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Poster 241: Transverse Myelitis Associated with Hepatitis C: A Case Report
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Poster 240 The Successful Resolution of Chronic Diarrhea after the Administration of the Probiotic, Saccharomyces boulardii: A Case Report. Himabindu Reddy, MD (Medical College of Wisconsin/Milwaukee VA, Milwaukee, WI); Sadhana R. Bienzen, RD, MS; Kevin T. White, MD. Disclosures: H. Reddy, None. Patients or Programs: A 63-year-old man with T9 ASIA D paraplegia. Program Description: Transferred from an outside hospital, the patient presented with a 4-month history of chronic, watery, explosive diarrhea. Previous work-up which included qualitative fecal fat, salmonella, shigella, E coli OH 157, campylobacter, vibrio, giardia, WBC, ova and parasites, and norovirus were all negative. Colonoscopy did not show evidence of malignancy or inflammation. The patient was trialed on a lactose and gluten free diet which showed no change. Eventually, the patient was diagnosed with C. difficile colitis, toxin A, probably due to a course of antibiotics during the early part of his hospital stay. His diarrhea did not improve with oral vancomycin or metronidazole. The Gastroenterology service was consulted and the following work-up was found to be negative: Urine metanephrines, SPEP, gastrin, calcitonin, Sudan stain, immunoglobulins, and fecal leukocytes. Setting: Tertiary inpatient hospital. Results: The patient was started on Saccharomyces boulardii 250 mg 4 times a day, a probiotic yeast strain and his diarrhea resolved after 7 days. Discussion: The rationale for using probiotics is based on the assumption that they modify colonic microflora and counteract enteric pathogens. This yeast also has immunologic and anti-inflammatory effects. Of the at least eight clinical trials conducted using S. boulardii for the prevention of antibiotic-associated diarrhea (AAD), seven concluded that S. boulardii was an effective agent for the prevention of AAD. Conclusions: Overall, S. boulardii should be considered an early, safe intervention with few serious adverse effects in the treatment of chronic diarrhea. Keywords: Rehabilitation, Probiotics, Diarrhea.
Poster 241 Transverse Myelitis Associated with Hepatitis C: A Case Report. Galina Kolycheva, (Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY). Disclosures: G. Kolycheva, None. Patients or Programs: A 63-year-old woman with transverse myelitis. Program Description: The patient, a 63-year-old woman, complained on acute onset of mildly asymetric numbness and weakness in the bilateral lower limbs following a short episode (2-3 days) of upper abdominal discom-
POSTER PRESENTATIONS
fort.The patient’s medical history was unremarkable except 20⫹ year history of hepatitis C.MRI of the thoracic spine showed hyperintense signal with gadolinium enhancement in the spinal cord at T1-T5 levels. Brain MRI was normal. The test for neuromyelitis optica (NMO) Ig was positive.The evidence of optic neuritis which is one of the absolute criteria for Devic’s disease was not found. The patient was diagnosed with partial Devic’s disease. Over the course of 1 month, the patient developed the bladder incontinence. The patient received a course of intravenous steroids without positive results and was treated with plasmapheresis with some improvement in muscle strength and sensation to light touch/ pinprick. Two months later, the patient was re-admitted with worsening of lower extremities muscle weakness. The clinical picture and long proven history of HCV infection questioned the specificity of NMO antibodies in this case. Setting: Tertiary care hospital. Results: The intravenous steroid course failed to demonstrate clinical improvement. Some improvement in lower extremities muscle strength and greater improvement on MRI images were noted after treatment with plasmapheresis. Discussion: Four single report cases and a series of 7 patients describe an association between hepatitis C virus (HCV) infection and transverse myelopathy. The patients in those cases had recurrent myelopathy with motor, sensory, and bladder involvement, and multisegmental abnormalities on MRI of spine. Brain MRI was unremarkable. Patients had no visual symptoms. CSF analysis showed mild elevation of protein. HCV Ab and RNA were found in the serum/CSF. In one of the cases, similar to our case, the patient was positive for NMO antibodies. Conclusions: The NMO antibodies test may be less specific for diagnosis of Devic’s disease in patients with HCV infection. Considering that HCV infection is common, the differential diagnosis of transverse myelitis without visual manifestations needs to include HCV infection. Keywords: Rehabilitation, Transverse myelitis, Neuromyelitis optica, Hepatitis C.
