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Poster 383 Recurrent Anterior Talofibular Ligament Injury Treatment with Platelet Rich Plasma
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Abstracts / PM R 7 (2015) S83-S222
the midline L2-L4 region. MRI lumbar spine showed L3-L4 and L4-L5 interspinous ligament edema. Setting: Tertiary care academic medical center. Results or Clinical Course: Both patients were treated conservatively with rest, oral NSAIDs and a course of physical therapy with no improvement. Decision was made to perform interspinous ligament steroid injections to address ligament edema as a source of pain. Under ultrasound-guidance, betamethasone with 1% lidocaine was injected into bilateral L3-4 and L4-5 interspinous ligaments. Both patients reported significant improvement in symptoms and were able to resume their previous level of athletics. Discussion: To our knowledge, this is the first description of ultrasound-guided steroid injection to the interspinous ligament for the treatment of interspinous ligament injury in young female athletes. Interspinous ligament steroid injection, most often fluoroscopically guided, has been reported as a possible treatment for Baastrup’s disease. In these two cases, neither had findings of Baastrup’s disease, but their extension based pain could not be explained by any other radiographic findings. Of note, the spinous processes and high resistance interspinous ligaments restrict lumbar extension along with other soft tissue, facet joints and to some extent intervertebral discs. It is possible that an extension based mechanism of injury resulted in interspinous ligament edema and pain. Additionally, ultrasonography offered these young women a radiation free, diagnostic and therapeutic option. Conclusion: Ultrasound-guided steroid injection may be effective in treating young female athletes for interspinous ligament edema mediated back pain.
Poster 381 Pubic Body Stress Fracture in Pregnancy: A Case Report Sarah Hwang, MD, Megan Clark, MD (University of Missouri, Columbia, MO, United States) Disclosures: M. Clark: I Have No Relevant Financial Relationships To Disclose. Case Description: A 27-year-old G2 P0 woman, 25 weeks pregnant at the time of initial evaluation, who presented with a 2 week history of left hip and leg pain. She described pain with walking, turning in bed, and getting up from a seated position. Her pain improved slightly with rest and sitting. She noted that her leg would “give out” on her resulting in near falls. Physical examination was significant for an antalgic gait with tenderness to palpation of the left hip flexors, iliotibial band, and left greater trochanteric bursa. She had restricted internal and external rotation of the left hip, with increased pain with external rotation. Scours positive for pain in the left hip. Faber’s positive for left hip pain. Hop test was positive on the left. Setting: Women’s Health Rehabilitation Clinic. Results or Clinical Course: MRI of the pelvis was obtained and demonstrated findings typical of a left pubic body stress fracture. It was recommended that she use a walker for protected weight bearing, but the patient preferred to try crutches. Physical therapy was continued for core stabilization, soft tissue mobilization, flexibility, and use of assistive device for ambulation. Discussion: Pelvic stress fractures are typically seen in female runners and military recruits. Cases of pelvic stress fractures have been reported following pregnancy with excessive weight bearing activities without good pelvic and core stability, weakness of the pelvic stabilizers, or poor flexibility. To our knowledge there has only been one other report of pubic body fracture during pregnancy. The authors of that particular paper hypothesized an imbalance of the dorsal and abdominal muscles in conjunction with ligament laxity leading to stress fracture of the body of the pubis, however other etiologies such as transient osteoporosis of pregnancy have never been discussed. Treatment for this type of fracture in the peripartum period includes pain control, cold therapy to the area, rest, and
weight bearing restrictions/avoidance. Physical therapy can be utilized for soft tissue massage, joint mobilization, core stability, improved flexibility and proper use of walking aids. In this particular case, further workup for transient osteoporosis of pregnancy will be pursued postpartum. Conclusion: Stress fracture of the pubic body during pregnancy is a rare cause for hip pain.
