age and education level (high school completed).

Apart from the described symptoms, the patient was healthy for her age and had no other medical diagnosis. Her vital signs were within normal range. The medical work-up to rule out other causes of dementia yielded negative results. Lab values were normal, including electrolyte levels and thyroid tests. The patient’s hearing test showed age-related hearing loss of full range, not limited to high pitch. She was able to engage in a meaningful conversation at a normal volume. Clinically, however, it was concerning to observe the possible signs of EPS and the relatively high risperidone dosage, considering the patient’s advanced age.

After the meeting with the patient, a treatment plan was created to 1) gradually reduce the dosage of antipsychotic medication, and 2) refer her to a neurologist for a complete work-up to rule out underlying neurologic disorders, such as dementia. Risperidone was tapered by increments of 0.25 mg/d every three to four weeks; throughout this process, the patient was closely monitored by the nursing staff at the retirement living facility. Monthly appointments were scheduled at the outpatient mental health clinic for evaluation and medication management.

Two months after the initial mental health clinic visit, the patient’s condition was pronounced stable on the current regimen of sertraline 50 mg/d and risperidone 1.0 mg/d. She was later seen by a neurologist, who made a diagnosis of Parkinson’s disease and placed her on carbidopa-­levodopa (1 1/2 tablets, 25/100 mg, tid). The patient’s auditory hallucinations continued with the same intensity as at baseline, but fewer tremors were noted in her extremities. By six months into the tapering process (with risperidone reduced at that time to 0.25 mg/d and carbidopa-levodopa to 25/100 mg tid), the patient had begun to experience dissipation of the tremors, and her AIMS score² was 0. She was able to replace her four-point walker with a cane.

One year after her initial visit to the mental health clinic, the patient’s neurologist suggested replacing risperidone with quetia­pine (12.5 mg/d) for its improved tolerability and lower adverse effect profile.⁴ She continued to take sertraline and carbidopa-levodopa.

Improvement of symptoms was noted following the switch. After one month on the revised regimen, the patient reported that the number of auditory hallucinations persisted, but that their intensity had decreased dramatically. She had a brighter affect and appeared to feel uplifted and more energetic. She became involved in the social activities offered at the retirement living facility and the mental health clinic. She also maintained a steady gait without her cane. According to the patient’s daughter, her mother was at her best psychological state since the onset of psychotic symptoms six years earlier. The pharmacologic regimen had reached its maximum benefit.

At a mental health appointment at the outpatient clinic 18 months after her initial visit there, it was evident that the patient’s auditory hallucinations persisted as a major stressor. She began to complain about other residents in her facility. She said she disliked the resident with whom she shared meals, and she claimed that other residents often spit on the floor in front of her room. The nursing staff did not confirm these incidents, which they considered a delusion despite the patient’s “evidence” (the tissues she said she had used to clean up).

Additionally, a new theme had emerged in the patient’s auditory hallucinations. She reported hearing a male voice that announced changes in meal times. Although she knew there was no public address system in her room or in the hallway, the “announcement” was so convincing that she would go to the dining room and once there, realize that nothing had changed. She seemed to drift between reality and her hallucinations/delusions. According to her daughter, the patient’s independent and reserved personality forced her to internalize her stressors—in this case, her frustration about the other residents—which fed into her hallucinations and delusions.

In response to her worsening psychotic symptoms, the patient’s provider increased her quetia­pine dosage from 12.5 mg/d to 25 mg/d. Her MMSE score³ at this visit was 25/30.

Two months later, the patient exhibited increasing symptoms of paranoia, delusions, and auditory hallucinations. She continued to respond to the “broadcast” messages about meal times, and she voiced her frustrations to others who spoke Mandarin. She became agitated in response to out-of-the-ordinary events. When her alarm clock battery ran out, for example, she insisted that “a man’s voice” kept reminding her to replace the battery; in response, she placed the alarm clock in the refrigerator, later explaining, “Now I don’t need to worry about it.”

Her cognitive status began to show obvious, progressive deterioration, with an MMSE score³ of 22/30 at this visit—a significant reduction from previous scores. Worsening of her short-term memory became apparent when she had difficulty playing bingo and was unable to remember her appointment or the current date. She became upset when others corrected her.

In a review of the trends in this patient’s clinical presentation, it became increasingly evident to the patient’s mental health care providers that she had Lewy body dementia.

