Poster 380: Progressive Proximal Muscle Weakness in a 61-Year-Old Man: A Case Report

Abstracts / PM R 9 (2017) S131-S290 Poster 380: Progressive Proximal Muscle Weakness in a 61-Year-Old Man: A Case Report Molly E. Schill, DO (Vidant Rehab Ctr/East Carolina Univ/Brod) Disclosures: Molly Schill: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 61-year-old man presented to his primary care doctor outpatient with proximal muscle weakness and was diagnosed with polymyalgia rheumatica, started on prednisone, and referred to neurology for further work-up. Electromyography (EMG) revealed irritability and fibrillation potentials with reduced recruitment patterns. He was diagnosed with polymyositis and continued on low dose prednisone 20 milligrams daily as he had improved to baseline. He presented one year later to the hospital with progressively worsening proximal muscle weakness, rendering him wheelchair bound, and dysphagia. Creatine kinase was elevated. Anti-Jo-1 antibody, signal recognition particle antibody, and thiopurine methyltransferase were negative and muscle biopsy was not done. He was treated with high dose steroids and azathioprine but had little functional improvement. Physiatry was consulted and he was admitted to inpatient rehabilitation. Setting: General Inpatient Rehabilitation Center. Results: On admission to rehabilitation, he was unable to stand independently and had a nasogastric tube in for nutrition. He worked intensively with physical therapy and occupational therapy for 3 weeks. By discharge, his hip flexor strength increased from 2/5 to 4/5 and his elbow flexion and extension strength increased from 2/5 to 4/5. He was ambulating 50 feet with contact guard assist. After working with speech therapy on dysphagia exercises and receiving neuromuscular electrical stimulation, he was able to transition to a regular diet. Discussion: Polymyositis is an idiopathic inflammatory myopathy that should be considered when patients present with proximal muscle weakness. Dysphagia occurs in about a third of severe cases. EMG may show increased insertional activity and spontaneous fibrillations. Treatment usually consists of steroids. Conclusions: The clinical course for polymyositis is very unpredictable in terms of improvement in function. Although pharmacologic therapy should be started immediately, initiating therapies with the patient early on in the course can hasten their recovery. Level of Evidence: Level V Poster 381: Incomplete Recovery of Post-Sternotomy Plexopathy: A Case Report Mariko Kubinec, MD (University of Louisville, Louisville, Kentucky, United States), David Haustein, MD, Brenton C. Bohlig, MD Disclosures: Mariko Kubinec: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 60-year-old woman reported decreased sensation in left digits four and five, and clumsiness / weakness of the left hand following a median sternotomy for open heart surgery. An electrodiagnostic study demonstrated spontaneous activity in the left first dorsal interosseous, left flexor carpi ulnaris, and left extensor digitorum communis that was originally interpreted as a left C8 radiculopathy. She continued to have left hand tingling, numbness, and weakness for seven years and was referred for repeat electrodiagnostic evaluation. Left arm sensory and motor nerve conduction studies were normal, but EMG demonstrated decreased recruitment of long duration, large amplitude potentials in the left extensor digitorum communis. Needle study was abbreviated due to bleeding. Setting: Academic VA Medical Center. Results: Combined with clinical history of sternotomy and initial EMG findings, this patient appears to have experienced sternotomy related

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plexopathy with denervation then reinnervation in the left lower trunk distribution affecting C8-innervated muscles. Discussion: The incidence of brachial plexus injury following open heart surgery ranges from 2% to 38%. Patients most commonly present with medial hand sensory complaints. Electrodiagnostics can confirm decreased ulnar SNAP and CMAP amplitudes and axonal loss in muscles innervated by the C8 nerve root. Prognosis is usually excellent with an overwhelming majority of patients making a full recovery within one month of surgery. Conclusions: This is an unusual case of incomplete recovery of lower trunk brachial plexopathy secondary to open heart surgery in which the lower trunk was re-innervated, but the patient continued to have sensory complaints seven years later. Level of Evidence: Level V Poster 382: Ischemic Stroke due to Pituitary Adenoma Occluding the Internal Carotid Artery: A Case Report Vincent Y. Ma, MD (VA Greater LA Hlth Care Sys/UCLA, Los Angeles, CA, United States), Mary Nasmyth, MD, David N. Alexander, MD Disclosures: Vincent Ma: I Have No Relevant Financial Relationships To Disclose Case/Program Description: LB is a 56-year-old right-handed man who presented with right occipital headache, confusion, left pronator drift, no motor deficits. MRI/MRA showed a complete occlusion of the right ICA from the carotid bifurcation as well as a large suprasellar mass identified as a non-functioning pituitary adenoma without apoplexy. He was started on levothyroxine with plans for elective trans-sphenoidal resection after sufficient stroke recovery. On Hospital Day 5 (HD-5), the patient felt unwell during a bowel movement and became unresponsive with right eye deviation and new left leg and arm weakness. Vitals were notable for BP 80/29 and heart rate of 37. The event was attributed to cerebral hypoperfusion secondary to a vasovagal episode. He was started on fludrocortisone and midodrine to maintain a target systolic blood pressure goal of 120160 mmHg. Setting: Acute rehabilitation hospital. Results: The patient had no further signs of stroke re-expression for the remainder of his 15-day rehabilitation course and was discharged at stand-by-assist levels for self-care and mobility. Discussion: Pituitary adenoma leading to ICA occlusion is exceedingly rare, with just 14 cases identified since 1952. Of those, 11 presented with cerebral ischemia. This case highlights the rare association between pituitary macroadenoma and ischemic stroke, linked by the internal carotid artery’s vulnerability to occlusion around the suprasellar region. The patient’s transient stroke re-expression due to an episode of hypotension after physical therapy both supports the occlusive etiology, and demonstrates the need for vigilance against cerebral hypoperfusion in managing and rehabilitating such patients, with appropriate interventions including mineralocorticoid therapy and liberalization of dietary salt restrictions. Conclusions: In the rare case of ischemic stroke due to pituitary adenoma, the risk of symptom progression due to hypotension must be carefully managed to prevent complications that may worsen symptoms and interfere with rehabilitation. Level of Evidence: Level V Poster 383: No Smiling Matter: An Unusual Presentation of Guillain Barre Syndrome Kadir J. Carruthers, BS (Univ Med Cntr of Pittsburgh), Mary Ann Miknevich, MD Disclosures: Kadir Carruthers: I Have No Relevant Financial Relationships To Disclose