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Poster 296: Acute Transverse Myelitis in a Patient Diagnosed With Herpes Simplex Virus Meningitis With a Known History of Myasthenia Gravis: A Case Report
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
Poster 296 Acute Transverse Myelitis in a Patient Diagnosed With Herpes Simplex Virus Meningitis With a Known History of Myasthenia Gravis: A Case Report. Gautam Kothari, DO (Sinai Hospital of Baltimore, Baltimore, MD). Disclosure: G. Kothari, None. Setting: Acute inpatient rehabilitation unit. Patient: A 64-year-old woman with a history significant for myasthenia gravis post thymectomy. Case Description: The patient was initially admitted with headache, fever, and malaise and subsequently diagnosed with aseptic meningitis. On hospital day 3, the patient complained of severe weakness, numbness, and intermittent burning, sharp pain involving her bilateral lower extremities, beginning at the ankles and radiating to the upper abdominal and mid thoracic area. Examination revealed mild hypertonicity and decreased strength and patellar hyperreflexia involving bilateral lower extremities, and decreased sensation to light touch and pinprick involving bilateral lower extremities extending to the mid-thoracic level. Magnetic resonance imaging with gadolinium of the thoracic spine revealed an abnormally increased T2 signal involving the spinal cord extending from T1-6, and an abnormal signal involving the spinal cord at T8 and T10. There was an increase in the size of the spinal cord at the level of these lesions. Lumbar puncture displayed elevated cerebrospinal fluid white blood cell count with a lymphocytic predominance. Polymerase chain reaction for herpes simplex virus was positive. Assessment/Results: A diagnosis of transverse myelitis was made, and the patient was admitted to acute inpatient rehabilitation. The patient was treated with intravenous steroids as well as gabapentin and tramadol for pain, and baclofen for spasticity. The patient’s symptoms as well as functional status improved throughout the course of her rehabilitation stay. Discussion: Clinicians should be aware of transverse myelitis as an unusual complication of herpes simplex virus (HSV) meningitis and should consider this complication in patients with HSV meningitis presenting with lower-extremity weakness and numbness, particularly in patients with other autoimmune dysfunctions, including myasthenia gravis. Conclusions: Rehabilitation should be implemented early in recovery to maximize the patient’s functional improvements. Key Words: Herpes simplex virus; Myasthenia gravis; Myelitis, transverse; Rehabilitation. Poster 297 Cardiovascular Responses During Ejaculation in Spinal Cord Injured and Able-Bodied Men. Andrei Krassioukov, MD, PhD (University of British Columbia, Vancouver, BC, Canada); Fre´de´rique Courtois, PhD; Marc Belanger, PhD. Disclosure: A. Krassioukov, Christopher Reeve Foundation; F. Courtois, Christopher Reeve Foundation; M. Belanger, Christopher Reeve Foundation. Objective: To evaluate the cardiovascular changes occurring during vibrostimulation for sperm retrieval procedures in men with spinal cord injury (SCI) and able-bodied controls. Design: Not provided. Setting: Not provided. Participants: 6 SCI men with chronic tetraplegia and 12 healthy control men volunteered for the study. The average age of SCI subjects was 36 and of controls, 29 years. Intervention: SCI participants were asked to use vibrator stimulation (Ferticare) to reach ejaculation and control participants were asked to masturbate to ejaculation. Main Outcome Measures: Continuous electrocardiography as well as systolic blood pressure (SBP) and diastolic blood pressure were recorded. All parameters were obtained at baseline, ejaculation, and every 2 minutes following ejaculation, for a total of 20 minutes postejaculation. Results: The resting SBP was lower in tetraplegic subjects than in controls (102⫾11.8mmHg vs
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127⫾9.7mmHg). Bradycardia at rest was noted in tetraplegics (69.5⫾14bpm). At ejaculation, there was a significant increase in SBP in the SCI group (36⫾9.5mmHg vs 5⫾5.3mmHg). In SCI subjects, RR intervals varied on average at baseline from .897 to .932ms, with noticeable prolongation with vibrator stimulation to 1.063ms. In ablebodied men, RR interval varied on average during baseline from .838 to .679ms, with .849ms at ejaculation. Cardiovascular parameters returned to the resting level very shortly after ejaculation in controls but not in SCI men. Conclusions: The ejaculation following vibrostimulation procedure in SCI men is accompanied by significant cardiovascular responses that are not evident in able-bodied men. Key Words: Cardiovascular system; Rehabilitation; Sexual and gender disorders; Spinal cord injuries. Poster 298 Tetraplegia Status Post Right Cerebellar Pontine Angle Tumor Removal Via Translabyrinthine