Poster 198: Autoimmune Necrotizing Myopathy Following Statin Use: A Case Report

Abstracts / PM R 9 (2017) S131-S290 Poster 196: Electrophysiologic Study on Bilateral All-Ulnar Innervated Hands with Symptoms of Carpal Tunnel Syndrome: A Case Report Norr Santz (State University of New York Downstate Medical Center, Brooklyn, NY, USA), Arpit Arora, MD, Marcel G. Bayol, MD, Sanjeev Agarwal, MD Disclosures: Norr Santz: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 78-year-old woman with diabetes mellitus and hypertension who was referred by Geriatrics for electrodiagnostic evaluation for suspected carpal tunnel syndrome. The patient presented with a several-year history of decreased sensation in the distal third and fourth digits of her right hand, difficulty picking up small objects, and atrophy of the right thenar eminence. We performed the standard nerve conduction and electromyography screen for carpal tunnel syndrome. Setting: Outpatient physical medicine and rehabilitation clinic. Results: On the nerve conduction studies, stimulation of both median nerves at the wrist and stimulation of both ulnar nerves at the wrist, while recording over the abductor pollicis brevis, resulted in the same compound muscle action potential waveform (ie, the waveform typical of the ulnar nerve stimulation at the wrist). The amplitude of the ulnar nerve CMAPs was higher than that of the median nerve CMAPs when stimulated at the wrist, suggesting the median nerve response was a volume-conducted one. Stimulation of the median nerve at the antecubital fossa resulted in no response. No typical anastomosis patterns were identified. Needle EMG of the bilateral abductor pollicis brevis (APB) muscles revealed normal insertional activity without spontaneous activity, normal interference pattern, and normal recruitment. Discussion: Ulnar innervation of typically median innervated muscles is rare. This case presents a rare example of bilateral ulnar-dominated motor innervation with a clinical presentation consistent with median neuropathy [eg, marked atrophy of thenar eminence], but without any typical forearm or hand anastomosis. Conclusions: Physiatrists and electromyographers should keep a broad differential in patients presenting with signs and symptoms of median neuropathy, including an ulnar nerve-dominated hand, to prevent ineffective treatment strategies and inappropriate surgical referrals. Level of Evidence: Level V Poster 197: Early and Aggressive Management of Extracorporeal Membrane Oxygenation (ECMO) Related Complications on the Inpatient Rehabilitation Unit: A Case Report Jennifer L. Weekes, MD (Wm Beaumont Hosp) Disclosures: Jennifer Weekes: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 54-year-old man with no significant past medical history was admitted to a small regional hospital after five days of fevers, myalgias and dry cough. He began to decompensate and required intubation due to severe hypoxemic respiratory failure. Despite mechanical ventilation his respiratory status worsened requiring transfer to a large tertiary care facility and initiation of extracorporeal membrane oxygenation (ECMO). He was ultimately diagnosed with H1N1 influenza and superimposed Pseudomonas bacterial pneumonia. Setting: Tertiary Care Hospital. Results: The patient remained on ECMO for approximately 2 months and was subsequently transferred to the inpatient rehabilitation (IPR) unit. In addition to numerous medical complications he was diagnosed with major depression/post traumatic stress disorder

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(PTSD) secondary to his prolonged hospitalization and the use of ECMO. Early management of his PTSD by psychiatry and other supporting staff allowed for effective therapy on IPR. After only 11 days he was discharged home at a modified independent level for activities of daily living and ambulating greater than 120 feet without an assistive device. Discussion: The use of ECMO has been associated with long-term complications that can be seen in patients on IPR. It has been reported that patients treated with ECMO for acute respiratory distress syndrome (ARDS) experience decreased mental and social health as well as have an increased likelihood for PTSD compared to other ARDS survivors. These complications, if not addressed, hinder a patient’s progress on IPR and delay restoration of their previous level of functional health. Conclusions: As the utilization of ECMO continues to rise, physiatrists must become more cognizant of the challenges faced by this patient population during their rehabilitation course. ARDS treated with ECMO is associated with increased prevalence of long-term psychiatric disorders. Addressing these risk factors with comprehensive psychiatric care in addition to inpatient rehabilitation may minimize the longterm sequelae of ECMO. Level of Evidence: Level V Poster 198: Autoimmune Necrotizing Myopathy Following Statin Use: A Case Report Wyatt Kupperman, DO (Schwab Rehabilitation Hospital, Chicago, IL, United States), Theresa J. Lie-Nemeth, MD, Jenny Yin, DO, Roger R. Wang, DO Disclosures: Wyatt Kupperman: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 50-year-old man with diabetes mellitus, hypertension, and hyperlipidemia with statin use for “years” presented with generalized weakness and pain in his back and lower limbs, worsening over the last 5 months. He had multiple falls over the last year and eventually became dependent for self-care and mobility. On exam, he was noted to have symmetric proximal weakness of lower limbs worse than upper. Cervical MRI showed multilevel degenerative changes of the cervical spine, worse at C4-C5 with moderate to severe spinal canal stenosis, but no definite cord signal abnormality. Rheumatologic workup included negative GAD antibody, positive HMG CoA reductase inhibitor antibody, and elevated CPK. Muscle biopsy revealed active inflammatory myopathy with focal necrosis and minimal perimysial lymphocytic infiltrate. Patient was started on steroids and transferred to acute inpatient rehabilitation. Setting: Tertiary Care Hospital/Acute Inpatient Rehabilitation Hospital. Results: He completed acute inpatient rehabilitation and was discharged to a skilled nursing facility needing supervision for eating, minimum to moderate assistance for ADLs and transfers, and supervision for wheelchair propulsion. Discussion: Statins are generally well tolerated; however, 1 in 10,000 per year may experience weakness, elevated CK levels, and muscle damage. Patients normally recover with discontinuation. Rarely, an estimated 2 or 3 out of 100,000 may develop muscle necrosis and antibodies against 3-hydroxy-3methylglutaryl coenzyme leading to autoimmune myopathy. The etiology remains under investigation. Treatment consists of discontinuation of the statin, oral prednisone, and possible immunosuppressants. Strength generally improves. Conclusions: This case illustrates a rare side effect to commonly prescribed medications for cholesterol management. It highlights the importance for treatment in the event of a known side effect to commonly prescribed medications. Continued research is needed to understand the etiology of autoimmune myopathy to enhance treatment and recovery. Level of Evidence: Level V