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Poster 344 Upper Extremity Weakness Due to Bilateral Brachial Plexopathy from Guillain-Barre Syndrome in a Cancer Patient: A Case Report
Abstracts / PM R 8 (2016) S151-S332 completing comprehensive rehabilitation, including vestibular therapy, the patient was discharged home independent in ADLs and ambulating with a cane. One month later he presented with new-onset dysphagia, and worsening of left facial numbness and dizziness. A brain MRI confirmed acute left inferior cerebellar peduncle and lateral medullary infarct. Discussion: This patient initially presented with concern for occult central neurologic injury, but peripheral vertigo. We suspected left posterior cerebral circulation insufficiency including Anterior Inferior Cerebellar Artery (AICA). It was not until the second stroke that brain imaging confirmed clinical diagnosis. Conclusions: 1. Clinical evaluation remains the gold standard to diagnose stroke. 2. Patients with posterior circulation stroke might have vertigo of central or peripheral origin if the AICA is involved. Diagnosing uncompensated vestibular weakness, along with timely implementation of vestibular rehabilitation therapy has been proven to improve recovery and morbidity outcomes. Level of Evidence: Level V Poster 344 Upper Extremity Weakness Due to Bilateral Brachial Plexopathy from Guillain-Barre Syndrome in a Cancer Patient: A Case Report Sheetal Shroff, MD (Houston Methodist Hospital, Houston, TX, United States), Thomas Chai, MD, Girish S. Shroff, MD Disclosures: Sheetal Shroff: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 41-year-old man with oncologic history of leukemia presented with a 3-day history of progressive upper limb weakness, most prominent in the hands. On manual muscle testing, strength was 3/5 for wrist extension, finger abduction, and grip strength was markedly decreased. Sensation to light touch, pain, temperature were all reduced. The upper limbs were hyporeflexic. The patient’s pulmonary vital capacity was significantly reduced at 800 cc (normal > 4 L), prompting hospital admission and airway protection. Setting: Tertiary care hospital. Results: Cerebrospinal fluid (CSF) analysis revealed absence of white blood cells and elevation in protein level of 120 mg/dL (normal <40 mg/dL). CSF was negative for malignant cells, and polymerase chain testing for viral pathology was negative. Magnetic resonance imaging revealed enhancement of the bilateral brachial plexus. Electrodiagnostic studies demonstrated findings consistent with acute inflammatory demyelinating polyneuropathy and brachial plexopathy. Treatment measures included steroids, plasmapheresis, and intravenous immunoglobulin. Discussion: Bilateral brachial plexopathy is a rare condition rather, unilateral presentation is relatively more common and usually due to trauma or treatment sequelae (such as radiation therapy). Benign or malignant neoplastic processes and viral illness are also in the differential diagnoses. Guillain-Barre syndrome (GBS) is an acute polyneuropathy due to autoimmune dysfunction, resulting essentially in attack of peripheral nerve myelin sheaths. GBS is usually preceded by infection. Sensorimotor deficit and respiratory failure, among other symptoms, may occur. Diagnosis of GBS is clinical, but supported by findings on CSF analysis (albuminocytological dissociation), diagnostic imaging, and electrodiagnostic testing (particularly absent H-reflex and reduced sensory nerve action potentials in the upper limbs). Treatment for GBS includes Immunotherapy, attempting to reduce the autoimmune response. Conclusions: Bilateral upper limb weakness due to brachial plexopathy may be associated with viral illness, resulting in an autoimmune response. Level of Evidence: Level V
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Poster 345 Rehabilitation of Bickerstaff Brainstem Encephalitis: A Case Report Ray Chang, MD (Baylor College of Medicine, Houston, TX, United States), Manuel F. Mas, MD, Prathap J. Joseph, MD, Monica Verduzco-Gutierrez, MD Disclosures: Ray Chang: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 59-year-old man with no significant past medical history experienced a mild upper respiratory tract infection. Twelve days later, he developed progressive motor incoordination and diplopia. Upon arrival to the emergency room, he required mechanical ventilation due to respiratory failure. Laboratory workup pointed toward BBE based on cerebrospinal fluid findings and clinical picture. He received intravenous inmunoglobulins and plasmapheresis. However, despite being off sedation, he neither opened his eyes nor responded to stimuli. Three weeks into the coma, he spontaneously opened his eyes and began to follow verbal commands. He had profound generalized muscle weakness, lack of motor coordination, severe dysphagia and diplopia. He required total assistance for ambulation, transfers, and activities of daily living (ADLs). He began aggressive rehabilitation at the acute care facility and continued at an inpatient rehabilitation facility (IRF). Patient remained at IRF for two weeks and was then discharged home. Upon discharge, he was ambulating with a rolling walker and independent for most ADLs. Neuropsychological evaluation displayed intact cognitive