Craniotomy and Excision: A Case Report. Arik Mizrachi, MD (UMDNJ-NEWARK, Springfield, NJ). Disclosure: A. Mizrachi, None. Setting: Inpatient spinal cord injury (SCI) unit. Patient: A 28-year old woman. Case Description: The patient awoke, 2 years ago, with bilateral arm and hand numbness. Subsequently, she underwent magnetic resonance imaging (MRI) and computed tomography (CT) scan of her head. The CT scan was negative, and MRI revealed a right vestibular schwannoma. She underwent a cyberknife treatment and a 6-month follow-up MRI revealed no reduction in the tumor. Over the next 2 years, the patient developed abnormal gait. She experienced a decrease in hearing and a new MRI revealed an increased mass of a cerebellar pontine angle tumor budding the brainstem and internal auditory canal. A discussion was held about the potential complications concerning the surgery. Assessment/Results: The patient decided to undergo a translabyrinthine right-sided craniotomy and excision of vestibular schwannoma. Postoperatively, the patient was in respiratory distress and had no voluntary movements in her extremities. She had numerous attempts at extubation and reintubation due to respiratory distress. She underwent tracheostomy. The patient’s neurologic exam revealed a C4 American Spinal Injury Association (ASIA) grade C tetraplegia. Discussion: The patient underwent a right-sided craniotomy with subsequent excision of a right vestibular schwannoma and postoperatively became a C4 ASIA grade C tetraplegic. Conclusions: There is a possibility of the tumor causing compression and subsequent injury; I feel most likely the injury was due to a lack of perfusion to the spinal cord, either intra- or postoperatively. The procedure of a craniotomy and subsequent tumor removal of any kind carries the risk of infection, hemorrhage, stroke, and hemodynamic instabilities, as well as SCI. Unfortunately in this case, one of the potential complications described to the patient occurred. Although a postoperative course of this nature is rare, it is important to illustrate the extreme risks of this kind of procedure, as they do occur. Key Words: Quadriplegia; Rehabilitation. Poster 299 Motion Analysis of Head and Neck While Wearing Football Equipment. Christine E. Norton, MS, ATC (Mayo Clinic, Jacksonville, FL); Michael D. Osborne, MD. Disclosure: C.E. Norton, None; M.D. Osborne, None. Objectives: To quantify the segmental motion of the cervical vertebrae using videofluoroscopy and to examine the relationship between the motion of C4 and C5 and the motion of the skull when football Arch Phys Med Rehabil Vol 88, September 2007
Poster 296 Acute Transverse Myelitis in a Patient Diagnosed With Herpes Simplex Virus Meningitis With a Known History of Myasthenia Gravis: A Case Report. Gautam Kothari, DO (Sinai Hospital of Baltimore, Baltimore, MD). Disclosure: G. Kothari, None. Setting: Acute inpatient rehabilitation unit. Patient: A 64-year-old woman with a history significant for myasthenia gravis post thymectomy. Case Description: The patient was initially admitted with headache, fever, and malaise and subsequently diagnosed with aseptic meningitis. On hospital day 3, the patient complained of severe weakness, numbness, and intermittent burning, sharp pain involving her bilateral lower extremities, beginning at the ankles and radiating to the upper abdominal and mid thoracic area. Examination revealed mild hypertonicity and decreased strength and patellar hyperreflexia involving bilateral lower extremities, and decreased sensation to light touch and pinprick involving bilateral lower extremities extending to the mid-thoracic level. Magnetic resonance imaging with gadolinium of the thoracic spine revealed an abnormally increased T2 signal involving the spinal cord extending from T1-6, and an abnormal signal involving the spinal cord at T8 and T10. There was an increase in the size of the spinal cord at the level of these lesions. Lumbar puncture displayed elevated cerebrospinal fluid white blood cell count with a lymphocytic predominance. Polymerase chain reaction for herpes simplex virus was positive. Assessment/Results: A diagnosis of transverse myelitis was made, and the patient was admitted to acute inpatient rehabilitation. The patient was treated with intravenous steroids as well as gabapentin and tramadol for pain, and baclofen for spasticity. The patient’s symptoms as well as functional status improved throughout the course of her rehabilitation stay. Discussion: Clinicians should be aware of transverse myelitis as an unusual complication of herpes simplex virus (HSV) meningitis and should consider this complication in patients with HSV meningitis presenting with lower-extremity weakness and numbness, particularly in patients with other autoimmune dysfunctions, including myasthenia gravis. Conclusions: Rehabilitation should be implemented early in recovery to maximize the patient’s functional improvements. Key