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Poster 344: Diverticular Associated Colitis After Gastric Tube Placement in a Hemorrhagic Stroke Patient with Severe Dysphagia: A Case Report
Abstracts / PM R 9 (2017) S131-S290 Case/Program Description: A 61-year-old woman with a history of chronic back pain and radiculopathy presented with acute onset bilateral lower extremity (BLE) numbness, weakness, and urinary retention. Exam revealed BLE paraparesis (right greater than left), positive left Babinski’s sign, and bilaterally decreased sensation to light touch below the L1 dermatome. MRI demonstrated spinal cord edema and enhancement suggestive of transverse myelitis from T6-T7 through the Conus Medullaris. CSF analysis showed pleocytosis with high IgG. Infectious workup was negative. She received IV steroids and plasmapheresis for suspected NMO transverse myelitis. Patient was discharged from inpatient rehabilitation without significant improvement in pain symptoms. She returned to the hospital 5 weeks after discharge with complaints of worsening abdominal pain, neuropathy, spasms, and BLE weakness. Exam was remarkable for worsening paraparesis with increased left lower extremity weakness and a T5 sensory level. Repeat MRI showed increased cord enhancement from T3 through the Conus Medullaris. Spinal angiogram demonstrated a dural AV fistula (DAVF) supplied by a medullary branch at the level of right L1. Setting: Acute Rehabilitation Setting. Results: Presumed venous hypertension was the cause of the patient’s myelopathy. She underwent resection of the DAVF by Neurosurgery. Post operatively; she had slight improvement in the degree of her BLE weakness, spasticity, and neuropathy. Discussion: Delayed diagnosis of DAVF is common given the rarity of the disease. Patients may present with intermittent weakness, bowel and bladder dysfunction, paresthesias, and erectile dysfunction, which are also common symptoms of myelopathy. MRI demonstrates spinal cord edema and can mimic transverse myelitis but flow voids may also be seen. A spinal angiogram is often needed for definitive diagnosis. Conclusions: Although DAVF are rare, they must be considered in a patient with progressive myelopathy because rapid diagnosis and surgical treatment is indicated for the best prognosis. Level of Evidence: Level V Poster 344: Diverticular Associated Colitis After Gastric Tube Placement in a Hemorrhagic Stroke Patient with Severe Dysphagia: A Case Report Andrew Y. Chang, MD (WA Univ/BJH/SLCH Consortium), Sindhu Jacob, MD Disclosures: Andrew Chang: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Patient with recent IPH and subsequent aphasia, right sided hemiparesis, and severe dysphagia was unable to tolerate a pureed diet. Decision was made to place a gastric tube due to poor oral intake and concern for possible aspiration. Following placement of gastric tube patient spent a week at the acute care facility for treatment of pneumonia. Patient was readmitted to rehab following completion of antibiotic regimen. Following re-admission to rehab patient reported having abdominal pain that became more persistent and severe. Physical exam revealed some tenderness to palpation around the gastric tube site however rest of the exam was benign. Patient was tolerating tube feeds with no residuals and complete blood count (CBC) and basic metabolic panel (BMP) were within normal limits. Vitals obtained during this period were within normal limits as well. Abdominal xray obtained revealed no acute pathology. Patient then developed diarrhea and persistent emesis at which point patient was transferred to the Emergency Department. Work-up revealed diverticulosis with transverse and descending colitis on CT. Stool samples were negative for Clostridium difficile. Setting: Inpatient Rehabilitation of a community-based, academic, tertiary care facility.
