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Poster 218: Musculocutaneous Neuropathy Due to PICC Line Insertion: A Case Report
S202
Abstracts / PM R 9 (2017) S131-S290
Poster 218: Musculocutaneous Neuropathy Due to PICC Line Insertion: A Case Report Maria Janakos, MD (University of Louisville Physical Medicine, Louisville, KY, United States), David Haustein, MD, Preeti Panchang, MD Disclosures: Maria Janakos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with uncontrolled diabetes mellitus developed a diabetic foot ulcer and osteomyelitis requiring intravenous antibiotics. He underwent sonographically guided PICC line placement using a 5-French catheter with radiographic confirmation of the tip at the cavoatrial junction. The patient recalls terrible pain and extensive ecchymoses of his right arm and lateral thorax in the days following the procedure as well as weakness with right elbow flexion and paresthesias over the lateral forearm. He was seen 2 months later by a physiatrist at the VA hospital and found to have weak right elbow flexion and diminished sensation in the right lateral antebrachium; otherwise normal strength and sensation throughout the bilateral upper limbs. An abbreviated electrodiagnostic study was performed that day for further evaluation. Setting: VA hospital. Results: A limited EMG of the right upper limb demonstrated a right musculocutaneous neuropathy at least proximal to the fascicles to the biceps characterized by at least partial axonal loss. Also noted was an underlying peripheral polyneuropathy characterized by sensorimotor axonal loss and demyelination. Discussion: Given its deep location, musculocutanous nerve injuries are rare but have been reported in athletes performing repetitive overhead activities as well as a complication of direct trauma, shoulder dislocations, and surgery. Symptoms include arm pain, weakness with elbow flexion and/or supination as well as sensory loss over the lateral aspect of the forearm. Differential diagnoses include brachial plexopathies and cervical stenosis. Spontaneous recovery is possible but may take months to years. Conclusions: A musculocutaneous nerve injury is an unusual complication of upper extremity vascular access; given the close proximity of nerve and vascular structures in the limbs, close monitoring for neuropathy symptoms during and after the procedure is warranted. Level of Evidence: Level V Poster 219: Male Infertility Treatment Leading to Cerebellar Cerebrovascular Accident: A Case Report Hanzla Quraishi, MD (Marianjoy Rehab Hosp) Disclosures: Hanzla Quraishi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 47-year-old man with a past medical history of asthma, hypertension, and male infertility presented with a complaint of acute vertigo for 6 days. He stated that it came on suddenly with concurrent nausea, emesis and diplopia. Brain MRI was positive for acute right posterior inferior cerebellar artery occlusion and right vertebral occlusion. He subsequently underwent a midline suboccipital craniectomy with durotomy and resection of infarcted brain. The patient was seen by neurology and it was determined that his cerebrovascular accident was secondary to hCG injections for male infertility. Prior to presenting, the patient had no history of atherosclerotic disease or hypercoagulable state predisposing patient to stroke. Setting: Acute Rehabilitation Hospital. Results: The patient completed a course of comprehensive inpatient rehabilitation including physical, occupational, and speech therapies. Discussion: There is a known link between spinal cord injury and stroke with infertility, specifically in the male population. This case appears to be the first known event of male hCG treatments directly leading to cerebrovascular accident. Prior cases of hormone therapy
leading to stroke involved either female hormonal therapy or testosterone treatment. In the younger rehabilitation population, fertility and the ability to bear children are a distinct concern of many patients. Given this, there is merit to educating patients about risks of fertility therapy as well as monitoring patients actively undergoing fertility treatment. Comorbidities in the rehabilitation population may further predispose patients to adverse outcomes regardless of gender. Conclusions: Treatment of male infertility can be associated with increased risk of stroke, even in the absence of testosterone therapy, specifically with hCG or Clomiphene. Given the biopsychosocial profile of rehabilitative medicine, fertility concerns can often be of paramount importance in this population. Accordingly, it is the responsibility of the physician to educate patients in regards to risks and benefits of potential therapy regardless of gender. Level of Evidence: Level V Poster 220: The Psychosocial Impact of Rehabilitation Services as Highlighted by the Care of a Patient with