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Poster 288 Rehabilitation of Severe Vitamin D Deficiency Secondary to Gastric Bypass Surgery
PM&R
Setting: Tertiary care hospital. Results: Diagnostic testing was consistent with an acute demyelinating process. A diagnosis of Guillain-Barré syndrome (AIDP) was made, and treatment was started with IVIG, followed by plasmapheresis. Both were repeated due to early relapse. Minimal benefit was noted after a second course of plasmapheresis, with benefit noted after prednisone administration. The patient again relapsed and required retreatment with plasmapheresis, starting cyclosporine, and increasing prednisone. The diagnosis was changed to relapsing remitting polyradiculoneuropathy (CIDP) associated with GVHD. Discussion: Peripheral nervous system complications have a reported association with GVHD, including inflammatory demyelinating polyneuropathies (IDP). The IDPs are usually preceded by flu-like symptoms. Most reported cases are related to bone marrow transplantation, with usually mild GVHD that required no immunosuppression, and diagnosed as AIDP; few CIDP cases are documented. Peripheral neuropathies after stem cell transplantation are uncommon, however, a small subset of patients can develop IDPs; little is known regarding the length of treatment and long-term outcomes. This patient’s presentation was atypical for CIDP in that his weakness was not symmetric throughout, and he did not have predominantly motor involvement. Conclusions: There are few reports of IDPs related to chronic GVHD after peripheral blood stem cell transplantation, and none regarding acute myelogenous leukemia, in the medical literature. Immunosuppression may need to be continued long term, if not indefinitely, although further study is needed.
Poster 287 Ataxia in an Patient With Alcoholism Confounding and Delaying the Diagnosis of Progressive Supranuclear Palsy. Susan DiStasio, DO (NYU-RUSK, New York, NY, United States); Jacqueline Beltran, DO, Owen Kieran. Disclosures: S. DiStasio, none. Patients or Programs: The patient is a 56-year-old African American woman with known alcoholism and who had multiple falls. Program Description: The patient is a 56-year-old woman who presented to the emergency department after experiencing a fall at home. The patient was evaluated with noncontrast head computed tomography to rule out an intracranial bleed; the computed tomography revealed no abnormality. Upon further questioning, the patient admitted to being an alcoholic, and her last drink was 1 day before admission. The patient was admitted for further workup due to profound ataxia. Setting: Acute inpatient tertiary hospital. Results: A chlordiazepoxide taper was initiated to prevent delirium tremens. As treatment was completed, a repeated physical examination was significant for continued ataxia, bilateral eyelid weakness, difficulty with downward gaze, Bell phenomenon, and a “procerus sign.” At this time, the diagnosis of progressive supranuclear palsy was contemplated. A magnetic resonance image of the brain as well as lumbar puncture excluded other possible etiologies. The patient was started on a physical and occupational therapy program as well as anti-Parkinson medications, with improvement in ambulation, decreased ataxia, and instituted strategies to alleviate impact of visual-spatial deficits.
Vol. 3, Iss. 10S1, 2011
S271
Discussion: Ataxia is a common symptom of many neurodegenerative disorders. It is important to consider all possible etiologies of ataxia and not to attribute ataxia as a common symptom in patients with alcoholism. In this case, the diagnosis of progressive supranuclear palsy may have been made earlier in the disease process, with the possibility of increasing her quality of life years before her presentation. Conclusions: The presence of ataxia in patients with alcoholism is quite common. However, this case serves to underscore the importance of assessing patients for other underlying disease processes that may cause ataxia so that correct diagnosis and treatment that can improve quality of life and overall patient safety can be delivered.
Poster 288 Rehabilitation of Severe Vitamin D Deficiency Secondary to Gastric Bypass Surgery. Melissa M. Guanche, MD (Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, United States); Christina V. Oleson, MD. Disclosures: M. M. Guanche, none. Patients or Programs: Case report and review of the literature. Program Description: A 31-year-old woman with a history of obesity and gastric bypass 15 weeks earlier presented to a tertiary care hospital with myalgias, muscle weakness and pain, and balance deficits. Fifteen weeks earlier, the patient had undergone Roux-en-Y gastric bypass surgery and had lost 78 lb over a 15-week period. Setting: Acute rehabilitation in a tertiary care hospital. Results: Metabolic workup demonstrated severe deficiency serum vitamin D25OH (5.1 ng/mL). Other metabolic indexes were unremarkable; magnetic resonance imaging of thoracic and lumbar spine demonstrated no fractures or cord compression, The most likely cause of her severe muscle weakness was proposed to be severe vitamin D deficiency. Rehabilitation measures were initiated with attention to energy conservation and pacing of resistive muscle activities to facilitate moderate independence. To correct the metabolic deficit, the patient received 50,000 units of ergocalciferol weekly. Discussion: A formalized program of rehabilitation for endurance, balance training, and strengthening along with nutritional optimization is paramount to the successful recovery of patients with profound vitamin D deficiency. A combination of physiatric and pharmacologic measures of pain management can assist with treatment of myalgias and adverse neuropathic sensations. Additional recognition of this disorder is needed both among practitioners performing this procedure and patients undergoing gastric bypass surgery, especially because vitamin D stores that exist before surgery can compensate for losses for several months after surgery, so symptoms often arise months later, which makes it harder to immediately recognize. Monitoring of the patient’s vitamin D level every 3 months as well other metabolic indexes (prealbumin, pyridoxine, iron levels) should be a part the comprehensive care plan in the months after rehabilitation. Conclusions: Correction of nutritional deficits along with formalized rehabilitation for weakness, balance deficits, and neuropathic findings can lead to the successful recovery of patients with severe vitamin D deficiency.
