- Email: [email protected]
Poster 147 Rehabilitation in a Patient with Contrast-Induced Nephrogenic Systemic Fibrosis: A Case Report
S240
women elders. In particular, controlling depression and pain along with treatment of anemia in anemic women elders may be key elements in developing models for maintaining and promoting their health.
MUSCULOSKELETAL Poster 145 Development of Buttock Pain and Abscess Following a Progesterone in Oil Injection: A Case Report. Aaron Yang, MD (Rehabilitation Institute of Chicago/ McGaw Medical Center of Northwestern University, Chicago, IL, United States); Monica Rho, MD. Disclosures: A. Yang, No Disclosures. Case Description: A 37-year-old woman presented with bilateral buttock pain following a cycle of in vitro fertilization (IVF). Patient had initiated her cycle of IVF approximately 8 days prior by giving herself injections to her left buttock prior to implantation of an emybro in her uterus. She subsequently developed intense pain on the left buttock, so upon advice from her physician, switched her injections to the right buttock. Within a week, the patient developed intense right buttock pain as well and presented to the emergency department in which a small undrainable abscess was identified by ultrasound on the left buttock. The patient was given cephalexin and hydrocodone for pain and was discharged. The patient was taking hydrocodone every 5-6 hours for pain and was extremely fatigued. She presented to our clinic with intense bilateral buttock pain. Her husband admitted that he was not adequately trained in how to give the injection and described placing a 2-inch needle to the hub during the injections. Since this caused the patient pain, they iced her buttock immediately after for 30 minutes with each injection. Program Description: Rehabilitation Institute of Chicago/ Sports and Spine Center. Setting: Outpatient sports and spine center. Results or Clinical Course: At her initial visit, the patient had ongoing pain with areas of induration on her buttocks that felt as if she had “rocks in my buttocks.” The dosing of hydrocodone was decreased as it was thought to be contributing to her fatigue and after discussing topical alternatives, a prescription for 5% lidocaine transdermal patches was given. Follow-up phone call 3 days later revealed that the patient was doing much better after discontinuing her hydrocodone and using topical methylsalicylate/menthol for pain control. She stated the lidocaine patches did not provide any pain relief. Further follow-up revealed that the patient had a miscarriage with no further plans to attempt IVF. Patient did have 3 prior courses of IVF but never had used progesterone in oil in the past. Discussion: This case report describes a rare adverse event of an abscess formation and severe buttock pain following a progesterone in oil injection during a cycle of IVF. Conclusions: With increasing popularity of in vitro fertilization, referring physicians must be aware of potential adverse events of injectable fertility drugs. Poster 146 Challenging Diagnosis of a Hip Labral Tear: A Case Report. Aaron Yang, MD (Rehabilitation Institute of Chicago/ McGaw NW, Chicago, IL, United States); Ellen Casey, MD.
PRESENTATIONS
Disclosures: Yang, No Disclosures. Case Description: Patient is a 24-year-old woman with a 3-year history of left lower back and buttock pain that was insidious in onset and aggravated by squatting. Patient was diagnosed with sciatica of the left lower limb and underwent PT and received chiropractic manipulation with no relief. MRI of her lumbar spine showed minimal spondylosis at L4-5 with no disc herniation or spinal stenosis. She was referred to a neurologist for an electrodiagnostic workup which was normal. She received acupuncture which temporarily relieved symptoms, a left SI joint injection which increased pain, one facet and three transforaminal epidural steroid injections which each gave 2 weeks of pain relief. She presented to the clinic for further evaluation prior to having a recommended discogram for possible spinal fusion. Program Description: Rehabilitation Institute of Chicago. Setting: Outpatient sports and spine center. Results or Clinical Course: The initial visit revealed decreased lumbosacral extension with back and buttock pain and posterior thigh pain with left side bending. Left hip examination was notable for restricted internal rotation compared to the right and buttock pain with end range of motion in internal rotation, external rotation, and flexion. Provocative maneuvers of the left SI joint were negative. Left hip radiographs were suggestive of CAM-type femoroacetabular impingement. Prescribed PT did not alleviate the pain, so she underwent a fluoroscopically guided diagnostic left hip injection which relieved the pain for the duration of the anesthetic. Subsequent MR arthrogram revealed a tear in the anterior-superior labrum. The patient visited 3 different orthopedic surgeons due to the primary location of buttock pain without groin pain before finally receiving a left hip arthroscopic labral debridement and femoral head osteotomy. The patient had immediate pain relief post-surgery and remains pain free without functional limitations. Discussion: While hip labral tears commonly present with anterior hip or groin pain, this case reports a rare presentation that delayed the course of treatment. Conclusions: Diagnosis of hip labral tears can be challenging to the clinician. Studies show an average of 2 years before diagnosis. Atypical presentations can make diagnosis even more difficult and should be recognized in order to avoid delaying the appropriate medical treatments. Poster 147 Rehabilitation in a Patient with Contrast-Induced Nephrogenic Systemic Fibrosis: A Case Report. Abdussami Hadi, MD (NYU Medical Center, New York, NY, United States); Gary P. Laux, DO. Disclosures: Hadi, No Disclosures. Case Description: The patient has a past medical history significant for chronic kidney disease and was on hemodialysis. The patient was to have AV fistula placement and underwent multiple MRIs with gadolinium. The patient developed swelling and inflammation in his arms, legs and later throughout his body. He then had progressively worsening renal failure and was continued on hemodialysis. One year later he began to develop skin contractures. Skin biopsy was done and confirmed nephrogenic systemic fibrosis (NSF). The patient presented to an outpatient physical medicine and rehabilitation clinic as he was slowly beginning to develop flexion contractures at his elbows and knees. The patient was having more difficulty with ambulating and performing ADLs .
