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Poster 4 Methotrexate CNS Toxicity Improved with Dextromethorphan: Case Series
Abstracts / PM R 7 (2015) S83-S222 etiology varies. Once diagnosed, the PEG tube should be urgently removed as necrotizing fasciitis, peritonitis and sepsis can rapidly occur. Conclusion: Many patients are admitted to the rehabilitation unit after having undergone PEG tube placement. As a result, physiatrists should be aware of possible PEG complications. Although uncommon, buried bumper syndrome is a potentially fatal complication and physiatrists should have a high suspicion for this in any patient with abdominal pain after PEG placement.
Poster 4 Methotrexate CNS Toxicity Improved with Dextromethorphan: Case Series Joseph Rabi, MD (University of Chicago/Schwab Rehab, Chicago, IL, United States), Lauren Kremm, DO Disclosures: J. Rabi: I Have No Relevant Financial Relationships To Disclose. Case Description: 24-year-old man with leukemia undergoing consolidation therapy which consisted of intrathecal MTX presented with disorientation, slurry speech and weakness. MRI displayed diffusion restriction throughout cerebral white matter. DXM was given at 15mg QID for 28 days. At his initial consult he was mod to max assist with ADLs and mobility, and with completion of acute rehab he was mod I with ADLs, mobility, and cognition. 21-year-old man with T cell lymphoma undergoing consolidation therapy which consisted of intrathecal MTX presented with facial droop, hallucinations, and weakness. MRI displayed diffusion restriction in frontal white matter. DXM was given at 15mg QID for 28 days. His hospital course was complicated by agitation, dysautonomia, and seizures. At his initial consult he was max assist with ADLs and mobility. By completion of acute rehab he was mod I with ADLs and mobility and supervision with cognition. Program Description: Methotrexate Induced Leukoencephalopathy (MIL) is a complication that can occur in patients receiving intrathecal, -ventricular, or -venous MTX. Risks of MIL include elderly, CNS malignancy, cranial radiation and intra-thecal or -ventricular MTX administration. The incidence is not known. MIL typically occurs days to months after administration. We report 2 cases at our rehab hospital that both presented at mod to max assist for mobility and cognition and discharged at supervision level after dextromethorphan (DXM) administration and acute rehab. Setting: Inpatient Rehabilitation Hospital. Results or Clinical Course: Both patients improved functionally with DXM and acute rehab. Discussion: MTX can cause CNS toxicity after MTX administration. MTX disrupts the conversion of homocysteine (HC) to methionine causing a buildup of HC which is toxic to vascular endothelium and causes neurodegeneration. HC is an excitatory agonist of NMDA receptors. DXM is an NMDA antagonist that can counteract the role of HC. Both patients improved with DXM administration. In case 1, patient’s cognition, strength and speech improved to an independent level after DXM and acute rehab. In case 2, patient’s cognition, strength, and gait improved to an independent level after DXM and acute rehab. Conclusion: Future studies are needed to determine efficacy of DXM in MIL. DXM appears to be a promising therapy for patients with MIL and possibly non-TBI.
Poster 5 Recovery of an Injured Corticoreticular Pathway in a Patient with Pontine Hemorrhage: A Case Report Hanseon Kim (Asan Medical Center, Seoul, Korea (the Republic of)), In young Sung, PhD, MD Disclosures: H. Kim: I Have No Relevant Financial Relationships To Disclose.
S93
Case Description: A 53-year-old man underwent conservative treatment for management of spontaneous hemorrhage in the bilateral pontine tegmentum. Two weeks after onset, when he started rehabilitation, he showed mild quadriparesis with more severe proximal weakness and was not able to stand or walk independently. After four week’s rehabilitation, he had regained his ability to walk independently and showed good recovery of motor weakness. Setting: Tertiary care hospital Results or Clinical Course: On two-week DTT, discontinuation of the right CRP was observed at the midbrain level (fiber number: 340), and the left CRP was not reconstructed. On six-week DTT, the right CRP was extended to the right premotor cortex, and had become thicker (fiber number: 1076). In addition, transcallosal fibers originating from the right CRP descended below the corpus callosum in the left hemisphere. The left CRP ended at the midbrain level, although it was reconstructed on six-week DTT. Discussion: Although one study reported on recovery of an injured CRP in the affected hemisphere in a patient with a putaminal hemorrhage, this is the first study to demonstrate that patients with brain injury can regain walking ability with recovery of the injured CRPs. Conclusion: A patient with bilateral pontine hemorrhage who exhibited gait recovery by recovery of the injured CRPs. We believe that this is a mechanism for recovery of gait function in patients with bilateral pontine hemorrhage.
