Annals of Long Term Care

Case Presentation
Brief History

Mrs. O is a 71-year-old female resident of a long-term care (LTC) facility who presented in January 2007 with the chief complaint of “swelling below her chin.” The patient had been complaining of pain in her gums for several weeks. She had only two teeth remaining in her lower mandible. Given her risk factors for osteonecrosis of the jaw, she had been referred for dental evaluation a few weeks previously. A full examination and an orthopantography revealed no bone abnormalities. Her dentures were found to be ill-fitting, and recommendations for regular oral hygiene and denture refitting were made.

Mrs. O’s physician visited her emergently at the facility after a report from nursing that she had considerable swelling and redness under her chin. She was transferred to the hospital for further evaluation and treatment.

Her past medical history was significant for a nonambulatory woman with chronic obstructive pulmonary disease (COPD), anemia, mild pulmonary hypertension, obesity, venous insufficiency with lower-extremity stasis dermatitis, congestive heart failure, hypertension, atrial fibrillation, gastroesophogeal reflux disease, pancreatitis, type 2 diabetes mellitus, multiple myeloma, and osteoporosis.

The multiple myeloma was classified as Stage III. She was diagnosed in March 2005 and had begun treatment on March 12 with the following regimen: dexamethasone 40 mg intravenously (IV), given from the 1st to the 4th and from the 9th to the 12th days of each month, thalidomide 100 mg daily, and zoledronic acid 4 mg IV monthly. The multiple myeloma was under good control with this regimen (no bone pain, no renal insufficiency, and normal calcium) until January 2007, when this pain and swelling occurred.

Mrs. O’s other medications were as follows: darbepoetin alfa 300 mg intramuscularly (IM) weekly, furosemide 40 mg daily, valsartan 180 mg daily, atorvastatin 40 mg daily, sertraline 25 mg daily, sotalol 40 mg daily, fluticasone propionate/salmeterol xinafoate inhaler 250/50 twice daily, calcium carbonate with vitamin D 500 mg/400 IU twice daily, iron sulfate 325 mg 3 times daily, and warfarin 6 mg daily.

The review of systems was negative apart from the chief complaint; in particular, Mrs. O had no fever, hoarseness, dysphagia, or odynophagia. The social history was significant for remote tobacco use and very occasional social alcohol. Mrs. O was a retired teacher’s aide and had lived in the nursing facility for years.

Physical exam at the time of hospital admission was significant for slight distress due to pain. Her temperature was 99.0 degrees F; pulse was 55 beats per minute, and respirations were 18 per minute. Blood pressure was 106/85 mm Hg. Mrs. O’s cardiovascular, respiratory, gastrointestinal, and neurological exams were unremarkable. She had a purple swelling under her chin, approximately 16 cm across and localized more to her right side (Figure 1). Her submandibular/submental region was indurated, erythematous, and tender to palpation but without fluctuance or crepitus. There was swelling at the base of the tongue. She had two teeth in her left anterior lower jaw with some decay. A minute portion of the mandible was visible inside the mouth on the right anterior and left posterior lower mandible (Figure 2).

Data

The complete blood count demonstrated a hemoglobin of 9.4 g/dL and a hematocrit of 30.1%. The corpuscular indices were within normal limits; the white blood cell count was within normal limits at 10,000 with 81% neutrophils, 10% monocytes, 0% basophils, and 7% lymphocytes. The platelet count was 232 x 103/µL. Glucose was 103 mg/dL, BUN 18 mg/dL, creatinine 1.0 mg/dL, sodium 138 mEq/L, potassium 4.7 mEq/L, chloride 106 mEq/L, bicarbonate 23 mEq/L, AST and ALT 16 U/L, alkaline phosphatase 50 U/L, calcium 8.8 mg/dL, albumin 3.4 g/dL, and total protein 5.7 g/dL.