- Email: [email protected]
Poster 86: Sympathetic Skin Response in Kala-Azar: A Case Series
ACADEMY ANNUAL ASSEMBLY ABSTRACTS
suppressive therapy such as prednisone (1mg/kg/d) or cyclophosphamide. Key Words: Rehabilitation. Poster 84 Severe Mononeuritis Multiplex Secondary to Systemic Lupus Erythematosis Vasculopathy: A Case Report. Vijayasekhara R. Kalakata, MD (Kings County Hospital Center and SUNY Downstate Medical Center, Brooklyn, NY); Melissa Bednar, MD; Getahun Kifle, MD. Disclosure: M. Bednar, none; V.R. Kalakata, none; G. Kifle, none. Setting: Academic center. Patient: 33-year-old woman with systemic lupus erythematosis (SLE), left wrist drop, and forearm numbness of 3 months duration. Case Description: Patient underwent pericardiectomy for pericardial tamponade three months before presentation. Postoperatively she noticed swelling and pain in her left arm. Her medical history included SLE, mixed connective tissue disorder, antiphospholipid syndrome and deep vein thrombosis. She was on treatment with Imuran, Plaquenil, Prednisone, and Coumadin. There was normal range of motion and muscle strength in the left shoulder and elbow. Left wrist and finger examination revealed 0/5 extension and 4/5 flexion strength. Muscle stretch reflexes of left biceps and triceps were normal (2⫹). Left brachioradialis reflex was absent. There was sensory impairment in the left forearm over radial nerve distribution. Right extremity examination was normal. A wrist hand orthosis was advised. Electrodiagnostic study was performed. Left radial nerve motor and sensory conduction studies showed no response. Median and ulnar nerve motor and sensory studies were normal in distal latencies, amplitudes and conduction velocities bilaterally. Needle electromyogram of left extensor indicis and brachioradialis showed positive sharp waves and fibrillation potentials (4⫹). There were no motor units in left extensor indicis and brachioradialis muscles. Left triceps had no signs of membrane instability. Follow-up motor and sensory studies of the left radial nerves after 3 months showed no response. Assessment/Results: A diagnosis of left radial nerve neuropathy above the elbow and distal to triceps innervation secondary to SLE vasculitis was made. Conclusions: 10% to 15% of patients with SLE develop a peripheral neuropathy that is probably due to vasculopathy of vasa nervorum. Severe mononeuritis multiplex, as described in this case, secondary to SLE vasculopathy is quite rare and is almost always accompanied by evidence of active disease in other organs.We present a rare case of mononeuritis multiplex of the radial nerve due to SLE. Key Words: Rehabilitation. Poster 85 Sensory Nerve Action Potential Electrical Power May be More Sensitive Than Amplitude to Assess Digital Axonal Loss: A Case Report. Niles M. Roberts, MD (Zablocki VA Medical Center, Milwaukee, WI); Jacqueline Wertsch, MD. Disclosure: N.M. Roberts, none; J. Wertsch, none. Setting: Electromyography (EMG) clinic at a Wisconsin VA hospital. Patient: A 30-year-old woman had a chronically insensate right long finger along the lateral aspect, with a remote history of a deep laceration at this finger’s base. Examination confirmed scarring with loss of sensation distally. This finger’s median sensory nerve action potential (SNAP) amplitude was normal at 55micro-volts. Case Description: The subject’s median-innervated fingers were instrumented for SNAP studies. The montage was modified by connecting an external resistor Rext across E1-to-ground (and another Rext across E2-to-ground for common-mode rejection). A sequence of 17 SNAP measurements with17 unique Rext’s ranging from 100ohms to 1megaohm was recorded. SNAP power (voltage-squared over resistance) for each Rext was calculated from the SNAP-amplitude. A bell-shaped
E47
plot, SNAP-power versus Rext, resulted. It was regressed to the power transfer equation (PTE), whose peak defines maximal SNAP power (MSP). Assessment/Results: All fingers were regressed to the PTE. Residuals averaged 10% of MSP, and were uniformly distributed. Both index fingers had MSP’s of 660femto-watts. The injured and uninjured long fingers had MSP’s of 240 and 530femto-watts respectively. Our statistics from 12 normative, median-only innervated fingers showed a mean MSP of 530femto-watts, with SD 100. The injured finger’s MSP was 2.9 SDs below the mean (and contralateral long finger), consistent with axonal loss. Discussion: This case explored whether a SNAP measurement and analysis technique that estimated MSP suggested axonal loss. Clinical evidence for complete axonal loss in the injured digital nerve was compelling. Although SNAP-amplitude in the insensate finger was normal, the significantly low value for MSP suggested that power measurements might convey additional information that could suggest axonal loss. Conclusions: A new technique that measures SNAP electrical power may be more sensitive than SNAP amplitude for assessing digital axonal loss. Key Words: Action