DISCUSSION
Dementia with Lewy bodies (DLB), a progressive disease, is the second most common cause of neurodegenerative dementia after Alzheimer’s disease.^5-7 It is estimated that DLB accounts for 20% of US cases of dementia (ie, about 800,000 patients).^8,9 Although public awareness of DLB is on the rise, the disorder is still underrecognized and underdiagnosed because its clinical manifestations so closely resemble those of Alzheimer’s disease, Parkinson’s disease, and psychosis.^10,11

Clinical symptoms of DLB include progressive cognitive decline, cognitive fluctuation, EPS, and parkinsonism; hallucinations involving all five senses, particularly sight; delusions; REM sleep disturbance, with or without vivid and frightening dreams; changes in mood and behavior; impaired judgment and insight; and autonomic dysfunction, such as orthostatic hypotension and carotid-sinus hypersensitivity.^5,11-15

The symptoms of DLB are caused by the accumulations of Lewy bodies, that is, deposits of alpha-synuclein protein in the nuclei of neurons. Lewy bodies destroy neurons over time, resulting in the destruction of dopaminergic and acetylcholinergic pathways from the brain stem to areas of the cerebral cortex associated with cognition and motor functions.^4,5,16

DLB is a spectrum disorder; it often coexists with Parkinson’s disease or Alzheimer’s disease, as Lewy bodies are also found in patients with these illnesses.⁷ This poses a challenge for formulating a differential diagnosis, particularly in patients with fluctuating cognition,¹⁰ and for attempting to establish disease prevalence.

Diagnosis
Currently, a conclusive diagnosis of DLB can be confirmed only through postmortem autopsy, although use of medial temporal lobe volume (via structural MRI) and regional blood flow (via single photon emission CT [SPECT] tracers) is being investigated.¹⁷

The diagnosis of DLB is currently based on the presenting clinical symptoms and the exclusion of other medical conditions whose symptoms mimic those of DLB.⁷ The screening assessment may include a neurologic/psychiatric assessment (MMSE, psychiatric evaluation, and interviews with family members or caretakers), neuroimaging such as MRI to rule out other organic causes, and laboratory evaluation to rule out potentially reversible causes of dementia, including electrolyte imbalance, vitamin deficiency (specifically vitamin B12), anemia, thyroid dysfunction, and kidney or liver impairment.¹⁸

The American Psychiatric Assocation¹ categorizes DLB under “Dementia Due to Other General Medical Conditions” (294.1x). The World Health Organization¹⁹ includes it among “Other specified degenerative diseases of the nervous system” (G31.8).

Treatment
Lewy body dementia is an irreversible neurologic degenerative disorder. Treatment for DLB comprises symptom management, primarily through pharmacology; however, the response to medication is highly individualized. Treatment includes management of the following symptoms:

Cognitive impairment. Cholinesterase inhibitors, such as rivastigmine (3 to 12 mg/d), donepezil (10 mg/d), or galantamine (titrated up to 12 mg bid),^20-23 improve attention and behavior and reduce apathy, anxiety, delusions, and hallucinations. As cognitive impairment worsens, memantine (10 mg bid) may be effective.²⁴ The potential for anticholinergic adverse effects requires close monitoring in patients taking these agents.

Parkinsonian symptoms. Medications indicated for Parkinson’s disease and syndrome, such as carbidopa-levodopa (25/100 mg tid), can be effective; dosage may be slowly titrated upward as tolerated and if needed for symptom management.^25,26 The dopaminergic effect of antiparkinson medications may intensify the psychotic symptoms and worsen the REM sleep pattern. In this case, a low-dose atypical antipsychotic is suggested^27,28 (see below).

Psychotic symptoms. An atypical antipsychotic agent, such as quetiapine (12.5 mg), risperidone (0.25 mg), olanzapine (2.5 mg), ziprasidone (20 mg), aripiprazole (2 mg), or paliperidone (1.5 mg), may be used. Because of the DLB-associated risk of neuroleptic sensitivity, atypical antipsychotic agents should be initiated at a low dose with slow upward titration^17,26,29; quetiapine appears less likely than risperidone or olanzapine to cause neuroleptic sensitivity or to trigger EPS.⁴ For Asian patients, who often respond to lower doses of these medications (and are more easily affected by associated adverse effects), Chen et al³⁰ recommend a starting dose of about one-half the recommended dose.

Depression. An SSRI antidepressant with relatively simple pharmacologic properties and moderate half-life may be used to manage symptoms of depression.^26,31,32 Long–half-life SSRIs (eg, fluoxetine) should be avoided in elderly patients; in response to SNRIs (serotonin-norepinephrine reuptake inhibitors), these patients may experience elevated blood pressures and pulses, with subsequent morbidity.³³

REM sleep disturbances. Clo­nazepam (0.25 mg), melatonin (3.0 mg), or quetiapine (12.5 mg) may be administered at bedtime.³⁴

Important Lessons
In general, providers should consider the benefits and risks of any pharmacologic treatment and avoid polypharmacy, if possible. Family and caretakers should be included in the treatment planning, with a focus on prioritizing and managing the most debilitating symptoms or dysfunctions that prompt concerns for safety.

For optimal homeostasis, some DLB patients may require joint pharmacologic modalities that appear counterintuitive—for example, an antiparkinsonism (dopaminergic) agent for parkinsonian symptoms or neuroleptic-induced EPS, versus an antipsychotic (eg, a dopamine antagonist) to treat profound hallucinations.²⁶

As the response to treatment for DLB is highly individualized, it is essential to titrate and augment with care.

