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Cough, acute enterocolitis and worsening of delirium in an elderly patient: case report An 80-year-old Japanese woman developed a dry cough during treatment with enalapril for hypertension; incorrect treatment with levofloxacin led to acute enterocolitis, and she also experienced worsening delirium after using a codeine-containing cough syrup. The woman had been receiving enalapril 5 mg/day for several months which was increased to 10 mg/day 1 week prior to presentation. She presented with a 7-day history of dry non-productive cough, a 2-day history of severe diarrhoea, and acute delirium. Her doctor prescribed a guaifenesin and codeine-containing cough syrup [dosage not stated], which initially relieved the cough. Two days later, she reported increased cough and lethargy to her doctor. She began taking levofloxacin [dosage not stated] for presumptive pneumonia, and 3 days later, she developed diarrhoea and presented to the hospital. She was diagnosed with Clostridium difficile. At this time, her medications included levofloxacin 500mg daily for 7 days, enalapril 10mg, guaifenesin and codeine (100/10/5mL, 5mL every 4 hours as needed), paracetamol [acetaminophen], alendronic acid, calcium and hydrochlorothiazide. The woman was given metronidazole. Over the following 24 hours, her fever and delirium resolved, but her cough persisted. Enalapril, guaifenesin and codeine were discontinued. Following enalapril cessation, her cough improved and she was discharged to a rehabilitation centre. Author comment: "This case is an example of a prescribing cascade. The patient had a dry cough from enalapril but was misdiagnosed with pneumonia and treated with antibiotics. The antibiotics brought about pseudomembranous colitis. In addition, the opioid-based syrup and dehydration from colitis also contributed to [the] patient’s acute delirium." Liu PT, et al. Prescribing cascade in an 80-year-old Japanese immigrant. Geriatrics 803013920 & Gerontology International 9: 402-4, No. 4, Dec 2009 - USA

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Reactions 15 May 2010 No. 1301