PM&R
Setting: Outpatient clinic. Results or Clinical Course: The patient participates in physical and occupational therapy two times a week in an outpatient setting. Patient improved ROM at elbows and knees from 30 to 42 degrees and 72 to 80 degrees, respectively. The patient continues to participate in a therapeutic exercise program with a focus on gait training with assistive devices which allows the patient to continue to ambulate household distances independently. Discussion: NSF has been noted to develop after gadolinium exposure in 13% of cases. NSF not only involves the skin, but also the eyes, joints and internal organs. It is important to recognize functional deficits that arise from NSF and provide comprehensive care to patients as to prevent an accelerated decline in function as is the course of the disease. Conclusions: NSF is a rare condition; however, it involves aggressive multidisciplinary care to improve quality of life in patients. Poster 148 Exercise-Induced Anaphylaxis in a Collegiate Cross Country Runner: A Case Report. Adam M. Pourcho, DO (Wayne State University, Taylor, MI, United States). Disclosures: A. M. Pourcho, No Disclosures. Case Description: A 21-year-old female cross country runner presented to the sports medicine clinic complaining of multiple episodes of small, punctuate, erythematous papules on her trunk and arms appearing towards the end of her runs. The urticarial rash was not associated with shortness of breath or any other constitutional symptoms. The patient’s symptoms lasted for 20 minutes to up to 4 hours after activity. Setting: Collegiate Sports Medicine Clinic. Results or Clinical Course: The patient was found to have elevated plasma histamine levels on exercise provocation testing on a stationary bike, with reproduction of the same rash. She was diagnosed with variant type exercise-induced anaphylaxis. Coaches and trainers were alerted of the condition. The patient was treated by being instructed to avoid aspirin and NSAIDs before activity, to avoid eating full meals 4 hours prior to her runs, and to avoid strenuous exercise around menses, as these activities have been shown to increase chances of anaphylaxis in the literature. She was given Loratadine 10mg 1 hour prior to activity. The patient was also assigned an exercise partner who was trained in basic life support and knowledge of how to administer epinephrine. She was able to complete the remainder of the season without serious complications. Discussion: The variant form of exercise-induced anaphylaxis is the least common form and is only provoked by exercise. It is estimated that the variant type makes up 10 percent of all cases of exercise-induced anaphylaxis. Allergic reactions can range from 2 to 5 mm urticarial rash on trunk and arms to severe vascular collapse and death. Only one death has been attributed directly to exercise-induced anaphylaxis in the literature. However, precautions to protect the athlete’s health must be taken and if reactions are severe enough, avoidance or modification of exercise is warranted. Conclusions: In a certain select group of people, exercise can produce a self-induced allergic reaction ranging from an erythematous, irritation skin eruption to life-threatening anaphylaxis and death. Although rare, exercise-induced anaphylaxis should be on
Vol. 4, Iss. 10S, 2012
S241
the differential for the athlete who develops an urticarial rash during activity and action should be taken to protect the athlete and supervising staff. Poster 149 Varicella-Zoster Infection Presenting with an Acute Disk Herniation with Radicular Pain: A Case Report. Ajay Patel, MD (Stanford University, Redwood City, CA, United States); Eugene Y. Roh, MD. Disclosures: A. Patel, No Disclosures. Case Description: A 65-year-old man with acute onset radicular pain from herniated disk with active varicella zoster virus infection (VZVI). Program Description: A 65-year-old man presented with subacute onset low back pain with radiation to his right lower extremity (RLE) after performing hyperextension exercises. He noticed fluidfilled skin lesions a few days after onset of pain. There were several 2-3 mm fluid-filled vesicles starting from the lateral aspect of the right knee following the lateral aspect of the calf and into the web space of the first and second digits. Physical examination was significant for 4/5 strength in the right extensor halluces longus muscle and decreased sensation to light touch in the RLE over the L5 distribution. Straight leg raise test was positive on the right. MRI of the lumbar spine showed broad-based disk bulges at L4-5 and L5-S1 with moderate right-sided foraminal and lateral recess narrowing. Setting: University-based outpatient musculoskeletal clinic. Results