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General Rehabilitation

(Kiosk 1) Masked Bleeding and Autonomic Dysfunction in Parkinson’s Disease: A Case Report

Thursday, November 16, 2023
12:45 PM – 2:15 PM CT

    Primary Author(s)

  • Anam Purewal, MD (she/her/hers)

    Resident
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

    • Co-Author(s)

  • Marc C. Ramos Emos, MD (he/him/his)

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

  • Miriam Bekhit, MD, Other

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Brooklyn, New York

  • Ryan Kim, DO

    Resident Physician
    State University of New York (SUNY) Downstate Health Sciences Univ PM&R Program
    Saddle Brook, New Jersey

  • Shreya Jain, Other

    Medical Student
    SUNY Downstate College of Medicine
    Staten Island, New York

  • JM

    Jack Mensch, MD

    Attending Physician
    Staten Island University Hospital
    Staten Island, New York

  • SA

    Sanjeev Agarwal, MD

    Program Director
    SUNY Downstate Medical Center
    Brooklyn, New York

Case Diagnosis: Parkinson’s Disease and indolent gastrointestinal (GI) bleeding

Case Description or Program Description: 88-year-old male with a history of stage 3A non-small cell lung cancer Parkinson’s Disease (PD) with orthostatic hypotension found to have GI bleeding

Setting: Inpatient rehabilitation facility

Assessment/Results: This patient with deconditioning secondary to cancer-related sequelae including malnutrition and dysphagia was admitted to acute rehabilitation for physical, occupational, and speech therapies. His course was complicated by melena secondary to stomach ulcers seen on endoscopy that were endo-clipped. Readmission labs showed a hemoglobin of 8.5 g/dL. He participated well in therapies but occasionally would require bedside adaptation because of lightheadedness from chronic orthostatic hypotension. On routine vitals four days later, he was acutely hypothermic 94.9F, with remainder vitals within normal limits. On assessment, he denied fatigue, light-headedness, nausea, visual changes, shortness of breath, bloody stools, and had no abdominal pain on palpation. Repeat blood work showed a hemoglobin of 6.1 g/dL, suggestive of repeat bleeding. Further interventional management of GI bleeding was not pursued per patient wishes so he was discharged to the palliative care service.

Discussion (relevance): Autonomic nervous system dysfunction is a common feature of neurodegenerative diseases like PD. This dysfunction can present as light-headedness from orthostatic hypotension, dysphagia from esophageal spasms, nausea from gastroparesis, and constipation from reduced colonic motility. This patient did not present with tell-tale signs or symptoms of GI bleeding due to his autonomic dysfunction. His only sign of bleeding was hypothermia; he was not hypotensive and did not have an appropriate compensatory mechanism of tachycardia. It is important for clinicians to be aware of the extent of autonomic dysfunction in Parkinson’s Disease, as the most associated feature is orthostatic hypotension.

Conclusions: This case illustrates the importance of having a high index of suspicion of bleeding in a patient on anticoagulation with an isolated sign of hemodynamic instability such as hypothermia.