Poster 382 Heterotopic Ossification of the Quadriceps Muscle Complicating Distal Femoral Traction with Pins: A Case Report Ramzi Ben-Youssef, MD (Keck Medical Center of USC, Los Angeles, CA, United States), Jennifer Tanaka, DPT, David Richards, DPT Disclosures: R. Ben-Youssef: I Have No Relevant Financial Relationships To Disclose. Case Description: A 59-year-old man status post auto vs. bike accident. He sustained closed head injury with subarachnoid hemorrhage, cervical and thoracic vertebral column injuries, pubic symphysis diastasis, right sacrum fracture, and left tibia open fracture. He was admitted to the ICU, developed ARDS and was on a ventilator for many weeks and had multiple pelvic and abdominal surgeries. His left tibia fracture was initially managed with 2 large-diameter traction pins inserted into the distal segment of the femur above the knee; he then had open reduction and internal fixation. Setting: Acute inpatient rehabilitation unit (ARU). Results or Clinical Course: The patient was admitted to ARU 2 months after trauma. He complained of pain is his left quadriceps muscle with limited knee range of motion. Clinical examination showed normal skin without inflammatory signs and found 2 non-tender solid masses 3x2 cm each at the distal anterior third of the left thigh with limited knee flexion (75 degrees). X-rays showed heterotopic ossification (HO) along and above the tracts of the traction pins. Discussion: Large-diameter pins inserted into the distal segment of the femur are frequently used for temporary skeletal traction in fractures of the lower leg when internal fixation has to be delayed. HO at the site of femoral traction pins is rarely reported. It is not clear if it is really rare, or it is frequently undiagnosed, particularly in the absence of pain and inflammatory signs. Our patient had pain and he was thin which facilitated the clinical diagnosis. Conclusion: HO complicating skeletal traction with large pins could potentially jeopardize function and quality of life. The diagnosis is crucial, and diligent care during pin placement and pharmacologic prophylaxis with indomethacin in high risk trauma patients may lower the risk of HO.
Poster 383 Recurrent Anterior Talofibular Ligament Injury Treatment with Platelet Rich Plasma Chane Price, MD (University of Miami, Miami, FL, United States), Michael K. Yamazaki, MD Disclosures: C. Price: I Have No Relevant Financial Relationships To Disclose. Case Description: A 42-year-old female, former gymnast presented to clinic with complaints of recurrent inversion ankle sprains that caused her to stop competing. She reported that her initial injury occurred when she was competing as a young teenager and that despite several trials of preventative measures she was unable to avoid recurrent injuries to the same ankle. She attempted physical therapy to restrengthen the ligament along with immobilizing the ankle for prolonged periods of time. She denies any injections for this chronic injury in the past. On physical examination there is laxity in the ATFL on anterior drawer testing compared to the opposite side. She did not have any gross swelling or discoloration during the time she was seen and she
Abstracts / PM R 7 (2015) S83-S222 reports that her most recent ankle sprain occurred approximately 3 weeks prior to her initial visit. Musculoskeletal ultrasound was used to evaluate the ATF ligaments bilaterally. The patient returned to clinic two weeks after her initial visit to have platelet rich plasma injected in to the area of interest using MSK ultrasound guidance. She was also given a CAM boot for which to wear for ambulation while out of bed and followed up 2 weeks, 4 weeks, and 3 months later. Setting: Outpatient Sports Clinic at Mount Sinai Hospital. Results or Clinical Course: After PRP was injected MSK ultrasound was used to evaluate the ATFL, it was found that the ligament not only regained its fibular texture but also became shorter decreasing anterior translocation during anterior drawer. Discussion: PRP is derived from autologous blood and plays a major role in the natural healing process of the body. In this case the ATFL showed increased laxity which likely contributed to the recurrent nature of the patient’s injury. PRP contains granules that stimulate angiogenesis, cell replication, and a variety of other processes needed to heal soft tissue injuries. This form of treatment appears to aid in the healing of chronic ligamentous injuries as evidenced by the return of the fibular texture of the ligament as well as the decreased length and laxity of the ligament seen on musculoskeletal ultrasound. Conclusion: Platelet rich plasma could play a vital role in the treatment of chronic and recurrent ligament injuries and should be further studied using similar techniques.
