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Poster 52 Acute Hallucinosis Related to Amantadine Use in the Setting of Traumatic Brain Injury: A Case Report
S178
Abstracts / PM R 8 (2016) S151-S332
Poster 51 Sleep Quality and Functional Outcome Measures, an Ongoing Prospective IRB Study Mohammad Aalai, MD (Brooklyn, NY, United States), Raj D. Murthy, MD, MPH, Todd R. Lefkowitz, DO, Nnabugo D. Ozurumba, MD Disclosures: Mohammad Aalai: I Have No Relevant Financial Relationships To Disclose Objective: To track sleep quality in an Inpatient Rehabilitation Facility (IRF) setting using standardized survey tools and correlate to functional outcome measures. Design: Prospective IRB study. Setting: Inner city Acute IRF serving patients of low socioeconomic status. Participants: 32 subjects of all diagnoses. Interventions: Not applicable. Main Outcome Measures: Pittsburgh Sleep Quality Index(PSQI), Functional Independence Measure(FIM), Insomnia Symptom Questionnaire (ISQ). Results: Of the 32 patients studied so far, 88% had poor premorbid sleep (PPS) defined as PSQI>5 (sensitivity 89.6% and specificity 86.5%). The average PSQI score was 9.4. 30% had no change in cognitive FIM scores from admission to discharge. 64% did not achieve the region adjusted average (RAA) cognitive FIM change. 55% of the PPS patients had no change in sleep quality at discharge and 21% had a decrement. Average length of stay (LOS) was 16 days. 93% of the patients did not achieve region adjusted mean length of stay efficiency. 69% of patients did not achieve the RAA total FIM gain. Patients deemed to have insomnia by ISQ had higher than average PSQI scores. Conclusions: Patients in an urban IRF setting have poor premorbid sleep quality due to various socioeconomic and psychosocial factors. Patients in this study with higher PSQI scores prior to admission to IRF did not achieve average FIM gains. Further screening and quality control measures are necessary to ensure those identified as high risk patients maximize their outcomes during IRF stay. This may include environmental alterations as well as changes in therapy and nursing schedule. Level of Evidence: Level I Poster 52 Acute Hallucinosis Related to Amantadine Use in the Setting of Traumatic Brain Injury: A Case Report Brett Schoen, MD (University of Kansas Medical Center, Merriam, KS, United States), Sarah Eickmeyer, MD Disclosures: Brett Schoen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was admitted to the acute rehabilitation unit following traumatic brain injury with subarachnoid hemorrhage (SAH). On day 2 she was started on amantadine 100 mg twice daily (BID) for cognitive impairment and mild agitation. This dose was tolerated for 4 days with only mild improvement of symptoms, so the dose was increased to 200 mg BID. On day 2 of the increased dose she began to report visual hallucinations, became disoriented, and by day 3 was unable to participate in therapy. Medical workup for acute encephalopathy revealed no apparent metabolic or infectious process. Her encephalopathy persisted, therefore amantadine was discontinued after 5 days of the increased dose. 2 days later she suffered an acute increase in the frequency of hallucinations and more severe agitation. Repeat head CT revealed no acute change with respect to her known SAH. Psychiatry was consulted and found that the patient had a remote history of visual hallucinations in addition to mild depression with anxiety. Her initial symptoms were attributed to increasing her dose to 200 mg BID, with the abrupt discontinuation 5 days later resulting in her more acute decline. Amantadine was never re-started, and mental status improved to near baseline. Setting: Acute rehabilitation unit.