Multiple Epiphyseal Dysplasia: A Case Report Charles P. Scott, MD (New York Presbyterian Hosp), Nasim Chowdhury, MD Disclosures: Charles Scott: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was diagnosed with MED at age 7 after 2 years of progressive gait impairment. Her father, paternal uncle, and paternal grandmother were previously diagnosed with MED; her father and uncle had each undergone bilateral hip replacements. Neither she, nor her family, has yet undergone genetic testing; all diagnoses were made clinically with plain film radiographs. She described feeling increasingly socially isolated as a teenager, largely due to her inability to participate in activities such as athletics and casual play, given chronic joint pain and severe fatigue within several minutes of activity onset. With progressive gait impairments causing her to limp, she began physical therapy as a young adult, allowing her to remain independent and to participate in academic, professional, and social pursuits. After graduating from college, she completed a 26month engagement with the Peace Corps in the developing world, remaining ambulatory with use of a cane. Due to progressive disease and functional deficits, she underwent bilateral hip replacement at age 29. Post-operatively, rehabilitation focused on retraining gait mechanics and increasing independence with household tasks. Setting: In-patient rehabilitation unit of a tertiary care hospital. Results: The patient made rapid progress with ambulation and functional tasks, and returned to full-time work 45 days after surgery. Discussion: Rehabilitation medicine played an integral role throughout the care of this patient by helping to maintain mobility and range of motion and through introduction of specific interventions such as teaching the use of a cane and retraining gait mechanics. Conclusions: MED patients face a variety of physical limitations that may have a marked impact on psychosocial functioning. Rehabilitation strategies play an integral role in management of MED and can help patients overcome significant physical barriers to social and professional integration. Level of Evidence: Level V Poster 221: Rehabilitation Considerations in a Patient With Klippel-Feil Syndrome: A Case Report Grace L. Maloney, MD (Marianjoy Rehab Hosp, Naperville, IL, United States), Anjum Sayyad, MD Disclosures: Grace Maloney: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with Klippel-Feil syndrome, morbid obesity (BMI 47.8), type II diabetes, and asthma
Abstracts / PM R 9 (2017) S131-S290
Poster 218: Musculocutaneous Neuropathy Due to PICC Line Insertion: A Case Report Maria Janakos, MD (University of Louisville Physical Medicine, Louisville, KY, United States), David Haustein, MD, Preeti Panchang, MD Disclosures: Maria Janakos: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with uncontrolled diabetes mellitus developed a diabetic foot ulcer and osteomyelitis requiring intravenous antibiotics. He underwent sonographically guided PICC line placement using a 5-French catheter with radiographic confirmation of the tip at the cavoatrial junction. The patient recalls terrible pain and extensive ecchymoses of his right arm and lateral thorax in the days following the procedure as well as weakness with right elbow flexion and paresthesias over the lateral forearm. He was seen 2 months later by a physiatrist at the VA hospital and found to have weak right elbow flexion and diminished sensation in the right lateral antebrachium; otherwise normal strength and sensation throughout the bilateral upper limbs. An abbreviated electrodiagnostic study was performed that day for further evaluation. Setting: VA hospital. Results: A limited EMG of the right upper limb demonstrated a right musculocutaneous neuropathy at least proximal to the fascicles to the biceps characterized by at least partial axonal loss. Also noted was an underlying peripheral polyneuropathy characterized by sensorimotor axonal loss and demyelination. Discussion: Given its deep location, musculocutanous nerve injuries are rare but have been reported in athletes performing repetitive overhead activities as well as a complication of direct trauma, shoulder dislocations, and surgery. Symptoms include arm pain, weakness with elbow flexion and/or supination as well as sensory loss over the lateral aspect of the forearm. Differential diagnoses include brachial plexopathies and cervical stenosis. Spontaneous recovery is possible but may take months to years. Conclusions: A musculocutaneous nerve injury is an unusual complication of upper extremity vascular access; given the close proximity of nerve and vascular structures in the limbs, close monitoring for neuropathy symptoms during and after the procedure is warranted. Level of Evidence: Level V Poster 219: Male Infertility Treatment Leading to Cerebellar Cerebrovascular Accident: A Case Report Hanzla