or Clinical Course: Patient was started on acyclovir for VZVI and treated with conservative measures, which included physical therapy. There was complete resolution of pain after 8 weeks. Discussion: Acute disk herniation can cause activation of herpes zoster at the level of the herniation. Treatment of VZVI with valacyclovir or acyclovir should not be delayed as it increases the patients risk for post herpetic neuralgia. Selective nerve root blocks should be considered in the treatment of zoster-induced radicular pain with or without evidence of nerve root impingement on imaging. Conclusions: Early identification and treatment of herpes zoster infection are critical for the prevention of post herptic neuralgia and can be confused with an acute disk herniation. Treatment with selective nerve root blocks should be considered for reduction of radicular pain symptoms. Poster 151 The Utility of Surgical Release in Chronic Isolated Suprascapular Nerve Injury in the Absence of Findings of External Compression on Imaging: A Case Report. Ami Mac, MD (Rehabilitation Institute of Michigan/ Detroit Medical Center, Detroit, MI); Chris Stuart, PA-C, Henry Goitz, MD. Disclosures: A. Mac, No Disclosures. Case Description: A 24-year-old man with a 1-year history of neck and left shoulder pain, weakness on left shoulder external rotation and abduction, occasional numbness and tingling of bilateral distal upper extremities, gross atrophy of the supraspinatus and infraspinatus. Program Description: Insidious onset with initial presentation to emergency department. Patient’s occupation required repeat lifting of boxes overhead. One year later, presented to the sports
women elders. In particular, controlling depression and pain along with treatment of anemia in anemic women elders may be key elements in developing models for maintaining and promoting their health.
MUSCULOSKELETAL Poster 145 Development of Buttock Pain and Abscess Following a Progesterone in Oil Injection: A Case Report. Aaron Yang, MD (Rehabilitation Institute of Chicago/ McGaw Medical Center of Northwestern University, Chicago, IL, United States); Monica Rho, MD. Disclosures: A. Yang, No Disclosures. Case Description: A 37-year-old woman presented with bilateral buttock pain following a cycle of in vitro fertilization (IVF). Patient had initiated her cycle of IVF approximately 8 days prior by giving herself injections to her left buttock prior to implantation of an emybro in her uterus. She subsequently developed intense pain on the left buttock, so upon advice from her physician, switched her injections to the right buttock. Within a week, the patient developed intense right buttock pain as well and presented to the emergency department in which a small undrainable abscess was identified by ultrasound on the left buttock. The patient was given cephalexin and hydrocodone for pain and was discharged. The patient was taking hydrocodone every 5-6 hours for pain and was extremely fatigued. She presented to our clinic with intense bilateral buttock pain. Her husband admitted that he was not adequately trained in how to give the injection and described placing a 2-inch needle to the hub during the injections. Since this caused the patient pain, they iced her buttock immediately after for 30 minutes with each injection. Program Description: Rehabilitation Institute of Chicago/ Sports and Spine Center. Setting: Outpatient sports and spine center. Results or Clinical Course: At her initial visit, the patient had ongoing pain with areas of induration on her buttocks that felt as if she had “rocks in my buttocks.” The dosing of hydrocodone was decreased as it was thought to be contributing to her fatigue and after discussing topical alternatives, a prescription for 5% lidocaine transdermal patches was given. Follow-up phone call 3 days later revealed that the patient was doing much better after discontinuing her hydrocodone and using topical methylsalicylate/menthol for pain control. She stated the lidocaine patches did not provide any pain relief. Further follow-up revealed that the patient had a miscarriage with no further plans to attempt IVF. Patient did have 3 prior courses of IVF but never had used progesterone in oil in the past. Discussion: This case report describes a rare adverse event of an abscess formation and severe buttock pain following a progesterone in oil injection during a cycle of IVF. Conclusions: With increasing popularity of in vitro fertilization, referring physicians must be aware of potential adverse events of injectable fertility drugs. Poster 146 Challenging Diagnosis of a Hip Labral Tear: A Case Report. Aaron Yang, MD (Rehabilitation Institute of Chicago/ McGaw NW, Chicago, IL, United States); Ellen Casey, MD.