potential; Axons; Rehabilitation. Poster 86 Sympathetic Skin Response in Kala-Azar: A Case Series. Reza S. Roghani, MD (University of Social Welfare & Rehabilitation, Tehran, Iran); Farin Soleimani, MD. Disclosure: R.S. Roghani, none; F. Soleimani, none. Objective: Kala-azar is a multisystem involving infectious disease caused by Leishmania species. In this disease, skin becomes grayish, dry, thin and scaly, and hair may be lost. Our objective was to evaluate the integrity of peripheral nervous system, especially autonomic parts and correlation of skin changes with possible abnormal electrodiagnostic findings. Design: An analytic cross-sectional study. Setting: this study was conducted in winter and spring 2006 in the department of physical medicine and rehabilitation, Nemazi Hospital, Shiraz University of Medical Science, Iran. Participants: An analytic crosssectional study was done on 3 (2 boys and 1 girl) visceral leishmaniasis patients, aging 4, 5, and 7 years old, and 20 (11 girls and 9 boys) healthy, age-matched children in a consecutive pattern. Main Outcome Measures: Routine nerve conduction studies (NCS), sympathetic skin response (SSR). Results: The clinical neurologic examination did not reveal any symptoms or signs of peripheral nervous system involvement. NCS data in all 3 patients were normative and in the range of control group. SSR data were abnormal in all 3 patients; both hands and feet in 2 patients and only in the hands in another one. The SSR results were correlated well with skin changes of patients. Conclusions: Based on normative routine nerve conduction studies and obvious abnormal SSR in all 3 patients, which correlated well with skin changes, autonomic system involvement is the probable etiology of skin changes in kala-azar patients. Larger studies are suggested for more reliable and definite results. Key Words: Kala-Azar; Rehabilitation. Poster 87 Tarsal Tunnel Syndrome in a Rural Health Care System. Richard Weiss, MD (East Carolina University/Pitt County Memorial Hospital, Greenville, NC); Monica Carrion-Jones, MD. Disclosure: M. Carrion-Jones, none; R. Weiss, none. Objective: To examine the epidemiology and clinical features of patients with tarsal tunnel syndrome (TTS) in a rural community. Design: Chart review from January 2005 to December 2007. Setting: University hospital and its associated electrodiagnostic clinics. Participants: 4 patients out of 1526 patients referred for electrodiagnostic studies (EDX). Interventions: Not applicable. Main Outcome MeaArch Phys Med Rehabil Vol 89, November 2008
suppressive therapy such as prednisone (1mg/kg/d) or cyclophosphamide. Key Words: Rehabilitation. Poster 84 Severe Mononeuritis Multiplex Secondary to Systemic Lupus Erythematosis Vasculopathy: A Case Report. Vijayasekhara R. Kalakata, MD (Kings County Hospital Center and SUNY Downstate Medical Center, Brooklyn, NY); Melissa Bednar, MD; Getahun Kifle, MD. Disclosure: M. Bednar, none; V.R. Kalakata, none; G. Kifle, none. Setting: Academic center. Patient: 33-year-old woman with systemic lupus erythematosis (SLE), left wrist drop, and forearm numbness of 3 months duration. Case Description: Patient underwent pericardiectomy for pericardial tamponade three months before presentation. Postoperatively she noticed swelling and pain in her left arm. Her medical history included SLE, mixed connective tissue disorder, antiphospholipid syndrome and deep vein thrombosis. She was on treatment with Imuran, Plaquenil, Prednisone, and Coumadin. There was normal range of motion and muscle strength in the left shoulder and elbow. Left wrist and finger examination revealed 0/5 extension and 4/5 flexion strength. Muscle stretch reflexes of left biceps and triceps were normal (2⫹). Left brachioradialis reflex was absent. There was sensory impairment in the left forearm over radial nerve distribution. Right extremity examination was normal. A wrist hand orthosis was advised. Electrodiagnostic study was performed. Left radial nerve motor and sensory conduction studies showed no response. Median and ulnar nerve motor and sensory studies were normal in distal latencies, amplitudes and conduction velocities bilaterally. Needle electromyogram of left extensor indicis and brachioradialis showed positive sharp waves and fibrillation potentials (4⫹). There were no motor units in left extensor indicis and brachioradialis muscles. Left triceps had no signs of membrane instability. Follow-up motor and sensory studies of the left radial nerves after 3 months showed no response. Assessment/Results: A diagnosis of left radial nerve neuropathy above the elbow and distal to triceps innervation secondary to SLE vasculitis was made. Conclusions: 10% to 15% of patients with SLE develop a peripheral neuropathy that is probably due to vasculopathy of vasa nervorum. Severe mononeuritis multiplex, as described in this case, secondary to SLE vasculopathy is quite rare and is almost always accompanied by evidence of active disease in other organs.We