CONCLUSION
In DLB, as with other dementing illnesses, the onset of symptoms can be gradual and insidious, posing a great challenge to the clinician who seeks to confirm the diagnosis. In the illness’s early stages, the clinician may have to treat targeted symptoms and adjust the treatment plan once signs of the pathologic origins emerge.

It is critical to understand the mechanisms of psychotropic medications and targeted neurotransmitters when evaluating treatment for DLB. Titrating or augmenting these medications in elderly patients requires the clinician to follow a principle of start low and go slow, making only one change at a time.

It is always helpful to include family members in the patient’s care and to gather information on previous history, personality traits, family history, and cultural components. It is also important to communicate with other specialists to implement collaborative care.

A 65-year-old man presented to the emergency department (ED) with a two-week history of progressively severe pain in his right hand and difficulty moving his fingers. He reported that approximately two weeks earlier, while shoveling snow, he slipped and fell, landing on his right hand. Initially, he had no problems with his hand. He finished his shoveling and continued his normal daily activities.

Within two to three days he started to experience pain in his right hand, which grew progressively worse.

Because he did not have a primary care provider, the patient had a limited medical history. He reported having a mildly elevated prostate-specific antigen test years earlier. He underwent an appendectomy at age 15. He denied any other medical problems.

The patient was taking no medications and reported no known allergies to medications. He denied the use of tobacco, said he had one or two beers on an average day, and denied IV drug use. He was an artist and was married with one adult child. His family history was unremarkable with the exception of an alcoholic sister who died of cirrhosis at age 70.

During triage, vital signs were essentially normal: blood pressure, 142/74 mm Hg; heart rate, 78 beats/min; and respiratory rate, 20 breaths/min. The patient was afebrile at 37.2°C (98.9°F). Physical examination was remarkable for some edema and warmth of the right hand without any notable erythema. There was no evidence of any wound. Fingers all had good sensation; however, flexion of the index and long fingers elicited a significant increase in pain.

The remainder of the exam was unremarkable. The patient’s head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Eyes were anicteric, and no rhinorrhea was evident. The neck was supple without palpable lymphadenopathy. Lungs were clear to auscultation bilaterally. No wheezes, rales, or rhonchi were appreciated. The heart had a regular rate and rhythm; no murmurs, rubs, or gallups were noted. The abdomen was soft and non-tender. The extremities, except as previously stated, were normal, with good pulses, sensation, and strength.

Initially, only radiographs of the right hand were ordered (see Figures 1 and 2). These demonstrated soft tissue swelling on the dorsum of the hand, and an area of hypodensity between the first and second metacarpals. There were no fractures, dislocations, or other bone or joint abnormalities.

After a review of the radiographs, it was clear that the patient’s diagnosis was not a simple answer of hand contusion or fracture; thus, the evaluation was expanded. Vital signs were repeated three hours after triage: blood pressure, 128/74 mm Hg; heart rate, 76 beats/min; and respiration, 20 breaths/min. The patient was now febrile at 37.6°C (99.7°F). Because of his fever and the anomaly on the patient’s hand radiograph, expansion of the evaluation continued.

Laboratory studies included a complete blood count: white blood cells (WBCs), 30,700/mcL (reference range,¹ 4,500 to 11,000/mcL); hemoglobin, 13.3 g/dL (13.8 to 17.2 g/dL for men); hematocrit, 40.0% (41% to 50% for men); platelets, 217,000/mcL (130 to 400 x 10³/mcL). Initial chemistry panel results were normal except for serum glucose, 143 mg/dL (70 to 125 mg/dL).

Liver function test results were normal except for aspartate aminotransferase, 33 U/L (reference range,¹ 10 to 30 U/L) and albumin, 2.5 g/dL (3.5 to 5.0 g/dL). Once WBCs were found to exceed 30,000/mcL, the search for a cause was widened once more.

The continued studies included a chest radiograph with normal results, unremarkable CT of the abdomen and pelvis with IV contrast, blood cultures, and urinalysis. The urinalysis showed: blood, moderate; protein, trace; nitrites, positive; leukocytes, large; WBCs > 50/high-power field (reference range,¹ 5/high-power field or less); and numerous bacteria.

The final study performed in the ED evaluation of the patient was a CT of the right hand with IV contrast (see Figure 3). It demonstrated diffuse edema and a 9.0-mm area of low attenuation with some rim enhancement. The differential for these findings includes an abscess or a foreign body; the latter was deemed unlikely in light of the patient’s physical exam. In consideration of his elevated WBC count, the high number of WBCs in his urine, the fever, and the CT results, the patient was diagnosed with an abscess in his right hand that had been seeded, it was surmised, by an occult urosepsis after his fall.

Before the patient’s admission, a hand surgeon was consulted. The surgeon agreed with the diagnosis, and the patient was taken to the operating room (OR). He had been given piperacillin/tazobactam in the ED.