Setting: Tertiary care hospital. Results: Diagnostic testing was consistent with an acute demyelinating process. A diagnosis of Guillain-Barré syndrome (AIDP) was made, and treatment was started with IVIG, followed by plasmapheresis. Both were repeated due to early relapse. Minimal benefit was noted after a second course of plasmapheresis, with benefit noted after prednisone administration. The patient again relapsed and required retreatment with plasmapheresis, starting cyclosporine, and increasing prednisone. The diagnosis was changed to relapsing remitting polyradiculoneuropathy (CIDP) associated with GVHD. Discussion: Peripheral nervous system complications have a reported association with GVHD, including inflammatory demyelinating polyneuropathies (IDP). The IDPs are usually preceded by flu-like symptoms. Most reported cases are related to bone marrow transplantation, with usually mild GVHD that required no immunosuppression, and diagnosed as AIDP; few CIDP cases are documented. Peripheral neuropathies after stem cell transplantation are uncommon, however, a small subset of patients can develop IDPs; little is known regarding the length of treatment and long-term outcomes. This patient’s presentation was atypical for CIDP in that his weakness was not symmetric throughout, and he did not have predominantly motor involvement. Conclusions: There are few reports of IDPs related to chronic GVHD after peripheral blood stem cell transplantation, and none regarding acute myelogenous leukemia, in the medical literature. Immunosuppression may need to be continued long term, if not indefinitely, although further study is needed.
Poster 287 Ataxia in an Patient With Alcoholism Confounding and Delaying the Diagnosis of Progressive Supranuclear Palsy. Susan DiStasio, DO (NYU-RUSK, New York, NY, United States); Jacqueline Beltran, DO, Owen Kieran. Disclosures: S. DiStasio, none. Patients or Programs: The patient is a 56-year-old African American woman with known alcoholism and who had multiple falls. Program Description: The patient is a 56-year-old woman who presented to the emergency department after experiencing a fall at home. The patient was evaluated with noncontrast head computed tomography to rule out an intracranial bleed; the computed tomography revealed no abnormality. Upon further questioning, the patient admitted to being an alcoholic, and her last drink was 1 day before admission. The patient was admitted for further workup due to profound ataxia. Setting: Acute inpatient tertiary hospital. Results: A chlordiazepoxide taper was initiated to prevent delirium tremens. As treatment was completed, a repeated physical examination was significant for continued ataxia, bilateral eyelid weakness, difficulty with downward gaze, Bell phenomenon, and a “procerus sign.” At this time, the diagnosis of progressive supranuclear palsy was contemplated. A magnetic resonance image of the brain as well as lumbar puncture excluded other possible etiologies. The patient was started on a physical and occupational therapy program as well as anti-Parkinson medications, with improvement in ambulation, decreased ataxia, and instituted strategies to alleviate impact of visual-spatial deficits.
Vol. 3, Iss. 10S1, 2011
S271
Discussion: Ataxia is a common symptom of many neurodegenerative disorders. It is important to consider all possible etiologies of ataxia and not to attribute ataxia as a common symptom in patients with alcoholism. In this case, the diagnosis of progressive supranuclear palsy may have been made earlier in the disease process, with the possibility of increasing her quality of life years before her presentation. Conclusions: The presence of ataxia in patients with alcoholism is quite common. However, this case serves to underscore the importance of assessing patients for other underlying disease processes that may cause ataxia so that correct diagnosis and treatment that can improve quality of life and overall patient safety can be delivered.
Poster 288 Rehabilitation of Severe Vitamin D Deficiency Secondary to Gastric Bypass Surgery. Melissa M. Guanche, MD (Jefferson Medical College of Thomas Jefferson University, Philadelphia, PA, United States); Christina V. Oleson, MD. Disclosures: M. M. Guanche, none. Patients or Programs: Case report and review of the literature. Program Description: A 31-year-old woman with a history of obesity and gastric bypass 15 weeks earlier presented to a tertiary care hospital with myalgias, muscle weakness and pain, and balance deficits. Fifteen weeks earlier, the patient had undergone Roux-en-Y gastric bypass surgery and had lost 78 lb over a 15-week period. Setting: Acute rehabilitation in a tertiary care hospital. Results: Metabolic workup demonstrated severe deficiency serum vitamin D25OH (5.1 ng/mL). Other metabolic indexes were unremarkable; magnetic resonance imaging of thoracic and lumbar spine demonstrated no fractures or cord compression, The most likely cause of her severe muscle weakness was proposed to be severe vitamin D deficiency. Rehabilitation measures were initiated with attention to energy conservation and pacing of resistive muscle activities to facilitate moderate independence. To correct the metabolic deficit, the patient received 50,000 units of ergocalciferol weekly. Discussion: A formalized program of rehabilitation for endurance, balance training, and strengthening along with nutritional optimization is paramount to the successful recovery of patients with profound vitamin D deficiency. A combination of physiatric and pharmacologic measures of pain management can assist with treatment of myalgias and adverse neuropathic sensations. Additional recognition of this disorder is needed both among practitioners performing this procedure and patients undergoing gastric bypass surgery, especially because vitamin D stores that exist before surgery can compensate for losses for several months after surgery, so symptoms often arise months later, which makes it harder to immediately recognize. Monitoring of the patient’s vitamin D level every 3 months as well other metabolic indexes (prealbumin, pyridoxine, iron levels) should be a part the comprehensive care plan in the months after rehabilitation. Conclusions: Correction of nutritional deficits along with formalized rehabilitation for weakness, balance deficits, and neuropathic findings can lead to the successful recovery of patients with severe vitamin D deficiency.