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Poster 339: Ptosis, Diagnosis, Neurosarcoidosis: A Case Report
Abstracts / PM R 9 (2017) S131-S290 Results: He had a 7 day second acute rehab admission after which his total ADL FIM score increased by 275% over his total ADL FIM score prior to cranioplasty. Discussion: Syndrome of the Trephined (SoT), or Sinking Skin Flap Syndrome (SSS) is a disorder of delayed neurological deterioration that occurs in patients with large cranial defects following craniectomy. It is not well-known amongst physiatrists but has implications for patient evaluation and management. Conclusions: SoT/SSS, is a potential complication of large craniectomies that can develop during the course of acute rehabilitation and may explain otherwise cryptogenic declines in function. Level of Evidence: Level V Poster 337: Medical and Functional Recovery in Neurologic Rehabilitation of Central Nervous System Toxoplasmosis: A Case Report Surein Theivakumar Disclosures: Surein Theivakumar: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 42-year-old healthy man presented to acute care hospital with 5-month history of progressive confusion, 25 pound weight loss, and night sweats. In addition, he reported decreased function in his left arm for 6 weeks. Upon workup, patient was found to have positive HIV-1 antibody and antigen as well as brain MRI consistent with toxoplasmosis. Cervical spine MRI showed large intramedullary mass from C1 to C7. Toxoplasmosis was confirmed with cerebral spinal fluid polymerase chain reaction as well as IgG antibody. For toxoplasmosis, patient was treated with Bactrim, steroid taper, and keppra. Patient was admitted to acute inpatient rehabilitation for 16-day course to improve functional deficits in cognition, activities of daily living, and ambulation. Upon arrival to acute inpatient rehabilitation, patient started on highly active antiretroviral therapy (HAART). EEG was performed showing no seizure like activity, thus keppra and steroids tapered off. In addition, patient continued on Bactrim, weekly azithromycin, and Genvoya for management of HIV treatment/prophylaxis and treatment of central nervous system toxoplasmosis throughout rehabilitation stay and upon discharge. Setting: Acute inpatient rehabilitation facility. Results: By the end of the 16-day rehabilitation course, patient showed significant improvement both medically and functionally. Repeat MRI of brain and cervical spine showed significant improvement of toxoplasmosis lesions. In addition, patient showed a large improvement in FIM scores when comparing initial and discharge therapy evaluations. The comparison of MRIs and FIM scores comparisons will be discussed. Discussion: There are a few case reports that also show good functional outcome of CNS toxoplasmosis when patients are undergoing appropriate medical treatment. However, more studies involving rehabilitation and medical courses are needed to support further support early neurologic rehabilitation. Conclusions: Neurologic rehabilitation provides promising medical and functional recovery for central nervous system toxoplasmosis, however more studies are required to further support early rehabilitation courses for these patients. Level of Evidence: Level V Poster 338: Brown-Sequard Syndrome due to Ischemia from a Vertebral Artery Occlusion: A Case Report Mayya Gorbal, MD (Albert Einstein Col of Med), Edward Alexeev, MD, Shayan Senthelal, MD, Maria A. Jouvin-Castro, MD Disclosures: Mayya Gorbal: I Have No Relevant Financial Relationships To Disclose
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Case/Program Description: A 42-year-old African-American man with a past medical history of recurrent anterior and posterior circulation cerebral infarcts and right subclavian vein occlusion who presented with sudden onset of right hemiplegia. Physical exam was notable for flaccid paralysis of the right upper and lower extremities and decreased sensation to pinprick and temperature on the left below the C4 sensory level, consistent with a right Brown-Sequard syndrome. MRI brain showed no acute infarcts. MRA of the head, neck and chest showed a new complete lack of flow within the right vertebral artery and thoracic vasculature ectasia with areas of aneurysm. MRI of the cervical spine without contrast was remarkable for intramedullary spinal cord signal abnormality from the level of C2 to C6. MRI of the cervical and thoracic spine with contrast showed edema compatible with spinal cord ischemia. Hypercoagulable, autoimmune and vasculitis workups were unrevealing and the patient remained hemiplegic on the right side. He was then discharged to acute inpatient rehabilitation for physical and functional optimization. Setting: Acute Inpatient Rehabilitation Facility. Results: The patient had a challenging neuromuscular rehabilitation course. He actively participated in a comprehensive therapy regimen and was only able to regain minimal strength of his right lower extremity at time of discharge while his right upper extremity remained plegic. Following discharge, he