Poster 401: An Incidental Finding of an Idiopathic Isolated Median Motor Neuropathy in an Asymptomatic Veteran: A Case Report

Abstracts / PM R 9 (2017) S131-S290 Poster 399: Acute Onset of Guillain-Barre Syndrome Secondary to Churgh-Strauss Syndrome: A Case Report Anthony Doss (Union, NJ, USA), Selorm Takyi, MD, Christine Greiss, DO, Derrick Eng, DO Disclosures: Anthony Doss: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient is a 57-year-old Caucasian man who presented to a community hospital with sudden onset of weakness in all extremities with pronounced right wrist and foot drop. Of note, the patient also had a history of long-standing, oral steroid dependent asthma. While admitted, a lung CT scan revealed a right lower lobe speculated mass with an adjacent 8 mm nodule. CT scan of abdomen and pelvis were unremarkable. CT guided lung biopsy revealed an inflammatory infiltrate with no evidence of malignancy. Lab work was remarkable for eosinophilia, positive P-ANCA and antimyeloperoxidase antibody. Thus, a diagnosis of Churgh-Strauss Syndrome was made, and the patient was started on methylprednisolone and cyclophosphamide therapy. He subsequently developed a rash of the bilateral lower extremities suspicious for vasculitis for which he underwent biopsy that was remarkable for demyelination. He was also noted to have significant improvement of his weakness after multiple intravenous immunoglobulin treatments. The patient was subsequently transferred to an acute inpatient rehabilitation unit where he showed persistent improvement of his muscle weakness. Setting: Community Hospital. Results: The patient’s muscle weakness improved with acute rehabilitation following intravenous immunoglobulin administration. Discussion: This is the first reported case, to our knowledge, of Guillain-Barre Syndrome secondary to Churgh-Strauss Syndrome. Conclusions: Acute onset of Guillain-Barre Syndrome is possible following any inflammatory state including Churgh-Strauss Syndrome. Level of Evidence: Level I Poster 400: Popliteus Rupture in Spinal Cord Injury Patient Presenting as Knee Effusion: A Case Report Eric S. Larsen (Thomas Jefferson University Hospital), Mendel Kupfer, MD Disclosures: Eric Larsen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 67-year-old man presents post aneurysm repair with post-operative paraplegia (T4 ASIA-C). Acute care complications included vocal cord paralysis and a small right Soleal thrombus for which an IVC filter was placed. He was admitted to an acute inpatient rehabilitation facility and 18 days into his stay, a new right knee effusion was noted on physical examination. X-rays were completed and showed cortical irregularity along the lateral margin of the tibial plateau raising concern for a segond fracture. Repeat right lower extremity ultrasound did not reveal a deep vein thrombosis. An MRI verified an acute popliteus disruption along with non-acute bilateral meniscus tears. Setting: Acute Inpatient Rehabilitation Hospital. Results: The patient developed an acute right knee effusion 18 days into his stay and while confounding factors such as a recent right soleal vein thrombus and bilateral meniscus tears may also cause edema that mimics these findings, an ultrasound no longer demonstrated the thrombus and the only acute findings included the lateral tibial avulsion with popliteus disruption. The popliteus internally rotates the tibia or externally rotate the femur based on position is utilized in knee flexion. This injury usually does not occur in isolation, but clinical exam and radiologic evidence support the diagnosis.

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Discussion: Knee effusions are a common entity seen across many medical specialties. Although spinal cord injury patients may develop these from most conditions that affect the general population, their unique condition may introduce risk to develop them. The injuries that cause knee effusions and their translation into spinal cord injury care should be reviewed and promote a discussion on injury prevention strategies. Conclusions: Our patient developed a knee effusion with evidence suggesting an acute injury of the popliteus muscle to be the inciting cause. The differential diagnoses were evaluated and potential mechanisms discussed to validate the diagnosis. Level of Evidence: Level V Poster 401: An Incidental Finding of an Idiopathic Isolated Median Motor Neuropathy in an Asymptomatic Veteran: A Case Report Lisanne C. Cruz, MD (Mt Sinai Hlth Sys, Brooklyn, New York, United States), Svetlana Ilizarov, MD Disclosures: Lisanne Cruz: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 34-year-old right handed man statuspost bilateral ulnar nerve transposition was referred for an electrodiagnostic study to evaluate ulnar nerves for long-term surgical outcome. Test demonstrated normal findings for bilateral ulnar nerves, however, an atypical isolated median motor neuropathy was identified in this young asymptomatic patient. Surgical treatment was avoided with close monitoring that showed continuous nerve recovery over a year period. Setting: Academic Physiatry Clinic. Results: The patient was a young, healthy military veteran. He denied hand paresthesias or weakness and the physical exam was negative for thenar atrophy. Phalen’s and tinnel’s were negative. The electrodiagnostic studies identified a rare median motor neuropathy with both axonal and demyelinating features suggestive of an isolated involvement of the motor branch of the median nerve. Left median motor nerve showed a significantly prolonged distal latency of 7.2 ms stimulating above and below the transcarpal ligament with reduced amplitude of 3.7 m. There was no evidence of denervation on needle exam of abductor policis brevis. Median sensory evaluation was normal as was the combined sensory index. Subsequent nerve conduction studies 3 months, and a year later showed gradual improvement in distal latency (5.9 ms) and normal amplitude of 7.8 Mv suggestive of a neuropraxic process below the transcarpal ligament. Discussion: The severity of carpal tunnel syndrome (CTS) is frequently assessed by a degree of motor nerve distal latency prolongation. In rare cases, absence of sensory involvement could be found and attributed to other etiologies (ganglion, fascia compression, etc) or anatomical variant rather than CTS. Conclusions: Rehabilitation physicians are uniquely equipped to diagnose and interpret rare neuropathies given their aptitude in electrodiagnostic studies. Their knowledge of clinical presentation and anatomical variants could guide other clinical decision making and often avoid unnecessary surgery. Level of Evidence: Level V Poster 402: Cerebral Amyloid Angiopathy in the Acute Rehabilitation Unit: A Case Series Atira H. Kaplan, MD (Albert Einstein Col of Med, Bronx, NY, United States), Maria A. Jouvin-Castro, MD, Gary N. Inwald, DO Disclosures: Atira Kaplan: I Have No Relevant Financial Relationships To Disclose