Poster 242 Treatment Regimen Leading to Functional Improvement in Opsoclonus-Myoclonus Syndrome: Two Case Reports. Daniel Albrecht, MD (Ohio State University, Columbus, OH); Sharon K. McDowell, MD; Melissa Radawski, MD. Disclosures: D. Albrecht, None. Patients or Programs: Both patients received pharmacotherapy with clonazepam and IV methylprednisolone. In addition, these adult patients were treated with rituximab, an anti-CD20 monoclonal antibody, which reduces cerebrospinal fluid B-cell expansion, and has begun to be used in children with opsoclonus-myoclonus. These 2 patients were enrolled in a regimen of therapy which used gradually tapered body weights and weighted adaptive equipment to dampen the amplitude of the movement disorder and im-
Poster 240 The Successful Resolution of Chronic Diarrhea after the Administration of the Probiotic, Saccharomyces boulardii: A Case Report. Himabindu Reddy, MD (Medical College of Wisconsin/Milwaukee VA, Milwaukee, WI); Sadhana R. Bienzen, RD, MS; Kevin T. White, MD. Disclosures: H. Reddy, None. Patients or Programs: A 63-year-old man with T9 ASIA D paraplegia. Program Description: Transferred from an outside hospital, the patient presented with a 4-month history of chronic, watery, explosive diarrhea. Previous work-up which included qualitative fecal fat, salmonella, shigella, E coli OH 157, campylobacter, vibrio, giardia, WBC, ova and parasites, and norovirus were all negative. Colonoscopy did not show evidence of malignancy or inflammation. The patient was trialed on a lactose and gluten free diet which showed no change. Eventually, the patient was diagnosed with C. difficile colitis, toxin A, probably due to a course of antibiotics during the early part of his hospital stay. His diarrhea did not improve with oral vancomycin or metronidazole. The Gastroenterology service was consulted and the following work-up was found to be negative: Urine metanephrines, SPEP, gastrin, calcitonin, Sudan stain, immunoglobulins, and fecal leukocytes. Setting: Tertiary inpatient hospital. Results: The patient was started on Saccharomyces boulardii 250 mg 4 times a day, a probiotic yeast strain and his diarrhea resolved after 7 days. Discussion: The rationale for using probiotics is based on the assumption that they modify colonic microflora and counteract enteric pathogens. This yeast also has immunologic and anti-inflammatory effects. Of the at least eight clinical trials conducted using S. boulardii for the prevention of antibiotic-associated diarrhea (AAD), seven concluded that S. boulardii was an effective agent for the prevention of AAD. Conclusions: Overall, S. boulardii should be considered an early, safe intervention with few serious adverse effects in the treatment of chronic diarrhea. Keywords: Rehabilitation, Probiotics, Diarrhea.
Poster 241 Transverse Myelitis Associated with Hepatitis C: A Case Report. Galina Kolycheva, (Montefiore Medical Center/ Albert Einstein College of Medicine, Bronx, NY). Disclosures: G. Kolycheva, None. Patients or Programs: A 63-year-old woman with transverse myelitis. Program Description: The patient, a 63-year-old woman, complained on acute onset of mildly asymetric numbness and weakness in the bilateral lower limbs following a short episode (2-3 days) of upper abdominal discom-
POSTER PRESENTATIONS
fort.The patient’s medical history was unremarkable except 20⫹ year history of hepatitis C.MRI of the thoracic spine showed hyperintense signal with gadolinium enhancement in the spinal cord at T1-T5 levels. Brain MRI was normal. The test for neuromyelitis optica (NMO) Ig was positive.The evidence of optic neuritis which is one of the absolute criteria for Devic’s disease was not found. The patient was diagnosed with partial Devic’s disease. Over the course of 1 month, the patient developed the bladder incontinence. The patient received a course of intravenous steroids without positive results and was treated with plasmapheresis with some improvement in muscle strength and sensation to light touch/ pinprick. Two months later, the patient was re-admitted with worsening of lower extremities muscle weakness. The clinical picture and long proven history of HCV infection questioned the specificity of NMO antibodies in this case. Setting: Tertiary care hospital. Results: The intravenous steroid course failed to demonstrate clinical improvement. Some improvement in lower extremities muscle strength and greater improvement on MRI images were noted after treatment with plasmapheresis. Discussion: Four single report cases and a series of 7 patients describe an association between hepatitis C virus (HCV) infection and transverse myelopathy. The patients in those cases had recurrent myelopathy with motor, sensory, and bladder involvement, and multisegmental abnormalities on MRI of spine. Brain MRI was unremarkable. Patients had no visual symptoms. CSF analysis showed mild elevation of protein. HCV Ab and RNA were found in the serum/CSF. In one of the cases, similar to our case, the patient was positive for NMO antibodies. Conclusions: The NMO antibodies test may be less specific for diagnosis of Devic’s disease in patients with HCV infection. Considering that HCV infection is common, the differential diagnosis of transverse myelitis without visual manifestations needs to include HCV infection. Keywords: Rehabilitation, Transverse myelitis, Neuromyelitis optica, Hepatitis C.
Poster 242 Treatment Regimen Leading to Functional Improvement in Opsoclonus-Myoclonus Syndrome: Two Case Reports. Daniel Albrecht, MD (Ohio State University, Columbus, OH); Sharon K. McDowell, MD; Melissa Radawski, MD. Disclosures: D. Albrecht, None. Patients or Programs: Both patients received pharmacotherapy with clonazepam and IV methylprednisolone. In addition, these adult patients were treated with rituximab, an anti-CD20 monoclonal antibody, which reduces cerebrospinal fluid B-cell expansion, and has begun to be used in children with opsoclonus-myoclonus. These 2 patients were enrolled in a regimen of therapy which used gradually tapered body weights and weighted adaptive equipment to dampen the amplitude of the movement disorder and im-