PRESENTATIONS
Disclosures: Yang, No Disclosures. Case Description: Patient is a 24-year-old woman with a 3-year history of left lower back and buttock pain that was insidious in onset and aggravated by squatting. Patient was diagnosed with sciatica of the left lower limb and underwent PT and received chiropractic manipulation with no relief. MRI of her lumbar spine showed minimal spondylosis at L4-5 with no disc herniation or spinal stenosis. She was referred to a neurologist for an electrodiagnostic workup which was normal. She received acupuncture which temporarily relieved symptoms, a left SI joint injection which increased pain, one facet and three transforaminal epidural steroid injections which each gave 2 weeks of pain relief. She presented to the clinic for further evaluation prior to having a recommended discogram for possible spinal fusion. Program Description: Rehabilitation Institute of Chicago. Setting: Outpatient sports and spine center. Results or Clinical Course: The initial visit revealed decreased lumbosacral extension with back and buttock pain and posterior thigh pain with left side bending. Left hip examination was notable for restricted internal rotation compared to the right and buttock pain with end range of motion in internal rotation, external rotation, and flexion. Provocative maneuvers of the left SI joint were negative. Left hip radiographs were suggestive of CAM-type femoroacetabular impingement. Prescribed PT did not alleviate the pain, so she underwent a fluoroscopically guided diagnostic left hip injection which relieved the pain for the duration of the anesthetic. Subsequent MR arthrogram revealed a tear in the anterior-superior labrum. The patient visited 3 different orthopedic surgeons due to the primary location of buttock pain without groin pain before finally receiving a left hip arthroscopic labral debridement and femoral head osteotomy. The patient had immediate pain relief post-surgery and remains pain free without functional limitations. Discussion: While hip labral tears commonly present with anterior hip or groin pain, this case reports a rare presentation that delayed the course of treatment. Conclusions: Diagnosis of hip labral tears can be challenging to the clinician. Studies show an average of 2 years before diagnosis. Atypical presentations can make diagnosis even more difficult and should be recognized in order to avoid delaying the appropriate medical treatments. Poster 147 Rehabilitation in a Patient with Contrast-Induced Nephrogenic Systemic Fibrosis: A Case Report. Abdussami Hadi, MD (NYU Medical Center, New York, NY, United States); Gary P. Laux, DO. Disclosures: Hadi, No Disclosures. Case Description: The patient has a past medical history significant for chronic kidney disease and was on hemodialysis. The patient was to have AV fistula placement and underwent multiple MRIs with gadolinium. The patient developed swelling and inflammation in his arms, legs and later throughout his body. He then had progressively worsening renal failure and was continued on hemodialysis. One year later he began to develop skin contractures. Skin biopsy was done and confirmed nephrogenic systemic fibrosis (NSF). The patient presented to an outpatient physical medicine and rehabilitation clinic as he was slowly beginning to develop flexion contractures at his elbows and knees. The patient was having more difficulty with ambulating and performing ADLs .
