- Email: [email protected]
Newly Diagnosed Central Cord Syndrome and Chiari Malformation in a Patient Previously Diagnosed with Fibromyalgia: A Case Report
PM&R
(average 60); PROMIS-Depression T-score 38-81 (average 59.2); and, BBS 8-56 out of 56 (average 42.0). Conclusions: Subjects with TBI >2 years and with chronic pain tend to be with moderate pain-related impairment and decreased global mental health, along with fair physical performance. The study found a trend relationship of the PRI to GMH and PPS and that the health burden of TBI care to be extensive due to the clinical complexity involving both physical and psychosocial aspects. It recommends that the PDQ and PROMIS be part of the outcome measures for these difficultto-manage subjects who need integrated care. Further study on the correlation of the PDQ, PROMIS, & PPS scores should be done. Poster 349 Use of IV Bisphosphonate as Alternative Therapy for Heterotopic Ossification: A Case Report. Allison Gannon (Stanford Hospital & Clinics, Palo Alto, CA, United States); Roberta Y. Wang, MD; Min Kim, DO. Disclosures: A. Gannon, No Disclosures: I Have Nothing To Disclose. Case Description: An 18-year-old male with no significant past medical history suffered a traumatic brain injury in a vehicular accident. Injuries included left basal ganglia intraparenchymal hemorrhage, sub-arachnoid hemorrhage, and pulmonary embolism. He developed heterotopic ossification (HO) of bilateral elbows, left greater than right. Treatment was initiated 6 weeks after injury with indomethacin and etidronate. The patient was admitted to acute rehabilitation 3 months after injury with cachexia, decreasing range of motion, and persistent metabolically active HO as evidenced by elevated inflammatory markers, including urine Ntelopeptide (NTX). He demonstrated poor tolerance of medication, causing possible interference of nutrition. Alternative HO treatments were evaluated. In collaboration with Endocrinology consultants, etidronate was discontinued and single dose of IV Zoledronate 2g was administered. Of note, due to severe loss of function secondary to limited range of motion the patient underwent left elbow HO resection with subsequent irradiation of that elbow. Setting: Tertiary Care Center Acute Rehabilitation Unit. Results or Clinical Course: Two weeks post Zoledronate administration, serial laboratory markers demonstrated normalization of alkaline phosphatase and a marked decrease in urine NTX level (from 214 to 140). The patient had post therapy hypophosphatemia, which required replacement therapy for 5 days. Discussion: This case represents an example of a newer generation bisphosphonate used as alternative treatment for HO. Newer generation bisphosphonates (BPs) are well studied & widely used among other specialties, however they remain underutilized as therapy for HO. Currently, oral BPs, such as etidronate, are often poorly tolerated or contraindicated. Application of newer generation BPs may be beneficial in the treatment of HO secondary to ease of use, more convenient dosing schedule, availability, cost, and better tolerance. Conclusions: Bisphosphonates, other than etidronate, may be an alternative treatment option for HO in patients who cannot tolerate PO bisphosphonates or when the medication is not readily available.