developed right sided spasticity managed with baclofen under the care of physiatrists. Discussion: Brown-Sequard syndrome is a spinal cord lesion characterized by ipsilateral weakness and loss of proprioception and contralateral loss of pain and temperature sensation. We present a case of this relatively uncommon condition manifesting in a patient with a medical history suggestive of a vasculopathy of unclear etiology. Conclusions: Vertebral artery occlusion can manifest in the setting of a diffuse vasculopathy and play a critical role in the development of spinal cord ischemia, resulting in decreased patient function. Level of Evidence: Level V Poster 339: Ptosis, Diagnosis, Neurosarcoidosis: A Case Report Brian P. Golden, DO (Nassau University Medical Center, East Meadow, NY, United States), Ketan Patel, Resident Physician, Yousaf Chowdhry, MD, Lyn D. Weiss, MD Disclosures: Brian Golden: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 25-year-old man presented to the emergency room with bilateral ptosis, generalized weakness and fatigue. He was discharged with no treatment. Three days later, the patient presented with progressively worsening symptoms and unsteady gait. He denied any recent travel or illnesses. On exam he was found to be extremely lethargic, had an ataxic gait, and cranial nerve palsies. An infectious etiology was initially ruled out, and the differential diagnosis was narrowed to myasthenia gravis (MG), GuillainBarre Syndrome (GBS), or multiple sclerosis (MS). He was started on bedside therapy, and his treatment course consisted of intravenous (IV) hydration, IV Immunoglobulin, and cholinesterase inhibitors. Setting: Tertiary care teaching hospital. Results: The CT head was negative, and lumbar puncture showed oligoclonal bands and elevated proteins in the cerebrospinal fluid (CSF). Magnetic resonance imaging (MRI) brain showed increased signal intensity in the brainstem, basal ganglia, and cortex. Electrodiagnostic testing (EDx), including repetitive nerve stimulation, needle electromyography, nerve conduction studies, and F waves were performed and were normal, concluding that there was no EDx evidence of GBS, MG, myopathy, or peripheral neuropathy. Discussion: IV steroids were started for suspected neurosarcoidosis as evidenced by bilateral cranial nerve palsies, high protein in CSF, and possible inflammation. The patient had significant improvement in symptoms and function after a trial of high dose steroids, further
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supporting the diagnosis. CT chest was ordered to evaluate for possible granulomatous lesions for future biopsy. Conclusions: Definitive diagnosis of neurosarcoidosis requires confirmation by biopsy, however, exclusion of other causes of neuropathy with EDx testing is also imperative. Early diagnosis is vital so the appropriate management can be started in a timely manner. Clinicians should be aware of this rare diagnosis in patients who present with unusual symptoms with negative workups. Level of Evidence: Level V Poster 340: Pancreatic Dysfunction as a Sequela of Autonomic Dysfunction in a Patient with Axonal Variant of Guillain-Barre Syndrome: A Case Report Peter D. Lee (New York Medical College (Metropolitan), White Plains, NY, USA), Radomir Kosanovic, MD, Haresh Sampathkumar, MD, Sumankumar Brahmbhatt, MD Disclosures: Peter Lee: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 30-year-old man with no significant past medical history admitted after severe ketoacidosis due to unknown substance consumption. Patient was managed with mechanical ventilation and he subsequently developed pneumonia and quadriparesis. Work up revealed diagnosis of Guillain-Barre syndrome. Patient received intravenous immunoglobulin. Electrodiagnostic study at a later date showed axonal sensorimotor polyneuropathy. His hospital course was also significant for cardiac arrests, respiratory and deglutory muscle weakness requiring tracheostomy and percutaneous endoscopic gastrostomy, severe autonomic dysfunction causing fluctuations in blood glucose and blood pressure, tachycardia, diarrhea, urinary retention, and decreased salivation. Setting: Acute Inpatient Rehabilitation. Results: After admission to acute inpatient rehabilitation gross blood glucose fluctuations despite stable feeding and insulin regimen, was most difficult to manage. Three months later his blood glucose levels stabilized along with other sequela of autonomic dysfunction. Discussion: To our knowledge, report of pancreatic dysfunction has not been reported in Guillain-Barre syndrome. The effect of autonomic nervous system dysfunction on the pancreas can be dangerous and life threatening. These patients would require very close monitoring of blood glucose. Prognosis of this condition is self-limiting. Conclusions: Clinicians should be alerted about the possibility of pancreatic dysfunction as a sequela of autonomic dysfunction in patients with axonal variant of Guillain-Barre syndrome. Level of Evidence: Level V Poster 341: Lower Trunk Brachial Plexus Injury Following Interscalene