Poster 222 Acute Onset Diffuse Proximal Muscle Weakness in Setting of Controlled Type 2 Diabetes Mellitus: A Case Report

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pharmacologic treatments (77.5%). Guidance modalities included electric stimulation and ultrasound (69.3%) or ultrasound only (27.3%). On average per procedure, 3.15 nerves were targeted and 10.95mL of phenol were used. Most commonly injected nerves included the obturator nerve (35.8%) and sciatic branches to hamstrings and adductor magnus (27.0%). Post PN assessment was recorded in 54.9% of encounters, in which 84.5% reported subjective benefit reported by physician, therapist, or patient. No procedure-related complications were reported. Postprocedure adverse events included pain (4.0%), swelling and inflammation (2.7%), dysesthesia (0.7%), and hypotension (0.7%). Conclusions: PN utilized for a variety of persons with spasticity resulted in a high rate of subjective benefit with limited occurrences of adverse events. Level of Evidence: Level III Poster 219 Carbidopa-Levodopa Improves Speech Apraxia after Hypoxic-Ischemic Brain Injury: A Case Report Benjamin Ingraham, DO (Rehabilitation Institute of Chicago, Chicago, IL, United States), David L. Ripley, MD, MS Disclosures: Benjamin Ingraham: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 40-year-old woman was admitted to an inpatient rehabilitation facility after developing hypoxic-ischemic encephalopathy secondary to acute hypoxemic respiratory failure. During her inpatient rehabilitation admission, she underwent magnetic resonance imaging of her brain that showed increased fluid attenuation inversion recovery signal involving the bilateral putamen. Speech therapy evaluation demonstrated moderate speech impairments, including fluctuations in intelligibility, slow rate of speech, effortful groping movements, inappropriate speech prosody, and vowel distortions. She was initially treated with carbidopa-levodopa 10-100 mg tablet twice per day. At that time, she was not taking any other stimulant medications. The dose was subsequently increased over three weeks to 25-100 mg tablet four times daily with one additional tablet in the morning and afternoon. This was combined with targeted speech therapy strategies, including oral spelling, over-exaggeration, over-pronunciation, and slow rate. After 4 weeks, she showed improved alternating motion rates and showed improved intelligibility from 25-50% at the conversational level to 70% intelligibility of speech across one session. Setting: Acute inpatient rehabilitation hospital. Results: After 6 months of combined treatment with carbidopa-levodopa and speech therapy interventions, she improved the consistency of her speech intelligibility with multisyllabic words and with conversational speech over consecutive sessions. She showed 80% accuracy of phonemes across multiple repetitions. Discussion: This case presents a patient with characteristic findings of speech apraxia and is the first reported case of speech apraxia secondary to HIE successfully treated with carbidopa-levodopa. Conclusions: Carbidopa-levodopa is an efficacious medication that should be considered for treatment of speech apraxia due to HIE. Level of Evidence: Level V Poster 221 Pregnancy Termination in a Female with Paraplegia: A Case Report Kate E. Delaney, MD (Spaulding Rehab Hospital/Harvard Medical School, Charlestown, MA, United States), Donna Huang, MD Disclosures: Kate Delaney: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 20-year-old female with T4 ASIA Impairment Scale C paraplegia from motor vehicle accident,

neurogenic bowel and bladder, spasticity, orthostatic hypotension, and frequent urinary tract infections (UTIs) presented to outpatient clinic with an unplanned pregnancy at 6 weeks gestation. A community provider recommended medical abortion at home to the patient, which raised concerns for spinal cord injury (SCI)specific complications including autonomic dysreflexia and inability to recognize complications of abortion such as uterine atony or retained products of conception due to impaired sensation. Setting: Outpatient clinic. Results: We recommended consultation with the family planning services at a nearby tertiary care center. The team opted for an operating room (OR) procedure with high-risk providers available and careful post-operative monitoring because of the concern that the patient may not recognize post-operative pain or complications. She had a dilatation and curettage at 7 weeks gestation and intrauterine device placement in the main OR without complication. Discussion: This is the first reported case, to our knowledge, of surgical termination of pregnancy in a patient with paraplegia. Patients with paraplegia are thought to be as likely to become pregnant as able-bodied counterparts, but have