Poster 6 An Oxytocin Gene Polymorphism Affects Social Outcome after Traumatic Brain Injury Heather M. Ma, MD, MS (Rehabilitation Institute of Chicago, Chicago, IL, United States), Jordan Grafman, PhD, Aileen Chau, MA Disclosures: H. M. Ma: I Have No Relevant Financial Relationships To Disclose. Objective: To assess the effects of patient oxytocin gene polymorphisms on caregiver burden. Design: A prospective study of combat veterans with penetrating traumatic brain injury (pTBI) enrolled in Phases 2 and 3 of the Vietnam Head Injury Study (VHIS). Setting: Outpatient evaluation of American combat veterans with pTBI injured between 1967-1970. Questionnaires, including the Katz Adjustment Scale (KAS), were mailed to the patients’ primary caregivers in 1985-1986. Blood samples were collected during Phase 3 (2003-2006). Participants: 131 combat veterans with pTBI and their caregivers (completed the KAS in 1985-1986). Interventions: Not applicable Main Outcome Measures: KAS subscales: R1 measures psychiatric symptoms; R2 indicates how frequently subjects participate in 16 socially expected activities; R3 measures caregiver expectations of subject participation in R2 activities; R4 measures the frequency of subjects’ involvement in 23 leisure activities; R5 measures caregiver satisfaction with subject participation in R4 activities. Oxytocin single nucleotide polymorphisms tested in combat veterans with pTBI included rs7632287, rs53576, and rs2254298 (A to G), as well as rs1042778 (G to T). Results or Clinical Course: There was a significant difference in R2 between oxytocin rs7632287 AG (mean 34) and G (mean 38, P¼.011). Subjects with G (a polymorphism that is known to be associated with pair-bonding relationships) compared to the AG polymorphism participated significantly more in household activities. There was also a significant difference in R4 between oxytocin rs2254298 AG (mean 38) and G (mean 43, P¼.024). Subjects with the G polymorphism (associated with emotion and amygdala size) participated more in leisure activities. Having the A allele at either location did not significantly effect caregiver ratings on R2 or R4. None of the other KAS subscales were significantly affected by oxytocin gene expression.
Poster 4 Methotrexate CNS Toxicity Improved with Dextromethorphan: Case Series Joseph Rabi, MD (University of Chicago/Schwab Rehab, Chicago, IL, United States), Lauren Kremm, DO Disclosures: J. Rabi: I Have No Relevant Financial Relationships To Disclose. Case Description: 24-year-old man with leukemia undergoing consolidation therapy which consisted of intrathecal MTX presented with disorientation, slurry speech and weakness. MRI displayed diffusion restriction throughout cerebral white matter. DXM was given at 15mg QID for 28 days. At his initial consult he was mod to max assist with ADLs and mobility, and with completion of acute rehab he was mod I with ADLs, mobility, and cognition. 21-year-old man with T cell lymphoma undergoing consolidation therapy which consisted of intrathecal MTX presented with facial droop, hallucinations, and weakness. MRI displayed diffusion restriction in frontal white matter. DXM was given at 15mg QID for 28 days. His hospital course was complicated by agitation, dysautonomia, and seizures. At his initial consult he was max assist with ADLs and mobility. By completion of acute rehab he was mod I with ADLs and mobility and supervision with cognition. Program Description: Methotrexate Induced Leukoencephalopathy (MIL) is a complication that can occur in patients receiving intrathecal, -ventricular, or -venous MTX. Risks of MIL include elderly, CNS malignancy, cranial radiation and intra-thecal or -ventricular MTX administration. The incidence is not known. MIL typically occurs days to months after administration. We report 2 cases at our rehab hospital that both presented at mod to max assist for mobility and cognition and discharged at supervision level after dextromethorphan (DXM) administration and acute rehab. Setting: Inpatient Rehabilitation Hospital. Results or Clinical Course: Both patients improved functionally with DXM and acute rehab. Discussion: MTX can cause CNS toxicity after MTX administration. MTX disrupts the conversion of homocysteine (HC) to methionine causing a buildup of HC which is toxic to vascular endothelium and causes neurodegeneration. HC is an excitatory agonist of NMDA receptors. DXM is an NMDA antagonist that can counteract the role of HC. Both patients improved with DXM administration. In case 1, patient’s cognition, strength and speech improved to an independent level after DXM and acute rehab. In case 2, patient’s cognition, strength, and gait improved to an independent level after DXM and acute rehab. Conclusion: Future studies are needed to determine efficacy of DXM in MIL. DXM appears to be a promising therapy for patients with MIL and possibly non-TBI.