Poster 384 Unilateral Femoral Neuropathy after Childbirth in the Context of an Undiagnosed Underlying Peripheral Polyneuropathy: A Case Report Jason Pan, MD (Hospital of the University of Pennsylvania, Philadelphia, PA, United States), John M. Vasudevan, MD Disclosures: J. Pan: I Have No Relevant Financial Relationships To Disclose. Case Description: A 30-year-old female professional scuba diver presented with sudden-onset left leg weakness of three months duration, beginning immediately after midwife-assisted birth of her first child. The patient presented for electrodiagnostic testing (EMG/ NCS), referred from sports medicine clinic. Her symptoms were left leg weakness and numbness of the anteromedial thigh and leg. Her positioning for childbirth included four hours lying on her left side with hips flexed and externally rotated. Examination revealed 4/5 left hip flexion and knee extension, decreased sensation in a left femoral/ saphenous nerve distribution, and a decreased left patellar reflex. MRI indicated muscle edema in the distribution of the left femoral nerve anterior division. EMG/NCS revealed subacute femoral neuropathy with > 50% axon loss and denervation on needle exam. In addition, there was evidence for an underlying predominately demyelinating sensorimotor peripheral polyneuropathy affecting all limbs. Laboratory workup for her polyneuropathy was unremarkable, including protein electrophoresis (serum and urine), hemoglobin A1c, TSH, ESR, RPR, arsenic, lead, and mercury. Setting: Quaternary-care academic hospital clinic. Results or Clinical Course: After ten months of physical therapy, the patient tolerated lifting sixty pounds on a ladder, simulating climbing with diving equipment. EMG/NCS performed eleven months after the initial injury demonstrated significant reinnervation of the muscles supplied by the left femoral nerve. Discussion: Postpartum femoral neuropathy is a rare phenomenon. The mechanism of injury may be compression near the inguinal ligament with hip flexion, external rotation, and abduction. Risk factors include primiparity and prolonged second stage of labor. Symptoms resolve in > 90% of patients, typically within 2-6 months. Conclusion: Positioning may be a modifiable risk factor for postpartum femoral neuropathy, especially in prolonged labor. The underlying polyneuropathy in this patient may have predisposed her to nerve injury.
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Fortunately, even with significant axonal loss on initial electrodiagnostic testing, prognosis for return to full function is favorable.
PEDIATRICS Poster 385 Use of Calcitonin as Treatment for Osteochondritis Dissecans of the Elbow: A Case Report Kevin M. Berry, MD (Rutgers-NJMS/Kessler, Newark, NJ, United States), Jeffrey L. Cole, MD Disclosures: K. M. Berry: I Have No Relevant Financial Relationships To Disclose. Case Description: A 15-yr-old girl developed lateral right elbow pain following a tumbling injury. Initial physical examination findings showed mild-to-moderate pain and limited extension in her right elbow. Strength was 4/5 in right elbow extension, but otherwise 5/5 in upper and lower extremities. There was intact sensation and reflexes in all four extremities. The patient was diagnosed with osteochondritis dissecans of her right elbow, grade II, which was subsequently confirmed with MRI. She was started on daily ibuprofen and calcitonin for inflammatory and osseal pains, respectively, and on a physical therapy program of increasing intensity, which she continued for several months. Setting: Outpatient PM&R clinic. Results or Clinical Course: Subsequent outpatient visits demonstrated a decrease in her elbow pain and increase in her right elbow extension strength from 4/5 to 5/5. Repeat x-ray/MRI revealed fusion of her capitellum and previously separate osteochondral fragment, an improvement from grade II to grade Ib. Discussion: Conservative management of osteochondritis dissecans has been controversial to date and most patients with unstable lesions advance to surgery. To our knowledge, there have been no previously published cases of calcitonin as treatment for osteochondritis of the elbow. Conclusion: Calcitonin can be used as an effective nonoperative treatment for osteochondritis dissecans of the elbow.
Poster 386 Neurologic Manifestations of Mycoplasma Pneumoniae Infection in a Child: A Case Report Karthik Sabapathy, Osteopathic Medical Student III (Western University, Upland, CA, United States), Mike Decker, DO Disclosures: K. Sabapathy: I Have No Relevant Financial Relationships To Disclose. Case Description: A 23-month-old girl presented to the ED with two weeks history of upper respiratory infection. The mother reported that two days prior to admission, the patient fell out of bed, was unable to hold her bottle because of wrist weakness and was unable to walk without tripping. Upon evaluation, the patient was noted to have cough, mild wheezing, a slightly elevated temperature and mild neurologic deficits involving bilateral arms and the left lower extremity. Work up including a C-spine, MRI brain and lumbar puncture was negative. PCR for Rhinovirus and Enterovirus was negative, but