In the OR, the surgeon made a 3.0-cm incision, conducted an exploration, and identified a cavity that contained a small amount of purulence. He determined the lesion to be a resolving abscess. The wound was washed out, and the area was closed with a Penrose drain.

The patient was continued on the piperacillin/tazobactam. His blood culture was positive for gram-positive rods, and a low-grade fever persisted. An infectious disease specialist was consulted, and levofloxacin was added to the patient’s regimen.

After 24 hours of treatment, findings on urinalysis improved: blood, small; protein, trace; nitrites, negative; leukocytes, small; WBCs, 15 to 20/high-power field; and no bacteria. Over the next three days, the patient’s condition continued to improve. His hand drain was removed, and the pain and swelling subsided. He became afebrile, and his WBC count fell to 24,700/mcL. He was discharged to home with prescriptions for cephalexin and levofloxacin. Follow-up for postoperative care was arranged with the hand surgeon.

Discussion
Pyomyositis is defined as abscess formation deep within large striated muscles.¹ Although this condition is uncommon, it is believed that an occult bacteremia can seed an area of damaged muscle (compared with healthy muscle, which ordinarily resists infection), allowing an abscess to form.^1,2

Epidemiology
In a 2002 review involving 676 patients with primary pyomyositis, Bickels et al³ reported the condition in ages ranging from two months to 82 years (mean, 28.1 years). In a majority of cases, only a single muscle was involved; 112 patients (16.6%) were identified with multiple-site involvement. Only seven cases (0.1%) involved the hand.

In 452 cases (66.9%), a bacterial agent was identified. Among these, 350 (77%) had a positive culture for Staphylococcus aureus. Other isolates included Streptococcus pyogenes, Escherichia coli, Salmonella enteritidus, and Mycobacterium tuberculosis.^1,3 It should be noted that community-­acquired methicillin-resistant S aureus (CA-MRSA) is being implicated with increasing frequency in cases of pyomyositis.^4-6

Because pyomyositis is not a reportable disease and has not been studied in large clinical trials, its incidence is uncertain, and proposed risk factors have not all been confirmed² (see Table^2,7).

Pathophysiology
While the etiology of primary pyomyositis is unclear, it is believed to be caused by a combination of bacteremia (chronic or transient) and damaged muscle. In a 1960 study published in the Lancet, Smith and Vickers⁸ performed autopsies on 327 patients who had died of culture-positive septicemia. Only two patients were found to have a muscle abscess. At that time, the investigators concluded that both muscle injury and bacteremia would need to be present in order for an abscess to form. In animal studies, bacteremia (eg, S aureus) does not appear to lead to pyomyositis except in cases of muscle abnormality or trauma (eg, electric shock, pinching injury).^9,10

When a history of trauma can be identified in patients with pyomyositis, the condition typically develops near the affected muscle, and the infection appears within days to weeks.3 In cases in which an antecedent infection is identified and hematogenous spread of the bacteria to the skeletal muscle occurs, this is termed secondary pyomyositis.¹¹

Disease Progression
Pyomyositis generally progresses in three stages, beginning with inflammation and advancing to a focal abscess, then to a septic state.³ The first stage develops between seven and 21 days after the initial incident, is typically subacute, involves mild pain and swelling with a “woody” texture, and is occasionally associated with fevers.²

Diagnosis of pyomyositis is usually made during the second stage, 10 to 21 days after the initial incident; by that time, the pain has increased, and the fever is more pronounced. Third-stage infection usually involves fluctuance and sepsis.²

Although MRI is considered most useful in the diagnosis of pyomyositis, CT and ultrasound allow for percutaneous needle aspiration and drainage.³

Treatment
The correct treatment for pyomyositis depends upon the stage at which the disease is identified. During the first stage (before formation of an abscess), antibiotic treatment alone may be sufficient.¹ Once an abscess has formed, an incision and drainage will be required, in conjunction with or followed by appropriate antibiotic therapy.

When pyomyositis is properly treated during the first or second stage, a full recovery is likely.^2,3 By the third stage, surgical debridement is required. Additionally, osteomyelitis may develop in the adjacent bones, followed by muscle scarring, residual weakness, and functional impairment.^2,3 Reported pyomyositis-associated mortality ranges between less than 1% and 4%.^2,12

The Case Patient

The case presented here was of particular interest for two reasons. First, the patient had a traumatic injury that initially caused him no concern but worsened progressively over 14 days. Although this is not the typical presentation of a traumatic injury, the ED staff could very easily have performed a radiograph, made a diagnosis of traumatic hand injury, and discharged the patient.

Second, men in their 60s do not commonly have urinary tract infections.¹³ The patient was questioned frequently by several providers about sexual behaviors, medical problems, and urinary symptoms. Repeatedly, he denied all of these issues. While a urinalysis may be omitted in the evaluation of an otherwise healthy, asymptomatic patient, its results in this case were a key piece of data.