Poster 5 Recovery of an Injured Corticoreticular Pathway in a Patient with Pontine Hemorrhage: A Case Report Hanseon Kim (Asan Medical Center, Seoul, Korea (the Republic of)), In young Sung, PhD, MD Disclosures: H. Kim: I Have No Relevant Financial Relationships To Disclose.
S93
Case Description: A 53-year-old man underwent conservative treatment for management of spontaneous hemorrhage in the bilateral pontine tegmentum. Two weeks after onset, when he started rehabilitation, he showed mild quadriparesis with more severe proximal weakness and was not able to stand or walk independently. After four week’s rehabilitation, he had regained his ability to walk independently and showed good recovery of motor weakness. Setting: Tertiary care hospital Results or Clinical Course: On two-week DTT, discontinuation of the right CRP was observed at the midbrain level (fiber number: 340), and the left CRP was not reconstructed. On six-week DTT, the right CRP was extended to the right premotor cortex, and had become thicker (fiber number: 1076). In addition, transcallosal fibers originating from the right CRP descended below the corpus callosum in the left hemisphere. The left CRP ended at the midbrain level, although it was reconstructed on six-week DTT. Discussion: Although one study reported on recovery of an injured CRP in the affected hemisphere in a patient with a putaminal hemorrhage, this is the first study to demonstrate that patients with brain injury can regain walking ability with recovery of the injured CRPs. Conclusion: A patient with bilateral pontine hemorrhage who exhibited gait recovery by recovery of the injured CRPs. We believe that this is a mechanism for recovery of gait function in patients with bilateral pontine hemorrhage.
Poster 6 An Oxytocin Gene Polymorphism Affects Social Outcome after Traumatic Brain Injury Heather M. Ma, MD, MS (Rehabilitation Institute of Chicago, Chicago, IL, United States), Jordan Grafman, PhD, Aileen Chau, MA Disclosures: H. M. Ma: I Have No Relevant Financial Relationships To Disclose. Objective: To assess the effects of patient oxytocin gene polymorphisms on caregiver burden. Design: A prospective study of combat veterans with penetrating traumatic brain injury (pTBI) enrolled in Phases 2 and 3 of the Vietnam Head Injury Study (VHIS). Setting: Outpatient evaluation of American combat veterans with pTBI injured between 1967-1970. Questionnaires, including the Katz Adjustment Scale (KAS), were mailed to the patients’ primary caregivers in 1985-1986. Blood samples were collected during Phase 3 (2003-2006). Participants: 131 combat veterans with pTBI and their caregivers (completed the KAS in 1985-1986). Interventions: Not applicable Main Outcome Measures: KAS subscales: R1 measures psychiatric symptoms; R2 indicates how frequently subjects participate in 16 socially expected activities; R3 measures caregiver expectations of subject participation in R2 activities; R4 measures the frequency of subjects’ involvement in 23 leisure activities; R5 measures caregiver satisfaction with subject participation in R4 activities. Oxytocin single nucleotide polymorphisms tested in combat veterans with pTBI included rs7632287, rs53576, and rs2254298 (A to G), as well as rs1042778 (G to T). Results or Clinical Course: There was a significant difference in R2 between oxytocin rs7632287 AG (mean 34) and G (mean 38, P¼.011). Subjects with G (a polymorphism that is known to be associated with pair-bonding relationships) compared to the AG polymorphism participated significantly more in household activities. There was also a significant difference in R4 between oxytocin rs2254298 AG (mean 38) and G (mean 43, P¼.024). Subjects with the G polymorphism (associated with emotion and amygdala size) participated more in leisure activities. Having the A allele at either location did not significantly effect caregiver ratings on R2 or R4. None of the other KAS subscales were significantly affected by oxytocin gene expression.