positive for Mycoplasma pneumonia. Rehabilitation was consulted to determine if she was an appropriate candidate for acute interdisciplinary rehab. A more thorough neurologic examination was difficult to conduct due to the patient’s age/poor compliance, but did reveal a bilateral wrist drop and a foot drop on the left. Hoffman’s and Babinski signs were negative and reflexes were intact, except for triceps bilaterally. Setting: UCI Medical Center. Results or Clinical Course: During her hospitalization the patient received occupational and physical therapy as part of her overall medical treatment. Her strength, endurance and coordination all improved rapidly and she was discharged home with a regimen for outpatient PT and OT. Discussion: There is very scant literature on children presenting with neurologic manifestations of M. pneumonia infections. This case
Abstracts / PM R 7 (2015) S83-S222
the midline L2-L4 region. MRI lumbar spine showed L3-L4 and L4-L5 interspinous ligament edema. Setting: Tertiary care academic medical center. Results or Clinical Course: Both patients were treated conservatively with rest, oral NSAIDs and a course of physical therapy with no improvement. Decision was made to perform interspinous ligament steroid injections to address ligament edema as a source of pain. Under ultrasound-guidance, betamethasone with 1% lidocaine was injected into bilateral L3-4 and L4-5 interspinous ligaments. Both patients reported significant improvement in symptoms and were able to resume their previous level of athletics. Discussion: To our knowledge, this is the first description of ultrasound-guided steroid injection to the interspinous ligament for the treatment of interspinous ligament injury in young female athletes. Interspinous ligament steroid injection, most often fluoroscopically guided, has been reported as a possible treatment for Baastrup’s disease. In these two cases, neither had findings of Baastrup’s disease, but their extension based pain could not be explained by any other radiographic findings. Of note, the spinous processes and high resistance interspinous ligaments restrict lumbar extension along with other soft tissue, facet joints and to some extent intervertebral discs. It is possible that an extension based mechanism of injury resulted in interspinous ligament edema and pain. Additionally, ultrasonography offered these young women a radiation free, diagnostic and therapeutic option. Conclusion: Ultrasound-guided steroid injection may be effective in treating young female athletes for interspinous ligament edema mediated back pain.
Poster 381 Pubic Body Stress Fracture in Pregnancy: A Case Report Sarah Hwang, MD, Megan Clark, MD (University of Missouri, Columbia, MO, United States) Disclosures: M. Clark: I Have No Relevant Financial Relationships To Disclose. Case Description: A 27-year-old G2 P0 woman, 25 weeks pregnant at the time of initial evaluation, who presented with a 2 week history of left hip and leg pain. She described pain with walking, turning in bed, and getting up from a seated position. Her pain improved slightly with rest and sitting. She noted that her leg would “give out” on her resulting in near falls. Physical examination was significant for an antalgic gait with tenderness to palpation of the left hip flexors, iliotibial band, and left greater trochanteric bursa. She had restricted internal and external rotation of the left hip, with increased pain with external rotation. Scours positive for pain in the left hip. Faber’s positive for left hip pain. Hop test was positive on the left. Setting: Women’s Health Rehabilitation Clinic. Results or Clinical Course: MRI of the pelvis was obtained and demonstrated findings typical of a left pubic body stress fracture. It was recommended that she use a walker for protected weight bearing, but the patient preferred to try crutches. Physical therapy was continued for core stabilization, soft tissue mobilization, flexibility, and use of assistive device for ambulation. Discussion: Pelvic stress fractures are typically seen in female runners and military recruits. Cases of pelvic stress fractures have been reported following pregnancy with excessive weight bearing activities without good pelvic and core stability, weakness of the pelvic stabilizers, or poor flexibility. To our knowledge there has only been one other report of pubic body fracture during pregnancy. The authors of that particular paper hypothesized an imbalance of the dorsal and abdominal muscles in conjunction with ligament laxity leading to stress fracture of the body of the pubis, however other etiologies such as transient osteoporosis of pregnancy have never been discussed. Treatment for this type of fracture in the peripartum period includes pain control, cold therapy to the area, rest, and
weight bearing restrictions/avoidance. Physical therapy can be utilized for soft tissue massage, joint mobilization, core stability, improved flexibility and proper use of walking aids. In this particular case, further workup for transient osteoporosis of pregnancy will be pursued postpartum. Conclusion: Stress fracture of the pubic body during pregnancy is a rare cause for hip pain.