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Results: Patient’s gastric tube was revised to gastric jejunal tube and following revision repeat CT imaging revealed resolution of the colitis. Patient’s pain also improved. Discussion: This is the first reported case, to our knowledge, of diverticular-associated colitis following gastric tube placement. Conclusions: Many stroke patients come to inpatient rehabilitation centers with gastric tubes and those with diverticulosis however rare, can develop colitis. Level of Evidence: Level V Poster 346: Lance Adams Syndrome Mistaken for Status Epilepticus in an Anoxic Encephalopathy Patient: A Case Report Annamaria L. Dunn, MD (JFK Med Cntr), Alessandra Dunn, N/A Disclosures: Annamaria Dunn: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The case of a 56-year-old woman with a history of asthma suffered respiratory and cardiac arrest and developed constant myoclonic activity which was wrongly diagnosed as status epilepticus and denied rehabilitation. Setting: Acute care 7000 bed Level one Trauma/Comprehensive Stroke Center. Results: A consult was called on a patient by the palliative care team to discuss functional goals of care. The patient was a 55-year-old woman with severe asthma who suffered respiratory and cardiac arrest after being exposed to cleaning products in a highway rest-stop. There was prolonged CPR. At the time of the consult the patient had generalized myoclonus which was determined to be status epilepticus as a result of the severe hypoxic-ischemic incident. This diagnosis carried a poor prognosis. The patient was evaluated by the consulting PM&R team and determined to be following commands. A neurologist was called in and the diagnosis of Lance-Adams was made. This diagnosis had a good prognosis with treatment. The patient was accepted to an inpatient rehabilitation facility and was subsequently discharged home after an intensive program. Discussion: Patients who suffer a severe hypoxic-ischemic event with subsequent myoclonic movements are sometimes misdiagnosed as having status epilepticus and are not referred for rehabilitation. A thorough physiatric examination can determine if the patient is tracking and command following and hence allow the patient to receive the benefits of an intensive inpatient rehabilitation program. Lance Adams syndrome has a good prognosis for recovery. Conclusions: More attention needs to be paid to the patients with severe hypoxic/ischemic events with subsequent myoclonic activity. Level of Evidence: Level V Poster 347: Moyamoya Disease, Intracranial Hemorrhage vs Ischemic Infarction: A Case Series Stephanie Li (Moss Rehabilitation/Temple University, Philadelphia, PA, USA), Ning Cao, MD, Tariq Rajnarine, MD, Jennifer Yu, MD Disclosures: Stephanie Li: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Case 1: A 38-year-old Hispanic man with Moyamoya disease (MMD) diagnosed in 2015 and who underwent right superior temporal artery (STA) to middle cerebral artery (MCA) bypass in January 2016 was found down at home on July 2016. His CT head showed large intraventricular hemorrhages in the 3rd and 4th ventricles along with hydrocephalus. He received evacuation of a frontal hematoma, but continued to present neurological deficits including impaired executive functioning and apraxia. Case 2: A 43-year-old African-American woman with a history of stroke with right-hemiparesis presented with worsening right-sided weakness and dysarthria.
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Results: Patient’s gastric tube was revised to gastric jejunal tube and following revision repeat CT imaging revealed resolution of the colitis. Patient’s pain also improved. Discussion: This is the first reported case, to our knowledge, of diverticular-associated colitis following gastric tube placement. Conclusions: Many stroke patients come to inpatient rehabilitation centers with gastric tubes and those with diverticulosis however rare, can develop colitis. Level of Evidence: Level V Poster 346: Lance Adams Syndrome Mistaken for Status Epilepticus in an Anoxic Encephalopathy Patient: A Case Report Annamaria L. Dunn, MD (JFK Med Cntr), Alessandra Dunn, N/A Disclosures: Annamaria Dunn: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The case of a 56-year-old woman with a history of asthma suffered respiratory and cardiac arrest and developed constant myoclonic activity which was wrongly diagnosed as status epilepticus and denied rehabilitation. Setting: Acute care 7000 bed Level one Trauma/Comprehensive Stroke Center. Results: A consult was called on a patient by the palliative care team to discuss functional goals of care. The patient was a 55-year-old woman with severe asthma who suffered respiratory and cardiac arrest after being exposed to cleaning products in a highway rest-stop. There was prolonged CPR. At the time of the consult the patient had generalized myoclonus which was determined to be status epilepticus as a result of the severe hypoxic-ischemic incident. This diagnosis carried a poor prognosis. The patient was evaluated by the consulting PM&R team and determined to be following commands. A neurologist was called in and the diagnosis of Lance-Adams was made. This diagnosis had a good prognosis with treatment. The patient was accepted to an inpatient rehabilitation facility and was subsequently discharged home after an intensive program. Discussion: Patients who suffer a severe hypoxic-ischemic event with subsequent myoclonic movements are sometimes misdiagnosed as having status epilepticus and are not referred for rehabilitation. A thorough physiatric examination can determine if the patient is tracking and command following and hence allow the patient to receive the benefits of an intensive inpatient rehabilitation program. Lance Adams syndrome has a good prognosis for recovery. Conclusions: More attention needs to be paid to the patients with severe hypoxic/ischemic events with subsequent myoclonic activity. Level of Evidence: Level V Poster 347: Moyamoya Disease, Intracranial Hemorrhage vs Ischemic Infarction: A Case Series Stephanie Li (Moss Rehabilitation/Temple University, Philadelphia, PA, USA), Ning Cao, MD, Tariq Rajnarine, MD, Jennifer Yu, MD Disclosures: Stephanie Li: I Have No Relevant Financial Relationships To Disclose Case/Program Description: Case 1: A 38-year-old Hispanic man with Moyamoya disease (MMD) diagnosed in 2015 and who underwent right superior temporal artery (STA) to middle cerebral artery (MCA) bypass in January 2016 was found down at home on July 2016. His CT head showed large intraventricular hemorrhages in the 3rd and 4th ventricles along with hydrocephalus. He received evacuation of a frontal hematoma, but continued to present neurological deficits including impaired executive functioning and apraxia. Case 2: A 43-year-old African-American woman with a history of stroke with right-hemiparesis presented with worsening right-sided weakness and dysarthria.