Block for Rotator Cuff Repair: A Case Report Diana L. Marchese Disclosures: Diana Marchese: I Have No Relevant Financial Relationships To Disclose Case/Program Description: MRI revealed full-thickness rotator cuff tear. Pre-surgical examination showed 4/5 strength with painful arc but no muscle atrophy, distal muscle weakness, or neurological symptoms. Prior to surgery, she had an uncomplicated, ultrasoundguided interscalene block with catheter placement. She underwent successful arthroscopic-guided rotator cuff repair. Setting: Tertiary Care Hospital. Results: Following her surgery, she complained of left wrist pain in the PACU. Orthopedics deemed her safe for discharge with the interscalene catheter. Two days later the patient removed her catheter at home per instructions without complication. Approximately 6 weeks
after surgery, she complained of residual numbness along the medial aspect of her forearm and 4th and 5th digits, and decreased grip strength with no flexion of the flexor digitorum profundus in her 4th and 5th digits. An NCS/EMG study revealed left brachial plexopathy, primarily affecting the lower trunk and ulnar nerve. Discussion: Brachial plexus injury is a rare but possible complication following shoulder surgery with an interscalene block. Her injury could have occurred during the block (less likely due to ultrasound guidance and painless injection), during positioning (traction has been known to cause brachial plexus injury, but this more commonly results in an upper not lower trunk injury) or sometime between catheter placement and removal (48 hours later). Conclusions: Brachial plexus injury, however rare, can occur with interscalene block despite ultrasound guidance, standard intra-operative positioning, and self-removal of the interscalene catheter Level of Evidence: Level V Poster 342: New Onset Upper Extremity Weakness in a Woman with Pre-Existing Paraplegia: A Case Report Geoffrey Henderson, MD (University of Pittsburgh Medical Center, Pittsburgh, PA, United States), Amanda L. Harrington, MD Disclosures: Geoffrey Henderson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient: A 42-year-old woman with T9 ASIA A paraplegia from a spinal cord injury that occurred in her midtwenties. Case Description: The patient, who has a history of depression and past inpatient psychiatric admission, presented with progressive left arm weakness. A few months prior, the patient had a fall from a stair glide resulting in left upper extremity myofascial pain but no motor changes. The patient underwent physical therapy and was noted to have progressive left upper extremity weakness to the point where she was unable to push her manual wheelchair. On presentation to the clinic, the patient’s left arm was non-functional and plegic. The patient did not appear distressed or even fazed by the weakness. She denied new trauma or systemic illness. Her acute on chronic pain was controlled with gabapentin, oxycodone, and cyclobenzaprine. On exam, the right upper extremity was normal. Left upper extremity strength was trace throughout with diminished light touch sensation in all dermatomes. Reflexes were intact bilaterally. Hoffman’s was negative. An EMG showed no evidence of neuropathic changes. Blood work was unremarkable. Diagnostic MRI of the cervical spine was negative for cervical pathology. Setting: Spinal cord injury clinic in a tertiary care hospital system. Results: The working diagnosis is conversion disorder and the patient has been referred to psychiatry for further evaluation. She continues to undergo physical therapy. Discussion: This is one of the first reported cases, to our knowledge, of possible conversion disorder in a patient with long-standing paraplegia from a spinal cord injury. Patients with conversion disorder should be treated with therapy and supportive treatment. Psychiatric evaluation may be beneficial. Conclusions: Conversion disorder should be considered in persons with chronic disability and new onset weakness which is not explained through diagnostic work-up. Level of Evidence: Level V Poster 343: Spinal Dural Arteriovenous Fistula-a Diagnostic Dilemma: A Case Report Alyssa Neph (University of Pittsburgh Medical Center, Pittsburgh, PA, USA), John A. Horton, MD Disclosures: Alyssa Neph: I Have No Relevant Financial Relationships To Disclose
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Case/Program Description: A 42-year-old African-American man with a past medical history of recurrent anterior and posterior circulation cerebral infarcts and right subclavian vein occlusion who presented with sudden onset of right hemiplegia. Physical exam was notable for flaccid paralysis of the right upper and lower extremities and decreased sensation to pinprick and temperature on the left below the C4 sensory level, consistent with a right Brown-Sequard syndrome. MRI brain showed no acute infarcts. MRA of the head, neck and chest showed a new complete lack of flow within the right vertebral artery and thoracic vasculature ectasia with areas of aneurysm. MRI of the cervical spine without contrast was