Poster 382 Heterotopic Ossification of the Quadriceps Muscle Complicating Distal Femoral Traction with Pins: A Case Report Ramzi Ben-Youssef, MD (Keck Medical Center of USC, Los Angeles, CA, United States), Jennifer Tanaka, DPT, David Richards, DPT Disclosures: R. Ben-Youssef: I Have No Relevant Financial Relationships To Disclose. Case Description: A 59-year-old man status post auto vs. bike accident. He sustained closed head injury with subarachnoid hemorrhage, cervical and thoracic vertebral column injuries, pubic symphysis diastasis, right sacrum fracture, and left tibia open fracture. He was admitted to the ICU, developed ARDS and was on a ventilator for many weeks and had multiple pelvic and abdominal surgeries. His left tibia fracture was initially managed with 2 large-diameter traction pins inserted into the distal segment of the femur above the knee; he then had open reduction and internal fixation. Setting: Acute inpatient rehabilitation unit (ARU). Results or Clinical Course: The patient was admitted to ARU 2 months after trauma. He complained of pain is his left quadriceps muscle with limited knee range of motion. Clinical examination showed normal skin without inflammatory signs and found 2 non-tender solid masses 3x2 cm each at the distal anterior third of the left thigh with limited knee flexion (75 degrees). X-rays showed heterotopic ossification (HO) along and above the tracts of the traction pins. Discussion: Large-diameter pins inserted into the distal segment of the femur are frequently used for temporary skeletal traction in fractures of the lower leg when internal fixation has to be delayed. HO at the site of femoral traction pins is rarely reported. It is not clear if it is really rare, or it is frequently undiagnosed, particularly in the absence of pain and inflammatory signs. Our patient had pain and he was thin which facilitated the clinical diagnosis. Conclusion: HO complicating skeletal traction with large pins could potentially jeopardize function and quality of life. The diagnosis is crucial, and diligent care during pin placement and pharmacologic prophylaxis with indomethacin in high risk trauma patients may lower the risk of HO.
Poster 383 Recurrent Anterior Talofibular Ligament Injury Treatment with Platelet Rich Plasma Chane Price, MD (University of Miami, Miami, FL, United States), Michael K. Yamazaki, MD Disclosures: C. Price: I Have No Relevant Financial Relationships To Disclose. Case Description: A 42-year-old female, former gymnast presented to clinic with complaints of recurrent inversion ankle sprains that caused her to stop competing. She reported that her initial injury occurred when she was competing as a young teenager and that despite several trials of preventative measures she was unable to avoid recurrent injuries to the same ankle. She attempted physical therapy to restrengthen the ligament along with immobilizing the ankle for prolonged periods of time. She denies any injections for this chronic injury in the past. On physical examination there is laxity in the ATFL on anterior drawer testing compared to the opposite side. She did not have any gross swelling or discoloration during the time she was seen and she
Abstracts / PM R 7 (2015) S83-S222 reports that her most recent ankle sprain occurred approximately 3 weeks prior to her initial visit. Musculoskeletal ultrasound was used to evaluate the ATF ligaments bilaterally. The patient returned to clinic two weeks after her initial visit to have platelet rich plasma injected in to the area of interest using MSK ultrasound guidance. She was also given a CAM boot for which to wear for ambulation while out of bed and followed up 2 weeks, 4 weeks, and 3 months later. Setting: Outpatient Sports Clinic at Mount Sinai Hospital. Results or Clinical Course: After PRP was injected MSK ultrasound was used to evaluate the ATFL, it was found that the ligament not only regained its fibular texture but also became shorter decreasing anterior translocation during anterior drawer. Discussion: PRP is derived from autologous blood and plays a major role in the natural healing process of the body. In this case the ATFL showed increased laxity which likely contributed to the recurrent nature of the patient’s injury. PRP contains granules that stimulate angiogenesis, cell replication, and a variety of other processes needed to heal soft tissue injuries. This form of treatment appears to aid in the healing of chronic ligamentous injuries as evidenced by the return of the fibular texture of the ligament as well as the decreased length and laxity of the ligament seen on musculoskeletal ultrasound. Conclusion: Platelet rich plasma could play a vital role in the treatment of chronic and recurrent ligament injuries and should be further studied using similar techniques.