higher risk of complications of pregnancy, including increased risk of thromboembolic event, spasticity, UTIs, anemia, bladder incontinence, constipation, pressure ulcers, orthostatic hypotension, and difficulty of transfers. Complications of abortion in SCI patients include increased spasticity, autonomic dysreflexia, and decreased awareness of post-operative complications. Conclusions: Patients with paraplegia may require consultation with high-risk specialists for their obstetrics care, including for pregnancy termination. Surgical termination may be best considering the complications associated with home medical termination, including uterine atony or retained products of conception, which may not be recognized in patients with paraplegia. Additionally, pregnancy in patients with paraplegia requires thorough review of medications, consideration of thromboembolic prophylaxis, spasticity management, and ultimately, revisiting conversations about birth control options. Level of Evidence: Level V Poster 222 Acute Onset Diffuse Proximal Muscle Weakness in Setting of Controlled Type 2 Diabetes Mellitus: A Case Report Terry Mathew, MD (SUNY Downstate Medical Center, Brooklyn, NY, United States), Brian Pekkerman, DO, Getahun Kifle, MD Disclosures: Terry Mathew: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient was admitted 10 months ago to the medical intensive care unit (MICU) for diabetic ketoacidosis and subsequent newly diagnosed uncontrolled type 2 diabetes (T2D), with hemoglobin A1c (HbA1c) of 16.8%, confirmed with elevated fingerstick glucose measurements. No reported weakness at the time. On this admission, she complained of severe bilateral thigh pain, associated with difficulty standing from a seated position. She has mild sensory deficit at L5 level, right lower extremity greater than left. She has been compliant with insulin, as evidenced by improvement of HbA1c (5.8% 6 months after MICU presentation; currently 5.7%). She denied statin use, creatinine kinase normal, rheumatologic labs negative, no myoglobinuria, normal urine toxicology, HIV negative. Exam negative for ptosis, skin lesions, distal weakness or upper motor neuron signs. Exam positive for bilateral thigh atrophy and weakness, and proximal upper extremity weakness. CT head was unremarkable. MRI of cervical, thoracic, and lumbar spine showed a small cyst at T7 without interval change or

Abstracts / PM R 8 (2016) S151-S332 surgical candidacy. Lower extremity EMG demonstrated sensorimotor demyelinating and axonal polyneuropathy. Setting: Tertiary care hospital. Results: Three days after admission to acute rehabilitation, patient demonstrated increased strength and endurance. Patient able to ambulate at 7 days. Pain and glycemic control were managed. Clinical findings and improvement with conservative management demonstrates a likely diagnosis of diabetic amyotrophy. Discussion: This was an atypical presentation of diabetic amyotrophy. Weakness also involved bilateral scapulohumeral muscles, and patient had an acute presentation despite adequate glycemic control for 6 months. Conclusions: Glycemic control is not solely adequate in delaying or preventing the onset of diabetic amyotrophy. Level of Evidence: Level V Poster 223 Monomelic Peripheral Neuropathy after Exposure to Cold Weather in a Diplegic Cerebral Palsy Chong Tae Kim, MD, PhD (The Children’s Hospital of Philadelphia, Philadelphia, PA, United States) Disclosures: Chong Tae Kim: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient is a 17-year-old male with diplegic cerebral palsy (Gross Motor Functional Classification System), but a very active snow boarding athlete. He acutely, newly developed sensory loss and weakness of the right lower leg after seven hours of snow boarding practice at an outdoor slope in the last January. The exact temperature at that time was not obtainable, but reportedly very cold. He realized the symptoms developed two to three days after the practice. Three weeks after the symptom development, he was referred to the rehabilitation outpatient clinic. He denied any improvement of the symptoms at the clinic visit. Setting: Academic Children’s Hospital outpatient clinic. Results: Cognitive, speech-language, fine motor, and sphincter functions were normal as the baseline. Both pin prick and light touch sensation of the right lower leg were lost, but normal of the left side. The active flexions of the right ankle and foot were remarkably decreased compared to the left side. Bilateral ankle dorsiflexion was trace (baseline) and difficult to notice the difference. Ankle jerk was not obtainable on the right side. The compound muscle action potentials (CMAPs) of the tibial nerves (Rt/Lt) showed distal latencies 3.9/3.7 msec, conduction velocities 35.9/41 m/sec, and amplitudes 0.21/8.3 mV. The CMAPs of the peroneal