Words: Herpes simplex virus; Myasthenia gravis; Myelitis, transverse; Rehabilitation. Poster 297 Cardiovascular Responses During Ejaculation in Spinal Cord Injured and Able-Bodied Men. Andrei Krassioukov, MD, PhD (University of British Columbia, Vancouver, BC, Canada); Fre´de´rique Courtois, PhD; Marc Belanger, PhD. Disclosure: A. Krassioukov, Christopher Reeve Foundation; F. Courtois, Christopher Reeve Foundation; M. Belanger, Christopher Reeve Foundation. Objective: To evaluate the cardiovascular changes occurring during vibrostimulation for sperm retrieval procedures in men with spinal cord injury (SCI) and able-bodied controls. Design: Not provided. Setting: Not provided. Participants: 6 SCI men with chronic tetraplegia and 12 healthy control men volunteered for the study. The average age of SCI subjects was 36 and of controls, 29 years. Intervention: SCI participants were asked to use vibrator stimulation (Ferticare) to reach ejaculation and control participants were asked to masturbate to ejaculation. Main Outcome Measures: Continuous electrocardiography as well as systolic blood pressure (SBP) and diastolic blood pressure were recorded. All parameters were obtained at baseline, ejaculation, and every 2 minutes following ejaculation, for a total of 20 minutes postejaculation. Results: The resting SBP was lower in tetraplegic subjects than in controls (102⫾11.8mmHg vs
E97
127⫾9.7mmHg). Bradycardia at rest was noted in tetraplegics (69.5⫾14bpm). At ejaculation, there was a significant increase in SBP in the SCI group (36⫾9.5mmHg vs 5⫾5.3mmHg). In SCI subjects, RR intervals varied on average at baseline from .897 to .932ms, with noticeable prolongation with vibrator stimulation to 1.063ms. In ablebodied men, RR interval varied on average during baseline from .838 to .679ms, with .849ms at ejaculation. Cardiovascular parameters returned to the resting level very shortly after ejaculation in controls but not in SCI men. Conclusions: The ejaculation following vibrostimulation procedure in SCI men is accompanied by significant cardiovascular responses that are not evident in able-bodied men. Key Words: Cardiovascular system; Rehabilitation; Sexual and gender disorders; Spinal cord injuries. Poster 298 Tetraplegia Status Post Right Cerebellar Pontine Angle Tumor Removal Via Translabyrinthine Craniotomy and Excision: A Case Report. Arik Mizrachi, MD (UMDNJ-NEWARK, Springfield, NJ). Disclosure: A. Mizrachi, None. Setting: Inpatient spinal cord injury (SCI) unit. Patient: A 28-year old woman. Case Description: The patient awoke, 2 years ago, with bilateral arm and hand numbness. Subsequently, she underwent magnetic resonance imaging (MRI) and computed tomography (CT) scan of her head. The CT scan was negative, and MRI revealed a right vestibular schwannoma. She underwent a cyberknife treatment and a 6-month follow-up MRI revealed no reduction in the tumor. Over the next 2 years, the patient developed abnormal gait. She experienced a decrease in hearing and a new MRI revealed an increased mass of a cerebellar pontine angle tumor budding the brainstem and internal auditory canal. A discussion was held about the potential complications concerning the surgery. Assessment/Results: The patient decided to undergo a translabyrinthine right-sided craniotomy and excision of vestibular schwannoma. Postoperatively, the patient was in respiratory distress and had no voluntary movements in her extremities. She had numerous attempts at extubation and reintubation due to respiratory distress. She underwent tracheostomy. The patient’s neurologic exam revealed a C4 American Spinal Injury Association (ASIA) grade C tetraplegia. Discussion: The patient underwent a right-sided craniotomy with subsequent excision of a right vestibular schwannoma and postoperatively became a C4 ASIA grade C tetraplegic. Conclusions: There is a possibility of the tumor causing compression and subsequent injury; I feel most likely the injury was due to a lack of perfusion to the spinal cord, either intra- or postoperatively. The procedure of a craniotomy and subsequent tumor removal of any kind carries the risk of infection, hemorrhage, stroke, and hemodynamic instabilities, as well as SCI. Unfortunately in this case, one of the potential complications described to the patient occurred. Although a postoperative course of this nature is rare, it is important to illustrate the extreme risks of this kind of procedure, as they do occur. Key Words: Quadriplegia; Rehabilitation. Poster 299 Motion Analysis of Head and Neck While Wearing Football Equipment. Christine E. Norton, MS, ATC (Mayo Clinic, Jacksonville, FL); Michael D. Osborne, MD. Disclosure: C.E. Norton, None; M.D. Osborne, None. Objectives: To quantify the segmental motion of the cervical vertebrae using videofluoroscopy and to examine the relationship between the motion of C4 and C5 and the motion of the skull when football Arch Phys Med Rehabil Vol 88, September 2007