PM&R
Setting: Outpatient clinic. Results or Clinical Course: The patient participates in physical and occupational therapy two times a week in an outpatient setting. Patient improved ROM at elbows and knees from 30 to 42 degrees and 72 to 80 degrees, respectively. The patient continues to participate in a therapeutic exercise program with a focus on gait training with assistive devices which allows the patient to continue to ambulate household distances independently. Discussion: NSF has been noted to develop after gadolinium exposure in 13% of cases. NSF not only involves the skin, but also the eyes, joints and internal organs. It is important to recognize functional deficits that arise from NSF and provide comprehensive care to patients as to prevent an accelerated decline in function as is the course of the disease. Conclusions: NSF is a rare condition; however, it involves aggressive multidisciplinary care to improve quality of life in patients. Poster 148 Exercise-Induced Anaphylaxis in a Collegiate Cross Country Runner: A Case Report. Adam M. Pourcho, DO (Wayne State University, Taylor, MI, United States). Disclosures: A. M. Pourcho, No Disclosures. Case Description: A 21-year-old female cross country runner presented to the sports medicine clinic complaining of multiple episodes of small, punctuate, erythematous papules on her trunk and arms appearing towards the end of her runs. The urticarial rash was not associated with shortness of breath or any other constitutional symptoms. The patient’s symptoms lasted for 20 minutes to up to 4 hours after activity. Setting: Collegiate Sports Medicine Clinic. Results or Clinical Course: The patient was found to have elevated plasma histamine levels on exercise provocation testing on a stationary bike, with reproduction of the same rash. She was diagnosed with variant type exercise-induced anaphylaxis. Coaches and trainers were alerted of the condition. The patient was treated by being instructed to avoid aspirin and NSAIDs before activity, to avoid eating full meals 4 hours prior to her runs, and to avoid strenuous exercise around menses, as these activities have been shown to increase chances of anaphylaxis in the literature. She was given Loratadine 10mg 1 hour prior to activity. The patient was also assigned an exercise partner who was trained in basic life support and knowledge of how to administer epinephrine. She was able to complete the remainder of the season without serious complications. Discussion: The variant form of exercise-induced anaphylaxis is the least common form and is only provoked by exercise. It is estimated that the variant type makes up 10 percent of all cases of exercise-induced anaphylaxis. Allergic reactions can range from 2 to 5 mm urticarial rash on trunk and arms to severe vascular collapse and death. Only one death has been attributed directly to exercise-induced anaphylaxis in the literature. However, precautions to protect the athlete’s health must be taken and if reactions are severe enough, avoidance or modification of exercise is warranted. Conclusions: In a certain select group of people, exercise can produce a self-induced allergic reaction ranging from an erythematous, irritation skin eruption to life-threatening anaphylaxis and death. Although rare, exercise-induced anaphylaxis should be on
Vol. 4, Iss. 10S, 2012
S241
the differential for the athlete who develops an urticarial rash during activity and action should be taken to protect the athlete and supervising staff. Poster 149 Varicella-Zoster Infection Presenting with an Acute Disk Herniation with Radicular Pain: A Case Report. Ajay Patel, MD (Stanford University, Redwood City, CA, United States); Eugene Y. Roh, MD. Disclosures: A. Patel, No Disclosures. Case Description: A 65-year-old man with acute onset radicular pain from herniated disk with active varicella zoster virus infection (VZVI). Program Description: A 65-year-old man presented with subacute onset low back pain with radiation to his right lower extremity (RLE) after performing hyperextension exercises. He noticed fluidfilled skin lesions a few days after onset of pain. There were several 2-3 mm fluid-filled vesicles starting from the lateral aspect of the right knee following the lateral aspect of the calf and into the web space of the first and second digits. Physical examination was significant for 4/5 strength in the right extensor halluces longus muscle and decreased sensation to light touch in the RLE over the L5 distribution. Straight leg raise test was positive on the right. MRI of the lumbar spine showed broad-based disk bulges at L4-5 and L5-S1 with moderate right-sided foraminal and lateral recess narrowing. Setting: University-based outpatient musculoskeletal clinic. Results or Clinical Course: Patient was started on acyclovir for VZVI and treated with conservative measures, which included physical therapy. There was complete resolution of pain after 8 weeks. Discussion: Acute disk herniation can cause activation of herpes zoster at the level of the herniation. Treatment of VZVI with valacyclovir or acyclovir should not be delayed as it increases the patients risk for post herpetic neuralgia. Selective nerve root blocks should be considered in the treatment of zoster-induced radicular pain with or without evidence of nerve root impingement on imaging. Conclusions: Early identification and treatment of herpes zoster infection are critical for the prevention of post herptic neuralgia and can be confused with an acute disk herniation. Treatment with selective nerve root blocks should be considered for reduction of radicular pain symptoms. Poster 151 The Utility of Surgical Release in Chronic Isolated Suprascapular Nerve Injury in the Absence of Findings of External Compression on Imaging: A Case Report. Ami Mac, MD (Rehabilitation Institute of Michigan/ Detroit Medical Center, Detroit, MI); Chris Stuart, PA-C, Henry Goitz, MD. Disclosures: A. Mac, No Disclosures. Case Description: A 24-year-old man with a 1-year history of neck and left shoulder pain, weakness on left shoulder external rotation and abduction, occasional numbness and tingling of bilateral distal upper extremities, gross atrophy of the supraspinatus and infraspinatus. Program Description: Insidious onset with initial presentation to emergency department. Patient’s occupation required repeat lifting of boxes overhead. One year later, presented to the sports