nerves (Rt/Lt) showed distal latencies 5.3/4.8 msec, conduction velocities 40.2/40.6 m/sec below knee and 46/58 m/sec across the knee, respectively, and amplitudes 0.88/0.95 mV. The sensory nerve action potentials (SNAP)of the right sural and peroneal nerves were not elicited, but those of the left sural and superficial nerve were distal peak latencies 3.2 and 3.1 msec and amplitudes 8.3 and 5.3 microV, respectively. No conduction block was found. No abnormal spontaneous resting potentials were noticed of the right lower extremity with a monopolar needle electromyography. Magnetic resonance imaging study of the lumbosacral spine was negative for cord or root lesions. Anti-neutrophil cytoplasmic antibody (ANCA) test for rheumatic vasculitis was negative. Discussion: The findings of the nerve conduction study were consistent with acute axonal monomelic peripheral neuropathy presumably due to hypothermia. However, the needle electromyographic study did not show any abnormal resting potentials of the affected extremity muscles even three weeks after the symptom developed. Conclusions: We report a case of monomelic peripheral neuropathy presumably due to hypothermia with unusual electromyographic findings of remarkably decreased amplitudes of the motor and sensory

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nerves without abnormal resting potentials at the three weeks after neurological symptoms develop. Level of Evidence: Level IV Poster 224 Giant Cell Myocarditis Masked by Acute Inflammatory Demyelinating Polyneuropathy: A Case Report Jessalynn Adam, MD (Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, United States), Kristin Gustafson, DO Disclosures: Jessalynn Adam: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient: 42-year-old woman with acute inflammatory demyelinating polyneuropathy (AIDP) and giant cell myocarditis. Case Description: The patient first presented to the emergency department with dyspnea, dizziness, tingling in her arms, and profound weakness. She was hyponatremic, sodium of 103, and had profound sensory loss in stocking-glove distribution, with impaired proprioception, arreflexia, and pseudoathetosis. Mental status, cranial nerves, and cerebellar testing were normal. MRI brain and cervical spine were unremarkable. Lumbar puncture revealed acellular fluid, increased CSF protein, normal glucose, and no organisms or monoclonal bands. CSF paraneoplastic panel was negative. EMG showed absent sensory responses and decreased amplitude of motor responses. She was diagnosed with presumed AIDP, treated with IVIG, and improved somewhat. Of note, she had episodic chest pain in acute care but workup was unremarkable. While in rehab, she had severe orthostatic hypotension and persistent dyspnea despite normal oxygen saturations. After one week of rehab, she abruptly lost consciousness and seized. She was sent to the emergency department where she was noted to be in acute cardiogenic shock with native heart rate in the 30s, elevated troponins to 9.33, and severe biventricular failure due to complete non-perfusing heart block. She was placed on ECMO. Setting: Quaternary Academic Rehabilitation Hospital. Results: Cardiac biopsy revealed giant cell myocarditis. Discussion: Hyperacute onset of heart failure is a common presentation of giant cell myocarditis, however, this case is unusual as the AIDP may have obscured other symptoms and masked the diagnosis of giant cell myocarditis. Conclusions: Two thirds of patients with AIDP develop autonomic features, including postural hypotension, but sustained sinus tachycardia is the most common dysfunction. EKG is indicated in autonomic dysfunction with atypical cardiac responses, such as persistent dyspnea or hypotension with bradycardia. These symptoms should raise suspicion for other complications or diagnoses, and prompt further workup. Level of Evidence: Level V Poster 225 Bickerstaff’s Encephalitis with an Exemplary Recovery Following Rehabilitation: A Case Report Michael J. Irvine, DO (University of TX-UT Houston, Houston, Texas, United States), Paolo C. Mimbella, MD, Tomasz K. Podobinski, DO Disclosures: Michael Irvine: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 59-year-old man with no prior medical history who presented to the emergency department with rapidly progressing neurological symptoms. He had several days of flu like symptoms with sudden weakness, difficulty walking, and blurry vision prior to coming to the ED. He required intubation for airway protection and remained unresponsive for a period of 3 weeks. Based on serological testing and clinical findings, he was diagnosed with Bickerstaff’s encephalitis. He was treated with plasmapheresis and immunoglobulins and subsequently regained consciousness. The patient was medically stabilized, but he had tetraparesis, dysphagia, and