It should be noted that the patient thought it inappropriate to be asked for urine samples. He repeatedly said, “It’s my hand!”

Conclusion
Even in patients presenting with the most routine complaint, a careful evaluation can reveal unexpected, serious problems. This patient complained of pain in his hand some time after a fall and ultimately was treated for an occult urosepsis and hand abscess—pyomyositis, which rarely occurs in small muscles, such as those of the hand. Either condition, left untreated, could have led to serious morbidity or even mortality.

A 65-year-old man presented to the emergency department (ED) with a two-week history of progressively severe pain in his right hand and difficulty moving his fingers. He reported that approximately two weeks earlier, while shoveling snow, he slipped and fell, landing on his right hand. Initially, he had no problems with his hand. He finished his shoveling and continued his normal daily activities.

Within two to three days he started to experience pain in his right hand, which grew progressively worse.

Because he did not have a primary care provider, the patient had a limited medical history. He reported having a mildly elevated prostate-specific antigen test years earlier. He underwent an appendectomy at age 15. He denied any other medical problems.

The patient was taking no medications and reported no known allergies to medications. He denied the use of tobacco, said he had one or two beers on an average day, and denied IV drug use. He was an artist and was married with one adult child. His family history was unremarkable with the exception of an alcoholic sister who died of cirrhosis at age 70.

During triage, vital signs were essentially normal: blood pressure, 142/74 mm Hg; heart rate, 78 beats/min; and respiratory rate, 20 breaths/min. The patient was afebrile at 37.2°C (98.9°F). Physical examination was remarkable for some edema and warmth of the right hand without any notable erythema. There was no evidence of any wound. Fingers all had good sensation; however, flexion of the index and long fingers elicited a significant increase in pain.

The remainder of the exam was unremarkable. The patient’s head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Eyes were anicteric, and no rhinorrhea was evident. The neck was supple without palpable lymphadenopathy. Lungs were clear to auscultation bilaterally. No wheezes, rales, or rhonchi were appreciated. The heart had a regular rate and rhythm; no murmurs, rubs, or gallups were noted. The abdomen was soft and non-tender. The extremities, except as previously stated, were normal, with good pulses, sensation, and strength.

Initially, only radiographs of the right hand were ordered (see Figures 1 and 2). These demonstrated soft tissue swelling on the dorsum of the hand, and an area of hypodensity between the first and second metacarpals. There were no fractures, dislocations, or other bone or joint abnormalities.

After a review of the radiographs, it was clear that the patient’s diagnosis was not a simple answer of hand contusion or fracture; thus, the evaluation was expanded. Vital signs were repeated three hours after triage: blood pressure, 128/74 mm Hg; heart rate, 76 beats/min; and respiration, 20 breaths/min. The patient was now febrile at 37.6°C (99.7°F). Because of his fever and the anomaly on the patient’s hand radiograph, expansion of the evaluation continued.

Laboratory studies included a complete blood count: white blood cells (WBCs), 30,700/mcL (reference range,¹ 4,500 to 11,000/mcL); hemoglobin, 13.3 g/dL (13.8 to 17.2 g/dL for men); hematocrit, 40.0% (41% to 50% for men); platelets, 217,000/mcL (130 to 400 x 10³/mcL). Initial chemistry panel results were normal except for serum glucose, 143 mg/dL (70 to 125 mg/dL).

Liver function test results were normal except for aspartate aminotransferase, 33 U/L (reference range,¹ 10 to 30 U/L) and albumin, 2.5 g/dL (3.5 to 5.0 g/dL). Once WBCs were found to exceed 30,000/mcL, the search for a cause was widened once more.

The continued studies included a chest radiograph with normal results, unremarkable CT of the abdomen and pelvis with IV contrast, blood cultures, and urinalysis. The urinalysis showed: blood, moderate; protein, trace; nitrites, positive; leukocytes, large; WBCs > 50/high-power field (reference range,¹ 5/high-power field or less); and numerous bacteria.

The final study performed in the ED evaluation of the patient was a CT of the right hand with IV contrast (see Figure 3). It demonstrated diffuse edema and a 9.0-mm area of low attenuation with some rim enhancement. The differential for these findings includes an abscess or a foreign body; the latter was deemed unlikely in light of the patient’s physical exam. In consideration of his elevated WBC count, the high number of WBCs in his urine, the fever, and the CT results, the patient was diagnosed with an abscess in his right hand that had been seeded, it was surmised, by an occult urosepsis after his fall.

Before the patient’s admission, a hand surgeon was consulted. The surgeon agreed with the diagnosis, and the patient was taken to the operating room (OR). He had been given piperacillin/tazobactam in the ED.

In the OR, the surgeon made a 3.0-cm incision, conducted an exploration, and identified a cavity that contained a small amount of purulence. He determined the lesion to be a resolving abscess. The wound was washed out, and the area was closed with a Penrose drain.

