- Email: [email protected]
Dengue Fever and Longitudinally Extensive Transverse Myelitis: A Case Report
S276
Poster 395 Rehabilitation of Wound Botulism Caused by Heroin Skin Popping: A Case Report. Ryan Doan, MD (Stanford Hospital and Clinics, Stanford, CA, United States); Edward Chaw, DO. Disclosures: R. Doan, No Disclosures: I Have Nothing To Disclose. Case Description: The patient presented to the emergency department with neck pain, headache, bilateral ptosis, bulbar weakness, upper extremity spasms, and flaccid quadriparesis. She underwent emergent intubation in the emergency department for respiratory failure. She received heptavalent botulinum antitoxin on hospital day 3. Shiley # 6 tracheostomy was placed on hospital day 11. By hospital day 15, botulinum A serum assay returned positive, confirming diagnosis of wound botulism. She was transferred to rehabilitation trauma center on hospital day 18 for ventilator weaning. She received aggressive pulmonary toileting through intermittent percussive ventilator and dornase alfa for secretion management. Over the subsequent four weeks, she progressed through cuff down trials and transitioned to a portable LTV ventilator. She was moved to an inpatient acute rehabilitation unit on hospital day 56. Over the next four weeks, her respiratory status and motor strength gradually improved. She started passy-muir trials on hospital day 57 and was eventually decannulated on hospital day 83. She was ambulatory with crutches by the time she discharged to home on hospital day 86. Setting: Inpatient Rehabilitation Facility. Results or Clinical Course: Given the patient’s heroin skin popping and positive botulinum toxin assay, wound botulism was attributed to black tar heroin skin popping. By twelve weeks postinjury, motor and respiratory weakness had largely resolved. Discussion: This is the first reported case, to our knowledge, describing rehabilitation for wound botulism secondary to heroin skin popping. Conclusions: Although wound botulism causes severe paralysis and respiratory failure, an appropriate rehabilitation approach can return patients to functional independence. Poster 396 Amantadine Use in Heroin-induced Leukoencephalopathy: A Case Report. Giselle Vivaldi, MD (NYU Medical Center, New York, NY, United States); Melanie Howell, DO. Disclosures: G. Vivaldi, No Disclosures: I Have Nothing To Disclose. Case Description: A 45-year-old man with history of cocaine and heroin use who was brought to hospital due to altered mental status. Non-contrast head CT scan was normal. Brain MRI showed diffuse white matter flair abnormalities. Lumbar puncture was negative for acute infection and HIV, CMV, and HSV 1-2 testing were negative. Pt was thought to have encephalomyelitis and was started on a course of IV steroids. Symptoms did not improve overall and he developed aphasia which worsened to global aphasia. After further evaluation patient’s diagnosis was felt to be heroin-induced toxic leukoencephalopathy ("chasing the dragon" syndrome). Patient was started on treatment with high dose vitamin and anti-oxidant supplementation. Slight improvement in symptoms were noted but confusion, abulia, and limited speech output persisted. Patient was admitted to acute inpatient rehab 4 weeks
PRESENTATIONS
after admission to acute hospital. On admission patient required total assistance for ADLs and mobility, patient was aphasic and not following commands. Setting: Tertiary care municipal hospital. Results or Clinical Course: During rehab stay patient was started on Amantadine 100mg daily and was titrated up to 200mg twice a day. Therapists and staff noticed significant functional gains and increased cognitive functioning including initiation of automatic verbal responses after starting Amantadine. On discharge patient demonstrated ability to feed himself but remained at a max assistance level with most ADLs due to ongoing cognitive deficits. He was responding with short phrases intermittently, tracking to stimuli, appropriately responding to certain gestures and cues, and following simple commands inconsistently. Discussion: Amantadine is used to speed up functional recovery in traumatic brain injury patients. Conclusions: To our knowledge there is no other reported case in the literature of amantadine use in toxic leukoencephalopathy. Poster 397 Dengue Fever and Longitudinally Extensive Transverse Myelitis: A Case Report. Ashfaq Larik (Singapore General Hospital, Singapore, Singapore). Disclosures: A. Larik, No Disclosures: I Have Nothing To Disclose. Case Description: A 43-year-old man acutely presented to emergency department with features of dengue fever. Seventy two hours later, he developed urinary retention and bilateral leg weakness. The main features were flaccid paraparesis, absent deep tendon reflexes in legs, and plantar reflexes were equivocal, bilaterally. On American Spinal Injury Association impairment scale, he was classed at ASIA ‘B’ with sensory level at T4. A spinal MRI showed patchy areas of T2 prolongation in the cervical cord from C2 down to C7 and a diffusely scattered T2 hyper intensity within the thoracic cord extending up to T9 vertebral level. Dengue virus RNA and IgM were positive but CSF analysis, oligoclonal bands and viral cultures were unremarkable. On the day of admission, IV immunoglobulin was administered in a dose of 0.4gm/kg for 5 days, followed by IV penicillin, azithromycin and acyclovir for two weeks, to cover all possible infective causes of myelitis. Setting: Rehabilitation center in a tertiary care hospital. Results or Clinical Course: By the time of discharge, after five weeks of intensive rehabilitation, he had regained almost normal strength in his legs and was able to mobilize independently without aids. However, his bladder function remained compromised. Discussion: Longitudinally extensive transverse myelitis (LETM) is usually associated with neuromyelitis optica and other autoimmune and inflammatory disorders but this is the first report linking it with dengue fever. On the basis of dengue positive serology and development of spinal cord related symptoms with appearance of MRI features at about the same time, dengue is considered as the most likely cause of LETM in this case. Conclusions: This report has highlighted the fact that the dengue fever, which usually takes an uncomplicated course, may cause severe neurological dysfunction and that the recovery is sometimes unpredictably fast, contrary to the general belief.