remarkable for intramedullary spinal cord signal abnormality from the level of C2 to C6. MRI of the cervical and thoracic spine with contrast showed edema compatible with spinal cord ischemia. Hypercoagulable, autoimmune and vasculitis workups were unrevealing and the patient remained hemiplegic on the right side. He was then discharged to acute inpatient rehabilitation for physical and functional optimization. Setting: Acute Inpatient Rehabilitation Facility. Results: The patient had a challenging neuromuscular rehabilitation course. He actively participated in a comprehensive therapy regimen and was only able to regain minimal strength of his right lower extremity at time of discharge while his right upper extremity remained plegic. Following discharge, he developed right sided spasticity managed with baclofen under the care of physiatrists. Discussion: Brown-Sequard syndrome is a spinal cord lesion characterized by ipsilateral weakness and loss of proprioception and contralateral loss of pain and temperature sensation. We present a case of this relatively uncommon condition manifesting in a patient with a medical history suggestive of a vasculopathy of unclear etiology. Conclusions: Vertebral artery occlusion can manifest in the setting of a diffuse vasculopathy and play a critical role in the development of spinal cord ischemia, resulting in decreased patient function. Level of Evidence: Level V Poster 339: Ptosis, Diagnosis, Neurosarcoidosis: A Case Report Brian P. Golden, DO (Nassau University Medical Center, East Meadow, NY, United States), Ketan Patel, Resident Physician, Yousaf Chowdhry, MD, Lyn D. Weiss, MD Disclosures: Brian Golden: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 25-year-old man presented to the emergency room with bilateral ptosis, generalized weakness and fatigue. He was discharged with no treatment. Three days later, the patient presented with progressively worsening symptoms and unsteady gait. He denied any recent travel or illnesses. On exam he was found to be extremely lethargic, had an ataxic gait, and cranial nerve palsies. An infectious etiology was initially ruled out, and the differential diagnosis was narrowed to myasthenia gravis (MG), GuillainBarre Syndrome (GBS), or multiple sclerosis (MS). He was started on bedside therapy, and his treatment course consisted of intravenous (IV) hydration, IV Immunoglobulin, and cholinesterase inhibitors. Setting: Tertiary care teaching hospital. Results: The CT head was negative, and lumbar puncture showed oligoclonal bands and elevated proteins in the cerebrospinal fluid (CSF). Magnetic resonance imaging (MRI) brain showed increased signal intensity in the brainstem, basal ganglia, and cortex. Electrodiagnostic testing (EDx), including repetitive nerve stimulation, needle electromyography, nerve conduction studies, and F waves were performed and were normal, concluding that there was no EDx evidence of GBS, MG, myopathy, or peripheral neuropathy. Discussion: IV steroids were started for suspected neurosarcoidosis as evidenced by bilateral cranial nerve palsies, high protein in CSF, and possible inflammation. The patient had significant improvement in symptoms and function after a trial of high dose steroids, further
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supporting the diagnosis. CT chest was ordered to evaluate for possible granulomatous lesions for future biopsy. Conclusions: Definitive diagnosis of neurosarcoidosis requires confirmation by biopsy, however, exclusion of other causes of neuropathy with EDx testing is also imperative. Early diagnosis is vital so the appropriate management can be started in a timely manner. Clinicians should be aware of this rare diagnosis in patients who present with unusual symptoms with negative workups. Level of Evidence: Level V Poster 340: Pancreatic Dysfunction as a Sequela of Autonomic Dysfunction in a Patient with Axonal Variant of Guillain-Barre Syndrome: A Case Report Peter D. Lee (New York Medical College (Metropolitan), White Plains, NY, USA), Radomir Kosanovic, MD, Haresh Sampathkumar, MD, Sumankumar Brahmbhatt, MD Disclosures: Peter Lee: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 30-year-old man with no significant past medical history admitted after severe ketoacidosis due to unknown substance consumption. Patient was managed with mechanical ventilation and he subsequently developed pneumonia and quadriparesis. Work up revealed diagnosis of Guillain-Barre syndrome. Patient received intravenous immunoglobulin. Electrodiagnostic study at a later date showed axonal sensorimotor polyneuropathy. His hospital course was also significant for cardiac arrests, respiratory and deglutory muscle weakness requiring tracheostomy and percutaneous endoscopic gastrostomy, severe autonomic dysfunction causing fluctuations in blood glucose and blood pressure, tachycardia, diarrhea, urinary retention, and decreased salivation. Setting: Acute Inpatient Rehabilitation. Results: After admission to acute inpatient rehabilitation gross blood glucose fluctuations despite stable feeding and insulin