The patient was continued on the piperacillin/tazobactam. His blood culture was positive for gram-positive rods, and a low-grade fever persisted. An infectious disease specialist was consulted, and levofloxacin was added to the patient’s regimen.

After 24 hours of treatment, findings on urinalysis improved: blood, small; protein, trace; nitrites, negative; leukocytes, small; WBCs, 15 to 20/high-power field; and no bacteria. Over the next three days, the patient’s condition continued to improve. His hand drain was removed, and the pain and swelling subsided. He became afebrile, and his WBC count fell to 24,700/mcL. He was discharged to home with prescriptions for cephalexin and levofloxacin. Follow-up for postoperative care was arranged with the hand surgeon.

Discussion
Pyomyositis is defined as abscess formation deep within large striated muscles.¹ Although this condition is uncommon, it is believed that an occult bacteremia can seed an area of damaged muscle (compared with healthy muscle, which ordinarily resists infection), allowing an abscess to form.^1,2

Epidemiology
In a 2002 review involving 676 patients with primary pyomyositis, Bickels et al³ reported the condition in ages ranging from two months to 82 years (mean, 28.1 years). In a majority of cases, only a single muscle was involved; 112 patients (16.6%) were identified with multiple-site involvement. Only seven cases (0.1%) involved the hand.

In 452 cases (66.9%), a bacterial agent was identified. Among these, 350 (77%) had a positive culture for Staphylococcus aureus. Other isolates included Streptococcus pyogenes, Escherichia coli, Salmonella enteritidus, and Mycobacterium tuberculosis.^1,3 It should be noted that community-­acquired methicillin-resistant S aureus (CA-MRSA) is being implicated with increasing frequency in cases of pyomyositis.^4-6

Because pyomyositis is not a reportable disease and has not been studied in large clinical trials, its incidence is uncertain, and proposed risk factors have not all been confirmed² (see Table^2,7).

Pathophysiology
While the etiology of primary pyomyositis is unclear, it is believed to be caused by a combination of bacteremia (chronic or transient) and damaged muscle. In a 1960 study published in the Lancet, Smith and Vickers⁸ performed autopsies on 327 patients who had died of culture-positive septicemia. Only two patients were found to have a muscle abscess. At that time, the investigators concluded that both muscle injury and bacteremia would need to be present in order for an abscess to form. In animal studies, bacteremia (eg, S aureus) does not appear to lead to pyomyositis except in cases of muscle abnormality or trauma (eg, electric shock, pinching injury).^9,10

When a history of trauma can be identified in patients with pyomyositis, the condition typically develops near the affected muscle, and the infection appears within days to weeks.3 In cases in which an antecedent infection is identified and hematogenous spread of the bacteria to the skeletal muscle occurs, this is termed secondary pyomyositis.¹¹

Disease Progression
Pyomyositis generally progresses in three stages, beginning with inflammation and advancing to a focal abscess, then to a septic state.³ The first stage develops between seven and 21 days after the initial incident, is typically subacute, involves mild pain and swelling with a “woody” texture, and is occasionally associated with fevers.²

Diagnosis of pyomyositis is usually made during the second stage, 10 to 21 days after the initial incident; by that time, the pain has increased, and the fever is more pronounced. Third-stage infection usually involves fluctuance and sepsis.²

Although MRI is considered most useful in the diagnosis of pyomyositis, CT and ultrasound allow for percutaneous needle aspiration and drainage.³

Treatment
The correct treatment for pyomyositis depends upon the stage at which the disease is identified. During the first stage (before formation of an abscess), antibiotic treatment alone may be sufficient.¹ Once an abscess has formed, an incision and drainage will be required, in conjunction with or followed by appropriate antibiotic therapy.

When pyomyositis is properly treated during the first or second stage, a full recovery is likely.^2,3 By the third stage, surgical debridement is required. Additionally, osteomyelitis may develop in the adjacent bones, followed by muscle scarring, residual weakness, and functional impairment.^2,3 Reported pyomyositis-associated mortality ranges between less than 1% and 4%.^2,12

The Case Patient

The case presented here was of particular interest for two reasons. First, the patient had a traumatic injury that initially caused him no concern but worsened progressively over 14 days. Although this is not the typical presentation of a traumatic injury, the ED staff could very easily have performed a radiograph, made a diagnosis of traumatic hand injury, and discharged the patient.

Second, men in their 60s do not commonly have urinary tract infections.¹³ The patient was questioned frequently by several providers about sexual behaviors, medical problems, and urinary symptoms. Repeatedly, he denied all of these issues. While a urinalysis may be omitted in the evaluation of an otherwise healthy, asymptomatic patient, its results in this case were a key piece of data.

It should be noted that the patient thought it inappropriate to be asked for urine samples. He repeatedly said, “It’s my hand!”