Results: One week following discontinuation of amantadine, the patient’s hallucinations had resolved. She was able to tolerate three hours of daily therapy on the acute rehabilitation unit, and did not have return of her symptoms throughout the remaining ten days of her admission. She was ultimately discharged home with family supervision. Discussion: This case provides a vivid illustration of the potential for otherwise appropriate doses of amantadine to cause potentially debilitating hallucinations in certain individuals. Conclusions: Amantadine may contribute to the development of hallucinations in predisposed individuals, even at standard doses. Level of Evidence: Level V Poster 53 Daptomycin-Induced Acute Eosinophilic Pneumonia in a Patient Receiving Rehabilitation Post Prosthetic Joint Infection: A Case Report Christina G. Zaccarini, MD (SUNY Upstate Medical University/ Syracuse, Liverpool, NY, United States), Xiaoli Dong, MD Disclosures: Christina Zaccarini: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 88-year-old woman with history of left total knee replacement 15 years prior was admitted for inpatient rehabilitation following left knee hardware removal, corticotomy and temporary arthrodesis for an infected prosthetic joint. She was placed on a 6 week course of daptomycin and cefepime based on intraoperative cultures. Three weeks into rehabilitation, she developed fever and worsening leukocytosis (28.8). She had dyspnea and cough with scant sputum production, briefly requiring supplemental oxygen for hypoxia. She had rales on lung exam. No rashes were noted on skin exam. Work-up was significant for peripheral eosinophilia (11% compared to 1% at baseline). Chest radiography showed patchy parenchymal opacities in the periphery of bilateral upper lobes. Acute eosinophilic pneumonia was suspected. Daptomycin was discontinued and the patient was placed on prednisone 40 mg every 8 hours, with tapering over 10 days. Clinical and radiographic evidence of eosinophilic pneumonia promptly resolved over the next 3-4 days. Bronchoscopy was therefore not done. The patient completed her rehabilitation course with minor interruption. Setting: Inpatient Rehabilitation Facility. Results: The patient was discharged from her rehabilitation facility and has since undergone multiple revision surgeries including TKA reimplantation. She is presently living independently. She remains on chronic antibiotic suppression (doxycycline). Discussion: Daptomycin-induced acute eosinophilic pneumonia is a rare yet potentially fatal adverse drug event if not quickly recognized and appropriately managed. It often occurs 2-4 weeks into daptomycin treatment. Clinical suspicion and prompt cessation of daptomycin is crucial. Rechallenging with daptomycin is not recommended. Other significant adverse events associated with daptomycin include myositis, rhabdomolysis, and acute renal failure. Conclusions: Given the important role of daptomycin in the treatment of prosthetic joint infections, clinicians should be aware of the adverse events associated with daptomycin to aid in the proper identification and treatment of such in rehabilitation patients. Level of Evidence: Level V Poster 54 The Impact of Routine Lower Extremity Deep Vein Thrombosis Screening on Acute Rehabilitation Admissions Cynthia C. Hung, MD (Mt Sinai Health System, Edison, NJ, United States), Anne F. Ambrose, MD, MS Disclosures: Cynthia Hung: I Have No Relevant Financial Relationships To Disclose
Abstracts / PM R 8 (2016) S151-S332
Poster 51 Sleep Quality and Functional Outcome Measures, an Ongoing Prospective IRB Study Mohammad Aalai, MD (Brooklyn, NY, United States), Raj D. Murthy, MD, MPH, Todd R. Lefkowitz, DO, Nnabugo D. Ozurumba, MD Disclosures: Mohammad Aalai: I Have No Relevant Financial Relationships To Disclose Objective: To track sleep quality in an Inpatient Rehabilitation Facility (IRF) setting using standardized survey tools and correlate to functional outcome measures. Design: Prospective IRB study. Setting: Inner city Acute IRF serving patients of low socioeconomic status. Participants: 32 subjects of all diagnoses. Interventions: Not applicable. Main Outcome Measures: Pittsburgh Sleep Quality Index(PSQI), Functional Independence Measure(FIM), Insomnia Symptom Questionnaire (ISQ). Results: Of the 32 patients studied so far, 88% had poor premorbid sleep (PPS) defined as PSQI>5 (sensitivity 89.6% and specificity 86.5%). The average PSQI score was 9.4. 30% had no change in cognitive FIM scores from admission to discharge. 64% did not achieve the region adjusted average (RAA) cognitive FIM change. 55% of the PPS patients had no change in sleep quality at discharge and 21% had a decrement. Average length of stay (LOS) was 16 days. 93% of the patients did not achieve region adjusted mean length of stay efficiency. 69% of patients did not achieve the RAA total FIM gain. Patients deemed to have insomnia by ISQ had higher than average PSQI scores. Conclusions: Patients in an urban IRF setting have poor premorbid sleep quality due to various socioeconomic and psychosocial factors. Patients in this study with higher PSQI scores prior to admission to IRF did not achieve average FIM gains. Further screening and quality control measures are necessary to ensure those identified as high risk patients maximize their outcomes during IRF stay. This may include environmental alterations as well as changes in therapy and nursing schedule. Level of Evidence: Level I Poster 52 Acute Hallucinosis Related to Amantadine Use in the Setting of Traumatic Brain Injury: A Case Report Brett Schoen, MD (University of Kansas Medical Center, Merriam, KS, United States), Sarah Eickmeyer, MD Disclosures: Brett Schoen: I Have No Relevant Financial Relationships To Disclose Case/Program Description: The patient was admitted to the acute rehabilitation unit following traumatic brain injury with subarachnoid hemorrhage (SAH). On day 2 she was started on amantadine 100 mg twice daily (BID) for cognitive impairment and mild agitation. This dose was tolerated for 4 days with only mild improvement of symptoms, so the dose was increased to 200 mg BID. On day 2 of the increased dose she began to report visual hallucinations, became disoriented, and by day 3 was unable to participate in therapy. Medical workup for acute encephalopathy revealed no apparent metabolic or infectious process. Her encephalopathy persisted, therefore amantadine was discontinued after 5 days of the increased dose. 2 days later she suffered an acute increase in the frequency of hallucinations and more severe agitation. Repeat head CT revealed no acute change with respect to her known SAH. Psychiatry was consulted and found that the patient had a remote history of visual hallucinations in addition to mild depression with anxiety. Her initial symptoms were attributed to increasing her dose to 200 mg BID, with the abrupt discontinuation 5 days later resulting in her more acute decline. Amantadine was never re-started, and mental status improved to near baseline. Setting: Acute rehabilitation unit.