Poster 384 Unilateral Femoral Neuropathy after Childbirth in the Context of an Undiagnosed Underlying Peripheral Polyneuropathy: A Case Report Jason Pan, MD (Hospital of the University of Pennsylvania, Philadelphia, PA, United States), John M. Vasudevan, MD Disclosures: J. Pan: I Have No Relevant Financial Relationships To Disclose. Case Description: A 30-year-old female professional scuba diver presented with sudden-onset left leg weakness of three months duration, beginning immediately after midwife-assisted birth of her first child. The patient presented for electrodiagnostic testing (EMG/ NCS), referred from sports medicine clinic. Her symptoms were left leg weakness and numbness of the anteromedial thigh and leg. Her positioning for childbirth included four hours lying on her left side with hips flexed and externally rotated. Examination revealed 4/5 left hip flexion and knee extension, decreased sensation in a left femoral/ saphenous nerve distribution, and a decreased left patellar reflex. MRI indicated muscle edema in the distribution of the left femoral nerve anterior division. EMG/NCS revealed subacute femoral neuropathy with > 50% axon loss and denervation on needle exam. In addition, there was evidence for an underlying predominately demyelinating sensorimotor peripheral polyneuropathy affecting all limbs. Laboratory workup for her polyneuropathy was unremarkable, including protein electrophoresis (serum and urine), hemoglobin A1c, TSH, ESR, RPR, arsenic, lead, and mercury. Setting: Quaternary-care academic hospital clinic. Results or Clinical Course: After ten months of physical therapy, the patient tolerated lifting sixty pounds on a ladder, simulating climbing with diving equipment. EMG/NCS performed eleven months after the initial injury demonstrated significant reinnervation of the muscles supplied by the left femoral nerve. Discussion: Postpartum femoral neuropathy is a rare phenomenon. The mechanism of injury may be compression near the inguinal ligament with hip flexion, external rotation, and abduction. Risk factors include primiparity and prolonged second stage of labor. Symptoms resolve in > 90% of patients, typically within 2-6 months. Conclusion: Positioning may be a modifiable risk factor for postpartum femoral neuropathy, especially in prolonged labor. The underlying polyneuropathy in this patient may have predisposed her to nerve injury.
S217
Fortunately, even with significant axonal loss on initial electrodiagnostic testing, prognosis for return to full function is favorable.
PEDIATRICS Poster 385 Use of Calcitonin as Treatment for Osteochondritis Dissecans of the Elbow: A Case Report Kevin M. Berry, MD (Rutgers-NJMS/Kessler, Newark, NJ, United States), Jeffrey L. Cole, MD Disclosures: K. M. Berry: I Have No Relevant Financial Relationships To Disclose. Case Description: A 15-yr-old girl developed lateral right elbow pain following a tumbling injury. Initial physical examination findings showed mild-to-moderate pain and limited extension in her right elbow. Strength was 4/5 in right elbow extension, but otherwise 5/5 in upper and lower extremities. There was intact sensation and reflexes in all four extremities. The patient was diagnosed with osteochondritis dissecans of her right elbow, grade II, which was subsequently confirmed with MRI. She was started on daily ibuprofen and calcitonin for inflammatory and osseal pains, respectively, and on a physical therapy program of increasing intensity, which she continued for several months. Setting: Outpatient PM&R clinic. Results or Clinical Course: Subsequent outpatient visits demonstrated a decrease in her elbow pain and increase in her right elbow extension strength from 4/5 to 5/5. Repeat x-ray/MRI revealed fusion of her capitellum and previously separate osteochondral fragment, an improvement from grade II to grade Ib. Discussion: Conservative management of osteochondritis dissecans has been controversial to date and most patients with unstable lesions advance to surgery. To our knowledge, there have been no previously published cases of calcitonin as treatment for osteochondritis of the elbow. Conclusion: Calcitonin can be used as an effective nonoperative treatment for osteochondritis dissecans of the elbow.
Poster 386 Neurologic Manifestations of Mycoplasma Pneumoniae Infection in a Child: A Case Report Karthik Sabapathy, Osteopathic Medical Student III (Western University, Upland, CA, United States), Mike Decker, DO Disclosures: K. Sabapathy: I Have No Relevant Financial Relationships To Disclose. Case Description: A 23-month-old girl presented to the ED with two weeks history of upper respiratory infection. The mother reported that two days prior to admission, the patient fell out of bed, was unable to hold her bottle because of wrist weakness and was unable to walk without tripping. Upon evaluation, the patient was noted to have cough, mild wheezing, a slightly elevated temperature and mild neurologic deficits involving bilateral arms and the left lower extremity. Work up including a C-spine, MRI brain and lumbar puncture was negative. PCR for Rhinovirus and Enterovirus was negative, but positive for Mycoplasma pneumonia. Rehabilitation was consulted to determine if she was an appropriate candidate for acute interdisciplinary rehab. A more thorough neurologic examination was difficult to conduct due to the patient’s age/poor compliance, but did reveal a bilateral wrist drop and a foot drop on the left. Hoffman’s and Babinski signs were negative and reflexes were intact, except for triceps bilaterally. Setting: UCI Medical Center. Results or Clinical Course: During her hospitalization the patient received occupational and physical therapy as part of her overall medical treatment. Her strength, endurance and coordination all improved rapidly and she was discharged home with a regimen for outpatient PT and OT. Discussion: There is very scant literature on children presenting with neurologic manifestations of M. pneumonia infections. This case