Conclusion
Even in patients presenting with the most routine complaint, a careful evaluation can reveal unexpected, serious problems. This patient complained of pain in his hand some time after a fall and ultimately was treated for an occult urosepsis and hand abscess—pyomyositis, which rarely occurs in small muscles, such as those of the hand. Either condition, left untreated, could have led to serious morbidity or even mortality.

A 65-year-old man presented to the emergency department (ED) with a two-week history of progressively severe pain in his right hand and difficulty moving his fingers. He reported that approximately two weeks earlier, while shoveling snow, he slipped and fell, landing on his right hand. Initially, he had no problems with his hand. He finished his shoveling and continued his normal daily activities.

Within two to three days he started to experience pain in his right hand, which grew progressively worse.

Because he did not have a primary care provider, the patient had a limited medical history. He reported having a mildly elevated prostate-specific antigen test years earlier. He underwent an appendectomy at age 15. He denied any other medical problems.

The patient was taking no medications and reported no known allergies to medications. He denied the use of tobacco, said he had one or two beers on an average day, and denied IV drug use. He was an artist and was married with one adult child. His family history was unremarkable with the exception of an alcoholic sister who died of cirrhosis at age 70.

During triage, vital signs were essentially normal: blood pressure, 142/74 mm Hg; heart rate, 78 beats/min; and respiratory rate, 20 breaths/min. The patient was afebrile at 37.2°C (98.9°F). Physical examination was remarkable for some edema and warmth of the right hand without any notable erythema. There was no evidence of any wound. Fingers all had good sensation; however, flexion of the index and long fingers elicited a significant increase in pain.

The remainder of the exam was unremarkable. The patient’s head was normocephalic and atraumatic. Pupils were equal, round, and reactive to light. Eyes were anicteric, and no rhinorrhea was evident. The neck was supple without palpable lymphadenopathy. Lungs were clear to auscultation bilaterally. No wheezes, rales, or rhonchi were appreciated. The heart had a regular rate and rhythm; no murmurs, rubs, or gallups were noted. The abdomen was soft and non-tender. The extremities, except as previously stated, were normal, with good pulses, sensation, and strength.

Initially, only radiographs of the right hand were ordered (see Figures 1 and 2). These demonstrated soft tissue swelling on the dorsum of the hand, and an area of hypodensity between the first and second metacarpals. There were no fractures, dislocations, or other bone or joint abnormalities.

After a review of the radiographs, it was clear that the patient’s diagnosis was not a simple answer of hand contusion or fracture; thus, the evaluation was expanded. Vital signs were repeated three hours after triage: blood pressure, 128/74 mm Hg; heart rate, 76 beats/min; and respiration, 20 breaths/min. The patient was now febrile at 37.6°C (99.7°F). Because of his fever and the anomaly on the patient’s hand radiograph, expansion of the evaluation continued.

Laboratory studies included a complete blood count: white blood cells (WBCs), 30,700/mcL (reference range,¹ 4,500 to 11,000/mcL); hemoglobin, 13.3 g/dL (13.8 to 17.2 g/dL for men); hematocrit, 40.0% (41% to 50% for men); platelets, 217,000/mcL (130 to 400 x 10³/mcL). Initial chemistry panel results were normal except for serum glucose, 143 mg/dL (70 to 125 mg/dL).

Liver function test results were normal except for aspartate aminotransferase, 33 U/L (reference range,¹ 10 to 30 U/L) and albumin, 2.5 g/dL (3.5 to 5.0 g/dL). Once WBCs were found to exceed 30,000/mcL, the search for a cause was widened once more.

The continued studies included a chest radiograph with normal results, unremarkable CT of the abdomen and pelvis with IV contrast, blood cultures, and urinalysis. The urinalysis showed: blood, moderate; protein, trace; nitrites, positive; leukocytes, large; WBCs > 50/high-power field (reference range,¹ 5/high-power field or less); and numerous bacteria.

The final study performed in the ED evaluation of the patient was a CT of the right hand with IV contrast (see Figure 3). It demonstrated diffuse edema and a 9.0-mm area of low attenuation with some rim enhancement. The differential for these findings includes an abscess or a foreign body; the latter was deemed unlikely in light of the patient’s physical exam. In consideration of his elevated WBC count, the high number of WBCs in his urine, the fever, and the CT results, the patient was diagnosed with an abscess in his right hand that had been seeded, it was surmised, by an occult urosepsis after his fall.

Before the patient’s admission, a hand surgeon was consulted. The surgeon agreed with the diagnosis, and the patient was taken to the operating room (OR). He had been given piperacillin/tazobactam in the ED.

In the OR, the surgeon made a 3.0-cm incision, conducted an exploration, and identified a cavity that contained a small amount of purulence. He determined the lesion to be a resolving abscess. The wound was washed out, and the area was closed with a Penrose drain.

The patient was continued on the piperacillin/tazobactam. His blood culture was positive for gram-positive rods, and a low-grade fever persisted. An infectious disease specialist was consulted, and levofloxacin was added to the patient’s regimen.