Results: One week following discontinuation of amantadine, the patient’s hallucinations had resolved. She was able to tolerate three hours of daily therapy on the acute rehabilitation unit, and did not have return of her symptoms throughout the remaining ten days of her admission. She was ultimately discharged home with family supervision. Discussion: This case provides a vivid illustration of the potential for otherwise appropriate doses of amantadine to cause potentially debilitating hallucinations in certain individuals. Conclusions: Amantadine may contribute to the development of hallucinations in predisposed individuals, even at standard doses. Level of Evidence: Level V Poster 53 Daptomycin-Induced Acute Eosinophilic Pneumonia in a Patient Receiving Rehabilitation Post Prosthetic Joint Infection: A Case Report Christina G. Zaccarini, MD (SUNY Upstate Medical University/ Syracuse, Liverpool, NY, United States), Xiaoli Dong, MD Disclosures: Christina Zaccarini: I Have No Relevant Financial Relationships To Disclose Case/Program Description: An 88-year-old woman with history of left total knee replacement 15 years prior was admitted for inpatient rehabilitation following left knee hardware removal, corticotomy and temporary arthrodesis for an infected prosthetic joint. She was placed on a 6 week course of daptomycin and cefepime based on intraoperative cultures. Three weeks into rehabilitation, she developed fever and worsening leukocytosis (28.8). She had dyspnea and cough with scant sputum production, briefly requiring supplemental oxygen for hypoxia. She had rales on lung exam. No rashes were noted on skin exam. Work-up was significant for peripheral eosinophilia (11% compared to 1% at baseline). Chest radiography showed patchy parenchymal opacities in the periphery of bilateral upper lobes. Acute eosinophilic pneumonia was suspected. Daptomycin was discontinued and the patient was placed on prednisone 40 mg every 8 hours, with tapering over 10 days. Clinical and radiographic evidence of eosinophilic pneumonia promptly resolved over the next 3-4 days. Bronchoscopy was therefore not done. The patient completed her rehabilitation course with minor interruption. Setting: Inpatient Rehabilitation Facility. Results: The patient was discharged from her rehabilitation facility and has since undergone multiple revision surgeries including TKA reimplantation. She is presently living independently. She remains on chronic antibiotic suppression (doxycycline). Discussion: Daptomycin-induced acute eosinophilic pneumonia is a rare yet potentially fatal adverse drug event if not quickly recognized and appropriately managed. It often occurs 2-4 weeks into daptomycin treatment. Clinical suspicion and prompt cessation of daptomycin is crucial. Rechallenging with daptomycin is not recommended. Other significant adverse events associated with daptomycin include myositis, rhabdomolysis, and acute renal failure. Conclusions: Given the important role of daptomycin in the treatment of prosthetic joint infections, clinicians should be aware of the adverse events associated with daptomycin to aid in the proper identification and treatment of such in rehabilitation patients. Level of Evidence: Level V Poster 54 The Impact of Routine Lower Extremity Deep Vein Thrombosis Screening on Acute Rehabilitation Admissions Cynthia C. Hung, MD (Mt Sinai Health System, Edison, NJ, United States), Anne F. Ambrose, MD, MS Disclosures: Cynthia Hung: I Have No Relevant Financial Relationships To Disclose