present a rare case of mononeuritis multiplex of the radial nerve due to SLE. Key Words: Rehabilitation. Poster 85 Sensory Nerve Action Potential Electrical Power May be More Sensitive Than Amplitude to Assess Digital Axonal Loss: A Case Report. Niles M. Roberts, MD (Zablocki VA Medical Center, Milwaukee, WI); Jacqueline Wertsch, MD. Disclosure: N.M. Roberts, none; J. Wertsch, none. Setting: Electromyography (EMG) clinic at a Wisconsin VA hospital. Patient: A 30-year-old woman had a chronically insensate right long finger along the lateral aspect, with a remote history of a deep laceration at this finger’s base. Examination confirmed scarring with loss of sensation distally. This finger’s median sensory nerve action potential (SNAP) amplitude was normal at 55micro-volts. Case Description: The subject’s median-innervated fingers were instrumented for SNAP studies. The montage was modified by connecting an external resistor Rext across E1-to-ground (and another Rext across E2-to-ground for common-mode rejection). A sequence of 17 SNAP measurements with17 unique Rext’s ranging from 100ohms to 1megaohm was recorded. SNAP power (voltage-squared over resistance) for each Rext was calculated from the SNAP-amplitude. A bell-shaped
E47
plot, SNAP-power versus Rext, resulted. It was regressed to the power transfer equation (PTE), whose peak defines maximal SNAP power (MSP). Assessment/Results: All fingers were regressed to the PTE. Residuals averaged 10% of MSP, and were uniformly distributed. Both index fingers had MSP’s of 660femto-watts. The injured and uninjured long fingers had MSP’s of 240 and 530femto-watts respectively. Our statistics from 12 normative, median-only innervated fingers showed a mean MSP of 530femto-watts, with SD 100. The injured finger’s MSP was 2.9 SDs below the mean (and contralateral long finger), consistent with axonal loss. Discussion: This case explored whether a SNAP measurement and analysis technique that estimated MSP suggested axonal loss. Clinical evidence for complete axonal loss in the injured digital nerve was compelling. Although SNAP-amplitude in the insensate finger was normal, the significantly low value for MSP suggested that power measurements might convey additional information that could suggest axonal loss. Conclusions: A new technique that measures SNAP electrical power may be more sensitive than SNAP amplitude for assessing digital axonal loss. Key Words: Action potential; Axons; Rehabilitation. Poster 86 Sympathetic Skin Response in Kala-Azar: A Case Series. Reza S. Roghani, MD (University of Social Welfare & Rehabilitation, Tehran, Iran); Farin Soleimani, MD. Disclosure: R.S. Roghani, none; F. Soleimani, none. Objective: Kala-azar is a multisystem involving infectious disease caused by Leishmania species. In this disease, skin becomes grayish, dry, thin and scaly, and hair may be lost. Our objective was to evaluate the integrity of peripheral nervous system, especially autonomic parts and correlation of skin changes with possible abnormal electrodiagnostic findings. Design: An analytic cross-sectional study. Setting: this study was conducted in winter and spring 2006 in the department of physical medicine and rehabilitation, Nemazi Hospital, Shiraz University of Medical Science, Iran. Participants: An analytic crosssectional study was done on 3 (2 boys and 1 girl) visceral leishmaniasis patients, aging 4, 5, and 7 years old, and 20 (11 girls and 9 boys) healthy, age-matched children in a consecutive pattern. Main Outcome Measures: Routine nerve conduction studies (NCS), sympathetic skin response (SSR). Results: The clinical neurologic examination did not reveal any symptoms or signs of peripheral nervous system involvement. NCS data in all 3 patients were normative and in the range of control group. SSR data were abnormal in all 3 patients; both hands and feet in 2 patients and only in the hands in another one. The SSR results were correlated well with skin changes of patients. Conclusions: Based on normative routine nerve conduction studies and obvious abnormal SSR in all 3 patients, which correlated well with skin changes, autonomic system involvement is the probable etiology of skin changes in kala-azar patients. Larger studies are suggested for more reliable and definite results. Key Words: Kala-Azar; Rehabilitation. Poster 87 Tarsal Tunnel Syndrome in a Rural Health Care System. Richard Weiss, MD (East Carolina University/Pitt County Memorial Hospital, Greenville, NC); Monica Carrion-Jones, MD. Disclosure: M. Carrion-Jones, none; R. Weiss, none. Objective: To examine the epidemiology and clinical features of patients with tarsal tunnel syndrome (TTS) in a rural community. Design: Chart review from January 2005 to December 2007. Setting: University hospital and its associated electrodiagnostic clinics. Participants: 4 patients out of 1526 patients referred for electrodiagnostic studies (EDX). Interventions: Not applicable. Main Outcome MeaArch Phys Med Rehabil Vol 89, November 2008