Poster 395 Rehabilitation of Wound Botulism Caused by Heroin Skin Popping: A Case Report. Ryan Doan, MD (Stanford Hospital and Clinics, Stanford, CA, United States); Edward Chaw, DO. Disclosures: R. Doan, No Disclosures: I Have Nothing To Disclose. Case Description: The patient presented to the emergency department with neck pain, headache, bilateral ptosis, bulbar weakness, upper extremity spasms, and flaccid quadriparesis. She underwent emergent intubation in the emergency department for respiratory failure. She received heptavalent botulinum antitoxin on hospital day 3. Shiley # 6 tracheostomy was placed on hospital day 11. By hospital day 15, botulinum A serum assay returned positive, confirming diagnosis of wound botulism. She was transferred to rehabilitation trauma center on hospital day 18 for ventilator weaning. She received aggressive pulmonary toileting through intermittent percussive ventilator and dornase alfa for secretion management. Over the subsequent four weeks, she progressed through cuff down trials and transitioned to a portable LTV ventilator. She was moved to an inpatient acute rehabilitation unit on hospital day 56. Over the next four weeks, her respiratory status and motor strength gradually improved. She started passy-muir trials on hospital day 57 and was eventually decannulated on hospital day 83. She was ambulatory with crutches by the time she discharged to home on hospital day 86. Setting: Inpatient Rehabilitation Facility. Results or Clinical Course: Given the patient’s heroin skin popping and positive botulinum toxin assay, wound botulism was attributed to black tar heroin skin popping. By twelve weeks postinjury, motor and respiratory weakness had largely resolved. Discussion: This is the first reported case, to our knowledge, describing rehabilitation for wound botulism secondary to heroin skin popping. Conclusions: Although wound botulism causes severe paralysis and respiratory failure, an appropriate rehabilitation approach can return patients to functional independence. Poster 396 Amantadine Use in Heroin-induced Leukoencephalopathy: A Case Report. Giselle Vivaldi, MD (NYU Medical Center, New York, NY, United States); Melanie Howell, DO. Disclosures: G. Vivaldi, No Disclosures: I Have Nothing To Disclose. Case Description: A 45-year-old man with history of cocaine and heroin use who was brought to hospital due to altered mental status. Non-contrast head CT scan was normal. Brain MRI showed diffuse white matter flair abnormalities. Lumbar puncture was negative for acute infection and HIV, CMV, and HSV 1-2 testing were negative. Pt was thought to have encephalomyelitis and was started on a course of IV steroids. Symptoms did not improve overall and he developed aphasia which worsened to global aphasia. After further evaluation patient’s diagnosis was felt to be heroin-induced toxic leukoencephalopathy ("chasing the dragon" syndrome). Patient was started on treatment with high dose vitamin and anti-oxidant supplementation. Slight improvement in symptoms were noted but confusion, abulia, and limited speech output persisted. Patient was admitted to acute inpatient rehab 4 weeks
PRESENTATIONS
after admission to acute hospital. On admission patient required total assistance for ADLs and mobility, patient was aphasic and not following commands. Setting: Tertiary care municipal hospital. Results or Clinical Course: During rehab stay patient was started on Amantadine 100mg daily and was titrated up to 200mg twice a day. Therapists and staff noticed significant functional gains and increased cognitive functioning including initiation of automatic verbal responses after starting Amantadine. On discharge patient demonstrated ability to feed himself but remained at a max assistance level with most ADLs due to ongoing cognitive deficits. He was responding with short phrases intermittently, tracking to stimuli, appropriately responding to certain gestures and cues, and following simple commands inconsistently. Discussion: Amantadine is used to speed up functional recovery in traumatic brain injury patients. Conclusions: To our knowledge there is no other reported case in the literature of amantadine use in toxic leukoencephalopathy. Poster 397 Dengue Fever and Longitudinally Extensive Transverse Myelitis: A Case Report. Ashfaq Larik (Singapore General Hospital, Singapore, Singapore). Disclosures: A. Larik, No Disclosures: I Have Nothing To Disclose. Case Description: A 43-year-old man acutely presented to emergency department with features of dengue fever. Seventy two hours later, he developed urinary retention and bilateral leg weakness. The main features were flaccid paraparesis, absent deep tendon reflexes in legs, and plantar reflexes were equivocal, bilaterally. On American Spinal Injury Association impairment scale, he was classed at ASIA ‘B’ with sensory level at T4. A spinal MRI showed patchy areas of T2 prolongation in the cervical cord from C2 down to C7 and a diffusely scattered T2 hyper intensity within the thoracic cord extending up to T9 vertebral level. Dengue virus RNA and IgM were positive but CSF analysis, oligoclonal bands and viral cultures were unremarkable. On the day of admission, IV immunoglobulin was administered in a dose of 0.4gm/kg for 5 days, followed by IV penicillin, azithromycin and acyclovir for two weeks, to cover all possible infective causes of myelitis. Setting: Rehabilitation center in a tertiary care hospital. Results or Clinical Course: By the time of discharge, after five weeks of intensive rehabilitation, he had regained almost normal strength in his legs and was able to mobilize independently without aids. However, his bladder function remained compromised. Discussion: Longitudinally extensive transverse myelitis (LETM) is usually associated with neuromyelitis optica and other autoimmune and inflammatory disorders but this is the first report linking it with dengue fever. On the basis of dengue positive serology and development of spinal cord related symptoms with appearance of MRI features at about the same time, dengue is considered as the most likely cause of LETM in this case. Conclusions: This report has highlighted the fact that the dengue fever, which usually takes an uncomplicated course, may cause severe neurological dysfunction and that the recovery is sometimes unpredictably fast, contrary to the general belief.