regimen, was most difficult to manage. Three months later his blood glucose levels stabilized along with other sequela of autonomic dysfunction. Discussion: To our knowledge, report of pancreatic dysfunction has not been reported in Guillain-Barre syndrome. The effect of autonomic nervous system dysfunction on the pancreas can be dangerous and life threatening. These patients would require very close monitoring of blood glucose. Prognosis of this condition is self-limiting. Conclusions: Clinicians should be alerted about the possibility of pancreatic dysfunction as a sequela of autonomic dysfunction in patients with axonal variant of Guillain-Barre syndrome. Level of Evidence: Level V Poster 341: Lower Trunk Brachial Plexus Injury Following Interscalene Block for Rotator Cuff Repair: A Case Report Diana L. Marchese Disclosures: Diana Marchese: I Have No Relevant Financial Relationships To Disclose Case/Program Description: MRI revealed full-thickness rotator cuff tear. Pre-surgical examination showed 4/5 strength with painful arc but no muscle atrophy, distal muscle weakness, or neurological symptoms. Prior to surgery, she had an uncomplicated, ultrasoundguided interscalene block with catheter placement. She underwent successful arthroscopic-guided rotator cuff repair. Setting: Tertiary Care Hospital. Results: Following her surgery, she complained of left wrist pain in the PACU. Orthopedics deemed her safe for discharge with the interscalene catheter. Two days later the patient removed her catheter at home per instructions without complication. Approximately 6 weeks
after surgery, she complained of residual numbness along the medial aspect of her forearm and 4th and 5th digits, and decreased grip strength with no flexion of the flexor digitorum profundus in her 4th and 5th digits. An NCS/EMG study revealed left brachial plexopathy, primarily affecting the lower trunk and ulnar nerve. Discussion: Brachial plexus injury is a rare but possible complication following shoulder surgery with an interscalene block. Her injury could have occurred during the block (less likely due to ultrasound guidance and painless injection), during positioning (traction has been known to cause brachial plexus injury, but this more commonly results in an upper not lower trunk injury) or sometime between catheter placement and removal (48 hours later). Conclusions: Brachial plexus injury, however rare, can occur with interscalene block despite ultrasound guidance, standard intra-operative positioning, and self-removal of the interscalene catheter Level of Evidence: Level V Poster 342: New Onset Upper Extremity Weakness in a Woman with Pre-Existing Paraplegia: A Case Report Geoffrey Henderson, MD (University of Pittsburgh Medical Center, Pittsburgh, PA, United States), Amanda L. Harrington, MD Disclosures: Geoffrey Henderson: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient: A 42-year-old woman with T9 ASIA A paraplegia from a spinal cord injury that occurred in her midtwenties. Case Description: The patient, who has a history of depression and past inpatient psychiatric admission, presented with progressive left arm weakness. A few months prior, the patient had a fall from a stair glide resulting in left upper extremity myofascial pain but no motor changes. The patient underwent physical therapy and was noted to have progressive left upper extremity weakness to the point where she was unable to push her manual wheelchair. On presentation to the clinic, the patient’s left arm was non-functional and plegic. The patient did not appear distressed or even fazed by the weakness. She denied new trauma or systemic illness. Her acute on chronic pain was controlled with gabapentin, oxycodone, and cyclobenzaprine. On exam, the right upper extremity was normal. Left upper extremity strength was trace throughout with diminished light touch sensation in all dermatomes. Reflexes were intact bilaterally. Hoffman’s was negative. An EMG showed no evidence of neuropathic changes. Blood work was unremarkable. Diagnostic MRI of the cervical spine was negative for cervical pathology. Setting: Spinal cord injury clinic in a tertiary care hospital system. Results: The working diagnosis is conversion disorder and the patient has been referred to psychiatry for further evaluation. She continues to undergo physical therapy. Discussion: This is one of the first reported cases, to our knowledge, of possible conversion disorder in a patient with long-standing paraplegia from a spinal cord injury. Patients with conversion disorder should be treated with therapy and supportive treatment. Psychiatric evaluation may be beneficial. Conclusions: Conversion disorder should be considered in persons with chronic disability and new onset weakness which is not explained through diagnostic work-up. Level of Evidence: Level V Poster 343: Spinal Dural Arteriovenous Fistula-a Diagnostic Dilemma: A Case Report Alyssa Neph (University of Pittsburgh Medical Center, Pittsburgh, PA, USA), John A. Horton, MD Disclosures: Alyssa Neph: I Have No Relevant Financial Relationships To Disclose