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Poster 337: Medical and Functional Recovery in Neurologic Rehabilitation of Central Nervous System Toxoplasmosis: A Case Report
Abstracts / PM R 9 (2017) S131-S290 Results: He had a 7 day second acute rehab admission after which his total ADL FIM score increased by 275% over his total ADL FIM score prior to cranioplasty. Discussion: Syndrome of the Trephined (SoT), or Sinking Skin Flap Syndrome (SSS) is a disorder of delayed neurological deterioration that occurs in patients with large cranial defects following craniectomy. It is not well-known amongst physiatrists but has implications for patient evaluation and management. Conclusions: SoT/SSS, is a potential complication of large craniectomies that can develop during the course of acute rehabilitation and may explain otherwise cryptogenic declines in function. Level of Evidence: Level V Poster 337: Medical and Functional Recovery in Neurologic Rehabilitation of Central Nervous System Toxoplasmosis: A Case Report Surein Theivakumar Disclosures: Surein Theivakumar: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 42-year-old healthy man presented to acute care hospital with 5-month history of progressive confusion, 25 pound weight loss, and night sweats. In addition, he reported decreased function in his left arm for 6 weeks. Upon workup, patient was found to have positive HIV-1 antibody and antigen as well as brain MRI consistent with toxoplasmosis. Cervical spine MRI showed large intramedullary mass from C1 to C7. Toxoplasmosis was confirmed with cerebral spinal fluid polymerase chain reaction as well as IgG antibody. For toxoplasmosis, patient was treated with Bactrim, steroid taper, and keppra. Patient was admitted to acute inpatient rehabilitation for 16-day course to improve functional deficits in cognition, activities of daily living, and ambulation. Upon arrival to acute inpatient rehabilitation, patient started on highly active antiretroviral therapy (HAART). EEG was performed showing no seizure like activity, thus keppra and steroids tapered off. In addition, patient continued on Bactrim, weekly azithromycin, and Genvoya for management of HIV treatment/prophylaxis and treatment of central nervous system toxoplasmosis throughout rehabilitation stay and upon discharge. Setting: Acute inpatient rehabilitation facility. Results: By the end of the 16-day rehabilitation course, patient showed significant improvement both medically and functionally. Repeat MRI of brain and cervical spine showed significant improvement of toxoplasmosis lesions. In addition, patient showed a large improvement in FIM scores when comparing initial and discharge therapy evaluations. The comparison of MRIs and FIM scores comparisons will be discussed. Discussion: There are a few case reports that also show good functional outcome of CNS toxoplasmosis when patients are undergoing appropriate medical treatment. However, more studies involving rehabilitation and medical courses are needed to support further support early neurologic rehabilitation. Conclusions: Neurologic rehabilitation provides promising medical and functional recovery for central nervous system toxoplasmosis, however more studies are required to further support early rehabilitation courses for these patients. Level of Evidence: Level V Poster 338: Brown-Sequard Syndrome due to Ischemia from a Vertebral Artery Occlusion: A Case Report Mayya Gorbal, MD (Albert Einstein Col of Med), Edward Alexeev, MD, Shayan Senthelal, MD, Maria A. Jouvin-Castro, MD Disclosures: Mayya Gorbal: I Have No Relevant Financial Relationships To Disclose
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Case/Program Description: A 42-year-old African-American man with a past medical history of recurrent anterior and posterior circulation cerebral infarcts and right subclavian vein occlusion who presented with sudden onset of right hemiplegia. Physical exam was notable for flaccid paralysis of the right upper and lower extremities and decreased sensation to pinprick and temperature on the left below the C4 sensory level, consistent with a right Brown-Sequard syndrome. MRI brain showed no acute infarcts. MRA of the head, neck and chest showed a new complete lack of flow within the right vertebral artery and thoracic vasculature ectasia with areas of aneurysm. MRI of the cervical spine without contrast was remarkable for intramedullary spinal cord signal abnormality from the level of C2 to C6. MRI of the cervical and thoracic spine with contrast showed edema compatible with spinal cord ischemia. Hypercoagulable, autoimmune and vasculitis workups were unrevealing and the patient remained hemiplegic on the right side. He was then discharged to acute inpatient rehabilitation for physical and functional optimization. Setting: Acute Inpatient Rehabilitation Facility. Results: The patient had a challenging neuromuscular rehabilitation course. He actively participated in a comprehensive therapy regimen and was only able to regain minimal strength of his right lower extremity at time of discharge while his right upper extremity remained plegic. Following discharge, he developed right sided spasticity managed with baclofen under the care of physiatrists. Discussion: Brown-Sequard syndrome is a spinal cord lesion characterized by ipsilateral weakness and loss of proprioception and contralateral loss of pain and temperature sensation. We present a case of this relatively uncommon condition manifesting in a patient with a medical history suggestive of a vasculopathy of unclear etiology. Conclusions: Vertebral artery occlusion can manifest in the setting of a diffuse vasculopathy and play a critical role in the development of spinal cord ischemia, resulting in decreased patient function. Level of Evidence: Level V Poster 339: Ptosis, Diagnosis, Neurosarcoidosis: A Case Report Brian P. Golden, DO (Nassau University Medical Center, East Meadow, NY, United States), Ketan Patel, Resident Physician, Yousaf Chowdhry, MD, Lyn D. Weiss, MD Disclosures: Brian Golden: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 25-year-old man presented to the emergency room with bilateral ptosis, generalized weakness and fatigue. He was discharged with no treatment. Three days later, the patient presented with progressively worsening symptoms and unsteady gait. He denied any recent travel or illnesses. On exam he was found to be extremely lethargic, had an ataxic gait, and cranial nerve palsies. An infectious etiology was initially ruled out, and the differential diagnosis was narrowed to myasthenia gravis (MG), GuillainBarre Syndrome (GBS), or multiple sclerosis (MS). He was started on bedside therapy, and his treatment course consisted of intravenous (IV) hydration, IV Immunoglobulin, and cholinesterase inhibitors. Setting: Tertiary care teaching hospital. Results: The CT head was negative, and lumbar puncture showed oligoclonal bands and elevated proteins in the cerebrospinal fluid (CSF). Magnetic resonance imaging (MRI) brain showed increased signal intensity in the brainstem, basal ganglia, and cortex. Electrodiagnostic testing (EDx), including repetitive nerve stimulation, needle electromyography, nerve conduction studies, and F waves were performed and were normal, concluding that there was no EDx evidence of GBS, MG, myopathy, or peripheral neuropathy. Discussion: IV steroids were started for suspected neurosarcoidosis as evidenced by bilateral cranial nerve palsies, high protein in CSF, and possible inflammation. The patient had significant improvement in symptoms and function after a trial of high dose steroids, further
S239
Case/Program Description: A 42-year-old African-American man with a past medical history of recurrent anterior and posterior circulation cerebral infarcts and right subclavian vein occlusion who presented with sudden onset of right hemiplegia. Physical exam was notable for flaccid paralysis of the right upper and lower extremities and decreased sensation to pinprick and temperature on the left below the C4 sensory level, consistent with a right Brown-Sequard syndrome. MRI brain showed no acute infarcts. MRA of the head, neck and chest showed a new complete lack of flow within the right vertebral artery and thoracic vasculature ectasia with areas of aneurysm. MRI of the cervical spine without contrast was remarkable for intramedullary spinal cord signal abnormality from the level of C2 to C6. MRI of the cervical and thoracic spine with contrast showed edema compatible with spinal cord ischemia. Hypercoagulable, autoimmune and vasculitis workups were unrevealing and the patient remained hemiplegic on the right side. He was then discharged to acute inpatient rehabilitation for physical and functional optimization. Setting: Acute Inpatient Rehabilitation Facility. Results: The patient had a challenging neuromuscular rehabilitation course. He actively participated in a comprehensive therapy regimen and was only able to regain minimal strength of his right lower extremity at time of discharge while his right upper extremity remained plegic. Following discharge, he developed right sided spasticity managed with baclofen under the care of physiatrists. Discussion: Brown-Sequard syndrome is a spinal cord lesion characterized by ipsilateral weakness and loss of proprioception and contralateral loss of pain and temperature sensation. We present a case of this relatively uncommon condition manifesting in a patient with a medical history suggestive of a vasculopathy of unclear etiology. Conclusions: Vertebral artery occlusion can manifest in the setting of a diffuse vasculopathy and play a critical role in the development of spinal cord ischemia, resulting in decreased patient function. Level of Evidence: Level V Poster 339: Ptosis, Diagnosis, Neurosarcoidosis: A Case Report Brian P. Golden, DO (Nassau University Medical Center, East Meadow, NY, United States), Ketan Patel, Resident Physician, Yousaf Chowdhry, MD, Lyn D. Weiss, MD Disclosures: Brian Golden: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 25-year-old man presented to the emergency room with bilateral ptosis, generalized weakness and fatigue. He was discharged with no treatment. Three days later, the patient presented with progressively worsening symptoms and unsteady gait. He denied any recent travel or illnesses. On exam he was found to be extremely lethargic, had an ataxic gait, and cranial nerve palsies. An infectious etiology was initially ruled out, and the differential diagnosis was narrowed to myasthenia gravis (MG), GuillainBarre Syndrome (GBS), or multiple sclerosis (MS). He was started on bedside therapy, and his treatment course consisted of intravenous (IV) hydration, IV Immunoglobulin, and cholinesterase inhibitors. Setting: Tertiary care teaching hospital. Results: The CT head was negative, and lumbar puncture showed oligoclonal bands and elevated proteins in the cerebrospinal fluid (CSF). Magnetic resonance imaging (MRI) brain showed increased signal intensity in the brainstem, basal ganglia, and cortex. Electrodiagnostic testing (EDx), including repetitive nerve stimulation, needle electromyography, nerve conduction studies, and F waves were performed and were normal, concluding that there was no EDx evidence of GBS, MG, myopathy, or peripheral neuropathy. Discussion: IV steroids were started for suspected neurosarcoidosis as evidenced by bilateral cranial nerve palsies, high protein in CSF, and possible inflammation. The patient had significant improvement in symptoms and function after a trial of high dose steroids, further