After 24 hours of treatment, findings on urinalysis improved: blood, small; protein, trace; nitrites, negative; leukocytes, small; WBCs, 15 to 20/high-power field; and no bacteria. Over the next three days, the patient’s condition continued to improve. His hand drain was removed, and the pain and swelling subsided. He became afebrile, and his WBC count fell to 24,700/mcL. He was discharged to home with prescriptions for cephalexin and levofloxacin. Follow-up for postoperative care was arranged with the hand surgeon.

Discussion
Pyomyositis is defined as abscess formation deep within large striated muscles.¹ Although this condition is uncommon, it is believed that an occult bacteremia can seed an area of damaged muscle (compared with healthy muscle, which ordinarily resists infection), allowing an abscess to form.^1,2

Epidemiology
In a 2002 review involving 676 patients with primary pyomyositis, Bickels et al³ reported the condition in ages ranging from two months to 82 years (mean, 28.1 years). In a majority of cases, only a single muscle was involved; 112 patients (16.6%) were identified with multiple-site involvement. Only seven cases (0.1%) involved the hand.

In 452 cases (66.9%), a bacterial agent was identified. Among these, 350 (77%) had a positive culture for Staphylococcus aureus. Other isolates included Streptococcus pyogenes, Escherichia coli, Salmonella enteritidus, and Mycobacterium tuberculosis.^1,3 It should be noted that community-­acquired methicillin-resistant S aureus (CA-MRSA) is being implicated with increasing frequency in cases of pyomyositis.^4-6

Because pyomyositis is not a reportable disease and has not been studied in large clinical trials, its incidence is uncertain, and proposed risk factors have not all been confirmed² (see Table^2,7).

Pathophysiology
While the etiology of primary pyomyositis is unclear, it is believed to be caused by a combination of bacteremia (chronic or transient) and damaged muscle. In a 1960 study published in the Lancet, Smith and Vickers⁸ performed autopsies on 327 patients who had died of culture-positive septicemia. Only two patients were found to have a muscle abscess. At that time, the investigators concluded that both muscle injury and bacteremia would need to be present in order for an abscess to form. In animal studies, bacteremia (eg, S aureus) does not appear to lead to pyomyositis except in cases of muscle abnormality or trauma (eg, electric shock, pinching injury).^9,10

When a history of trauma can be identified in patients with pyomyositis, the condition typically develops near the affected muscle, and the infection appears within days to weeks.3 In cases in which an antecedent infection is identified and hematogenous spread of the bacteria to the skeletal muscle occurs, this is termed secondary pyomyositis.¹¹

Disease Progression
Pyomyositis generally progresses in three stages, beginning with inflammation and advancing to a focal abscess, then to a septic state.³ The first stage develops between seven and 21 days after the initial incident, is typically subacute, involves mild pain and swelling with a “woody” texture, and is occasionally associated with fevers.²

Diagnosis of pyomyositis is usually made during the second stage, 10 to 21 days after the initial incident; by that time, the pain has increased, and the fever is more pronounced. Third-stage infection usually involves fluctuance and sepsis.²

Although MRI is considered most useful in the diagnosis of pyomyositis, CT and ultrasound allow for percutaneous needle aspiration and drainage.³

Treatment
The correct treatment for pyomyositis depends upon the stage at which the disease is identified. During the first stage (before formation of an abscess), antibiotic treatment alone may be sufficient.¹ Once an abscess has formed, an incision and drainage will be required, in conjunction with or followed by appropriate antibiotic therapy.

When pyomyositis is properly treated during the first or second stage, a full recovery is likely.^2,3 By the third stage, surgical debridement is required. Additionally, osteomyelitis may develop in the adjacent bones, followed by muscle scarring, residual weakness, and functional impairment.^2,3 Reported pyomyositis-associated mortality ranges between less than 1% and 4%.^2,12

The Case Patient

The case presented here was of particular interest for two reasons. First, the patient had a traumatic injury that initially caused him no concern but worsened progressively over 14 days. Although this is not the typical presentation of a traumatic injury, the ED staff could very easily have performed a radiograph, made a diagnosis of traumatic hand injury, and discharged the patient.

Second, men in their 60s do not commonly have urinary tract infections.¹³ The patient was questioned frequently by several providers about sexual behaviors, medical problems, and urinary symptoms. Repeatedly, he denied all of these issues. While a urinalysis may be omitted in the evaluation of an otherwise healthy, asymptomatic patient, its results in this case were a key piece of data.

It should be noted that the patient thought it inappropriate to be asked for urine samples. He repeatedly said, “It’s my hand!”

Conclusion
Even in patients presenting with the most routine complaint, a careful evaluation can reveal unexpected, serious problems. This patient complained of pain in his hand some time after a fall and ultimately was treated for an occult urosepsis and hand abscess—pyomyositis, which rarely occurs in small muscles, such as those of the hand. Either condition, left untreated, could have led to serious morbidity or even mortality.