Quraishi, MD (Marianjoy Rehab Hosp) Disclosures: Hanzla Quraishi: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 47-year-old man with a past medical history of asthma, hypertension, and male infertility presented with a complaint of acute vertigo for 6 days. He stated that it came on suddenly with concurrent nausea, emesis and diplopia. Brain MRI was positive for acute right posterior inferior cerebellar artery occlusion and right vertebral occlusion. He subsequently underwent a midline suboccipital craniectomy with durotomy and resection of infarcted brain. The patient was seen by neurology and it was determined that his cerebrovascular accident was secondary to hCG injections for male infertility. Prior to presenting, the patient had no history of atherosclerotic disease or hypercoagulable state predisposing patient to stroke. Setting: Acute Rehabilitation Hospital. Results: The patient completed a course of comprehensive inpatient rehabilitation including physical, occupational, and speech therapies. Discussion: There is a known link between spinal cord injury and stroke with infertility, specifically in the male population. This case appears to be the first known event of male hCG treatments directly leading to cerebrovascular accident. Prior cases of hormone therapy
leading to stroke involved either female hormonal therapy or testosterone treatment. In the younger rehabilitation population, fertility and the ability to bear children are a distinct concern of many patients. Given this, there is merit to educating patients about risks of fertility therapy as well as monitoring patients actively undergoing fertility treatment. Comorbidities in the rehabilitation population may further predispose patients to adverse outcomes regardless of gender. Conclusions: Treatment of male infertility can be associated with increased risk of stroke, even in the absence of testosterone therapy, specifically with hCG or Clomiphene. Given the biopsychosocial profile of rehabilitative medicine, fertility concerns can often be of paramount importance in this population. Accordingly, it is the responsibility of the physician to educate patients in regards to risks and benefits of potential therapy regardless of gender. Level of Evidence: Level V Poster 220: The Psychosocial Impact of Rehabilitation Services as Highlighted by the Care of a Patient with Multiple Epiphyseal Dysplasia: A Case Report Charles P. Scott, MD (New York Presbyterian Hosp), Nasim Chowdhury, MD Disclosures: Charles Scott: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was diagnosed with MED at age 7 after 2 years of progressive gait impairment. Her father, paternal uncle, and paternal grandmother were previously diagnosed with MED; her father and uncle had each undergone bilateral hip replacements. Neither she, nor her family, has yet undergone genetic testing; all diagnoses were made clinically with plain film radiographs. She described feeling increasingly socially isolated as a teenager, largely due to her inability to participate in activities such as athletics and casual play, given chronic joint pain and severe fatigue within several minutes of activity onset. With progressive gait impairments causing her to limp, she began physical therapy as a young adult, allowing her to remain independent and to participate in academic, professional, and social pursuits. After graduating from college, she completed a 26month engagement with the Peace Corps in the developing world, remaining ambulatory with use of a cane. Due to progressive disease and functional deficits, she underwent bilateral hip replacement at age 29. Post-operatively, rehabilitation focused on retraining gait mechanics and increasing independence with household tasks. Setting: In-patient rehabilitation unit of a tertiary care hospital. Results: The patient made rapid progress with ambulation and functional tasks, and returned to full-time work 45 days after surgery. Discussion: Rehabilitation medicine played an integral role throughout the care of this patient by helping to maintain mobility and range of motion and through introduction of specific interventions such as teaching the use of a cane and retraining gait mechanics. Conclusions: MED patients face a variety of physical limitations that may have a marked impact on psychosocial functioning. Rehabilitation strategies play an integral role in management of MED and can help patients overcome significant physical barriers to social and professional integration. Level of Evidence: Level V Poster 221: Rehabilitation Considerations in a Patient With Klippel-Feil Syndrome: A Case Report Grace L. Maloney, MD (Marianjoy Rehab Hosp, Naperville, IL, United States), Anjum Sayyad, MD Disclosures: Grace Maloney: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old man with Klippel-Feil syndrome, morbid obesity (BMI 47.8), type II diabetes, and asthma