Vol. 5, Iss. 9S, 2013
S259
Poster 350 Newly Diagnosed Central Cord Syndrome and Chiari Malformation in a Patient Previously Diagnosed with Fibromyalgia: A Case Report. D’Wan J. Carpenter, DO, MS (Wayne State University, Taylor, MI, United States); Jay Meythaler, MD. Disclosures: D. J. Carpenter, No Disclosures: I Have Nothing To Disclose. Case Description: Two years prior to presentation, the patient was diagnosed with fibromyalgia with headaches being the primary complaint. However, two years later, the patient was involved in a motor vehicle collision which resulted in worsening headaches along with findings consistent with central cord syndrome. Magnetic resonance imaging revealed Chiari malformation type I. The patient then underwent posterior fossa surgical decompression and upon stabilization was transferred to rehab. Setting: Inpatient rehabilitation unit. Results or Clinical Course: On rehabilitation admission, the patient presented with diplopia on right lateral gaze, but no appreciable nystagmus. She also demonstrated weakness- most notably of upper extremities with 3þ/5 on right, 3/5 on left, and 4/ 5 in bilateral lower extremities. The patient also presented with decreased sensation to pinprick and light touch in all dermatomes of the left upper extremity. By the time of discharge, the patient’s strength improved to 4/5 and 4þ/5 in right and left upper extremity, respectively. Symptoms of numbness and tingling also improved. After successful completion of rehabilitation, the patient was ambulating with assistive device and discharged to home with family’s assistance. Discussion: This is a rare case in which a patient with undiagnosed Chiari malformation type I was previously diagnosed with fibromyalgia. It is possible that the two conditions have overlapping symptoms. Conclusions: Fibromyalgia is a combination of chronic ongoing symptoms (pain, sleep disturbance, associated symptoms, i.e. headaches). It is important in patients diagnosed with fibromyalgia to do thorough neurovascular and musculoskeletal history, physical and diagnostic testing, including imaging, to ensure there are no other co-existing pathologies causing similar symptoms such as in this patient’s case. Poster 351 Dysarthria and Dysphagia from a CNXII Palsy Caused by a Skull Base Osteomyelitis in an Immunocompromised Patient: A Case Report. Emilia Ravski, DO (NYULMC Rusk Institute of Rehabilitation Medicine, New York, NY, United States); Keri M. Danziger, MA, CCC-SLP, BRS-S; Jeffrey Cohen, MD. Disclosures: E. Ravski, No Disclosures: I Have Nothing To Disclose. Case Description: A 63-year-old man with diabetes mellitus, renal transplant on immunosuppression presented with one-week history of dysarthria, dysphagia, frontal headache and malaise. Magnetic resonance imaging findings were consistent with a skull base infection involving the clivus and extending to adjacent sinuses and the petrous temporal bone. Initial clinical speech and swallow evaluation revealed severe oral dysphagia with grossly intact pharyngeal phase swallow function and severe flaccid
(average 60); PROMIS-Depression T-score 38-81 (average 59.2); and, BBS 8-56 out of 56 (average 42.0). Conclusions: Subjects with TBI >2 years and with chronic pain tend to be with moderate pain-related impairment and decreased global mental health, along with fair physical performance. The study found a trend relationship of the PRI to GMH and PPS and that the health burden of TBI care to be extensive due to the clinical complexity involving both physical and psychosocial aspects. It recommends that the PDQ and PROMIS be part of the outcome measures for these difficultto-manage subjects who need integrated care. Further study on the correlation of the PDQ, PROMIS, & PPS scores should be done. Poster 349 Use of IV Bisphosphonate as Alternative Therapy for Heterotopic Ossification: A Case Report. Allison Gannon (Stanford Hospital & Clinics, Palo Alto, CA, United States); Roberta Y. Wang, MD; Min Kim, DO. Disclosures: A. Gannon, No Disclosures: I Have Nothing To Disclose. Case Description: An 18-year-old male with no significant past medical history suffered a traumatic brain injury in a vehicular accident. Injuries included left basal ganglia intraparenchymal hemorrhage, sub-arachnoid hemorrhage, and pulmonary embolism. He developed heterotopic ossification (HO) of bilateral elbows, left greater than right. Treatment was initiated 6 weeks after injury with indomethacin and etidronate. The patient was admitted to acute rehabilitation 3 months after injury with cachexia, decreasing range of motion, and persistent metabolically active HO as evidenced by elevated inflammatory markers, including urine Ntelopeptide (NTX). He demonstrated poor tolerance of medication, causing possible interference of nutrition. Alternative HO treatments were evaluated. In collaboration with Endocrinology consultants, etidronate was discontinued and single dose of IV Zoledronate 2g was administered. Of note, due to severe loss of function secondary to limited range of motion the patient underwent left elbow HO resection with subsequent irradiation of that elbow. Setting: Tertiary Care Center Acute Rehabilitation Unit. Results or Clinical Course: Two weeks post Zoledronate administration, serial laboratory markers demonstrated normalization of alkaline phosphatase and a marked decrease in urine NTX level (from 214 to 140). The patient had post therapy hypophosphatemia, which required replacement therapy for 5 days. Discussion: This case represents an example of a newer generation bisphosphonate used as alternative treatment for HO. Newer generation bisphosphonates (BPs) are well studied & widely used among other specialties, however they remain underutilized as therapy for HO. Currently, oral BPs, such as etidronate, are often poorly tolerated or contraindicated. Application of newer generation BPs may be beneficial in the treatment of HO secondary to ease of use, more convenient dosing schedule, availability, cost, and better tolerance. Conclusions: Bisphosphonates, other than etidronate, may be an alternative treatment option for HO in patients who cannot tolerate PO bisphosphonates or when the medication is not readily available.