and executive function. Setting: Inpatient Rehabilitation and Outpatient Clinic. Results: Continued outpatient therapy with subsequent follow up four months later revealed he improved to independence for ambulation, with mild lingering sequelae. Discussion: BBE is a rare inflammatory, demyelinating autoimmune disorder characterized by progressive ophthalmoplegia and ataxia, with features suggesting a central nervous system process. It overlaps with other similar conditions such as Miller Fischer Syndrome and Guillain-Barre Syndrome. Evidence of corticospinal tract abnormalities, a disturbed state of consciousness, or a significant brain-stem lesion on MRI or at autopsy can differentiate BBE from other similar diseases. Conclusions: Bickerstaff brainstem encephalitis is a potentially reversible syndrome which warrants aggressive rehabilitation and ancillary treatment to ensure good recovery. Level of Evidence: Level V Poster 346 Rehabilitation of Progressive Multifocal Leukoencephalopathy: A Case Report Brian T. Nguyen, MD (Temple University Hospital/Moss Rehabilitation, Gaithersburg, Maryland, United States), Arthur M. Gershkoff, MD, Cora H. Brown, MD, Alexander Feng, MD Disclosures: Brian Nguyen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 32-year-old woman, with history of HIV on Highly Active Antiretroviral Therapy (HAART), CD4+ Count 54, presented with 2-month course of right hemiparesis and aphasia. On neurological exam, she had right facial paresis, decreased right shoulder shrug, tongue deviation to the right, decreased light touch sensation over right face with right flaccid hemiplegia and expressive aphasia. Work-up showed CSF analysis positive for the JC virus, WBC 2, RBC 2, Glucose 46, Protein 18.6. Brain MRI revealed hyperintense signal involving the left cerebral hemisphere. The patient was diagnosed with progressive multifocal leukoencephalopathy (PML).
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Poster 345 Rehabilitation of Bickerstaff Brainstem Encephalitis: A Case Report Ray Chang, MD (Baylor College of Medicine, Houston, TX, United States), Manuel F. Mas, MD, Prathap J. Joseph, MD, Monica Verduzco-Gutierrez, MD Disclosures: Ray Chang: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 59-year-old man with no significant past medical history experienced a mild upper respiratory tract infection. Twelve days later, he developed progressive motor incoordination and diplopia. Upon arrival to the emergency room, he required mechanical ventilation due to respiratory failure. Laboratory workup pointed toward BBE based on cerebrospinal fluid findings and clinical picture. He received intravenous inmunoglobulins and plasmapheresis. However, despite being off sedation, he neither opened his eyes nor responded to stimuli. Three weeks into the coma, he spontaneously opened his eyes and began to follow verbal commands. He had profound generalized muscle weakness, lack of motor coordination, severe dysphagia and diplopia. He required total assistance for ambulation, transfers, and activities of daily living (ADLs). He began aggressive rehabilitation at the acute care facility and continued at an inpatient rehabilitation facility (IRF). Patient remained at IRF for two weeks and was then discharged home. Upon discharge, he was ambulating with a rolling walker and independent for most ADLs. Neuropsychological evaluation displayed intact cognitive and executive function. Setting: Inpatient Rehabilitation and Outpatient Clinic. Results: Continued outpatient therapy with subsequent follow up four months later revealed he improved to independence for ambulation, with mild lingering sequelae. Discussion: BBE is a rare inflammatory, demyelinating autoimmune disorder characterized by progressive ophthalmoplegia and ataxia, with features suggesting a central nervous system process. It overlaps with other similar conditions such as Miller Fischer Syndrome and Guillain-Barre Syndrome. Evidence of corticospinal tract abnormalities, a disturbed state of consciousness, or a significant brain-stem lesion on MRI or at autopsy can differentiate BBE from other similar diseases. Conclusions: Bickerstaff brainstem encephalitis is a potentially reversible syndrome which warrants aggressive rehabilitation and ancillary treatment to ensure good recovery. Level of Evidence: Level V Poster 346 Rehabilitation of Progressive Multifocal Leukoencephalopathy: A Case Report Brian T. Nguyen, MD (Temple University Hospital/Moss Rehabilitation, Gaithersburg, Maryland, United States), Arthur M. Gershkoff, MD, Cora H. Brown, MD, Alexander Feng, MD Disclosures: Brian Nguyen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 32-year-old woman, with history of HIV on Highly Active Antiretroviral Therapy (HAART), CD4+ Count 54, presented with 2-month course of right hemiparesis and aphasia. On neurological exam, she had right facial paresis, decreased right shoulder shrug, tongue deviation to the right, decreased light touch sensation over right face with right flaccid hemiplegia and expressive aphasia. Work-up showed CSF analysis positive for the JC virus, WBC 2, RBC 2, Glucose 46, Protein 18.6. Brain MRI revealed hyperintense signal involving the left cerebral hemisphere. The patient was diagnosed with progressive multifocal leukoencephalopathy (PML).