Vol. 5, Iss. 9S, 2013
S259
Poster 350 Newly Diagnosed Central Cord Syndrome and Chiari Malformation in a Patient Previously Diagnosed with Fibromyalgia: A Case Report. D’Wan J. Carpenter, DO, MS (Wayne State University, Taylor, MI, United States); Jay Meythaler, MD. Disclosures: D. J. Carpenter, No Disclosures: I Have Nothing To Disclose. Case Description: Two years prior to presentation, the patient was diagnosed with fibromyalgia with headaches being the primary complaint. However, two years later, the patient was involved in a motor vehicle collision which resulted in worsening headaches along with findings consistent with central cord syndrome. Magnetic resonance imaging revealed Chiari malformation type I. The patient then underwent posterior fossa surgical decompression and upon stabilization was transferred to rehab. Setting: Inpatient rehabilitation unit. Results or Clinical Course: On rehabilitation admission, the patient presented with diplopia on right lateral gaze, but no appreciable nystagmus. She also demonstrated weakness- most notably of upper extremities with 3þ/5 on right, 3/5 on left, and 4/ 5 in bilateral lower extremities. The patient also presented with decreased sensation to pinprick and light touch in all dermatomes of the left upper extremity. By the time of discharge, the patient’s strength improved to 4/5 and 4þ/5 in right and left upper extremity, respectively. Symptoms of numbness and tingling also improved. After successful completion of rehabilitation, the patient was ambulating with assistive device and discharged to home with family’s assistance. Discussion: This is a rare case in which a patient with undiagnosed Chiari malformation type I was previously diagnosed with fibromyalgia. It is possible that the two conditions have overlapping symptoms. Conclusions: Fibromyalgia is a combination of chronic ongoing symptoms (pain, sleep disturbance, associated symptoms, i.e. headaches). It is important in patients diagnosed with fibromyalgia to do thorough neurovascular and musculoskeletal history, physical and diagnostic testing, including imaging, to ensure there are no other co-existing pathologies causing similar symptoms such as in this patient’s case. Poster 351 Dysarthria and Dysphagia from a CNXII Palsy Caused by a Skull Base Osteomyelitis in an Immunocompromised Patient: A Case Report. Emilia Ravski, DO (NYULMC Rusk Institute of Rehabilitation Medicine, New York, NY, United States); Keri M. Danziger, MA, CCC-SLP, BRS-S; Jeffrey Cohen, MD. Disclosures: E. Ravski, No Disclosures: I Have Nothing To Disclose. Case Description: A 63-year-old man with diabetes mellitus, renal transplant on immunosuppression presented with one-week history of dysarthria, dysphagia, frontal headache and malaise. Magnetic resonance imaging findings were consistent with a skull base infection involving the clivus and extending to adjacent sinuses and the petrous temporal bone. Initial clinical speech and swallow evaluation revealed severe oral dysphagia with grossly intact pharyngeal phase swallow function and severe flaccid