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Poster 94 Mononeuritis Multiplex Secondary to HCV Cryoglobulinemia and Rheumatoid Vasculitis: A Case Report
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Abstracts / PM R 8 (2016) S151-S332
wave therapy has also been described as a non-invasive, affordable treatment for myositis ossificans with few side effects. Surgical excision remains the definitive treatment. Conclusions: Rehabilitation physicians should be aware of the possibility of myositis ossificans traumaticus in patients with recent trauma and proper prophylactic measures should be initiated. Level of Evidence: Level V Poster 93 Rare Presentation of Three Limb Compartment Syndrome: A Case Report Austin C. Myers, MD, MBA (East Carolina University/Vidant Medical Center, Greenville, North Carolina, United States), Clinton E. Faulk, MD Disclosures: Austin Myers: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old AA female with past medical history of substance abuse (cocaine use, alcohol abuse, and nicotine dependence), depression, chronic pain, Sjogren’s syndrome, osteomalacia, hypothyroidism and recently diagnosed stage IV abdominal neuroendocrine tumor with liver masses presented with complaints of bilateral leg pain and difficulty ambulating. Initial CPK was >44,000, and within a short time patient noted increased extremity pain; pulses became non-detectable, and emergency fasciotomy was performed on bilateral lower extremities and left upper extremity. With aggressive fluid management, CPK began trending down, but severe weakness remained. No specific etiology was ever determined for severe rhabdomyolysis and compartment syndrome, but was thought to be secondary to statin use and possible drug interaction e either from prescription medication (possibly PPI) or illicit drug. Setting: Inpatient Rehabilitation of Academic Medical Center. Results: Patient was admitted to inpatient rehab, and at that time she was able to ambulate 6’ with rolling walker and contact guard assist; she was also required maximum assistance with dressing. She made significant functional gains during rehab stay, and was able to ambulate independently well over 300 feet, and was independent with dressing. Surgery team followed with wound monitoring, and these healed well. Discussion: Compartment syndrome is typically seen after a specific inciting event such as trauma. This patient did not have a traumatic injury, however she was recently diagnosed with a neuroendocrine tumor, and had a history of illicit drug abuse with alcohol and tobacco use concomitantly. All of these factors could have been contributory to development of compartment syndrome in this patient. Conclusions: This patient’s case is unique in that no traumatic event occurred, and she developed compartment syndrome in three extremities. No definitive etiology has been discovered; however, patient did demonstrate significant improvement as CPK normalized, along with intensive therapy. Level of Evidence: Level V Poster 94 Mononeuritis Multiplex Secondary to HCV Cryoglobulinemia and Rheumatoid Vasculitis: A Case Report Abhishek Patel, DO (University Medical Center of Pittsburgh, Pittsburgh, PA, United States) Disclosures: Abhishek Patel: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 71-year-old woman with a past medical history of rheumatoid arthritis and untreated hepatitis C virus who presented with a new right foot drop and generalized pain. On examination she had weakness in the right dorsiflexors and on further exam patient had weakness in the right wrist extensors. MRI of the brain and lumbar spine was unremarkable for stenosis or herniation. Work up was revealing for ANA+ and above normal Rheumatoid Factor. She was started on Rituximab infusion. The patient was sent for NCS/ EMG showed evidence asymmetric generalized sensory motor
polyneuropathy with conduction blocks involving right fibular nerve, right tibial nerve, and right superficial radial mononeuropathy. Nerve biopsy was performed revealing necrotizing vasculitis. The patient was started on pulse steroid therapy and completed a prednisone taper. Her foot dorsiflexion improved to a 3/5 from 0/5 on admission. She still had inability to clear the right lower extremity and thus ankle foot orthosis was recommended. She was discharged to transitional care unit for rehabilitation needs. Setting: Acute Inpatient Floor. Results: At one week, the patient was readmitted to inpatient floors possible infection at her nerve biopsy site. At that time, we reassessed the patient and she made significant recovery of her dorsiflexors to a 3/5. AFO was discontinued and she was in fact modified independent with a cane (which she used at baseline prior to admission). Discussion: Mononeuritis Multiplex is a rare neurologic/neurovascular disorder and in this particular patient the cause was thought to be untreated hepatitis C cryoglobulinemia and rheumatoid vasculitis. Her workup was consistent with chronic hepatitis C infection and cryoglobulinemia workup was positive for cryoglobulins II and III, along with low complement C4 factors. Biopsy showed vasculitis with eosinophilic infiltrates consistent with history of HCV cryoglobulinemia. However, fibularis brevis muscle biopsy showed necrotizing vasculitis consistent with rheumatoid vasculitis given. EMG findings were interesting in that right sural and bilateral superficial peroneal sensory spots were absent, right radial sensory response was low with right fibular motor response to EDB showed low amplitude and prolonged distal latency and conduction block as well as the right tibial nerve. The right ulnar motor response was slowed across the elbow needle study showed fibrillations in the right gastroc. Conclusions: Mononeuritis Multiplex has a myriad of etiologies however untreated hepatitis C and rheumatoid arthritis flares simultaneously is an unusual phenomenon confirmed by NCS and EMG findings but most notably histological studies. Both are treated and respond well with pulse steroid therapies and the patient’s function was essentially unchanged. Level of Evidence: Level V Poster 95 Oncologist’s Attitude and Knowledge about Cancer Rehabilitation Rau´l A. Rosario-Concepcio´n, MD (University of Puerto Rico, Guaynabo, Puerto Rico, Puerto Rico), Fernando L. Sepu´lveda-Irizarry, MD, Yailiz B. Calderı´n Pellot, MS4, Marı´a E. Echevarrı´a, MD, Carmen E. Lo´pez-Acevedo, MD Disclosures: Rau ´n: I Have No Relevant Financial ´l Rosario-Concepcio Relationships To Disclose Objective: To assess the awareness and referral patterns among oncologists for rehabilitation in both pediatric and adult cancer patients. Design: Cross-sectional study. Setting: Medical Oncology State Society Annual Meeting. Participants: 42 oncologists completed a 10 item questionnaire. Interventions: All willing oncologists were handed a short questionnaire focused on demographics, knowledge and clinical practices about rehabilitation in cancer patients for the past 12 months. Main Outcome Measures: Identify the frequency, reasons, at what point in the continuum of care do oncologists refer cancer patients for rehabilitation. Determine the risk/benefit perception by oncologists about rehabilitation in their patients and its correlation to patient referrals, prognosis, type of cancer and type of symptoms. Results: Up to 88% of oncologists received minimal or zero education about cancer rehabilitation, its benefits and indications. This resulted in 72% of oncologists referring less than 15% of their patients for rehabilitation with almost 1/3 of the subjects referring less than 5% of patients. However, 92% think that rehabilitation is always or frequently beneficial for their patients. Meanwhile 36% decide not to refer patients if prognosis is less than 6 months, and 40% of the
Abstracts / PM R 8 (2016) S151-S332
wave therapy has also been described as a non-invasive, affordable treatment for myositis ossificans with few side effects. Surgical excision remains the definitive treatment. Conclusions: Rehabilitation physicians should be aware of the possibility of myositis ossificans traumaticus in patients with recent trauma and proper prophylactic measures should be initiated. Level of Evidence: Level V Poster 93 Rare Presentation of Three Limb Compartment Syndrome: A Case Report Austin C. Myers, MD, MBA (East Carolina University/Vidant Medical Center, Greenville, North Carolina, United States), Clinton E. Faulk, MD Disclosures: Austin Myers: I Have No Relevant Financial Relationships To Disclose Case/Program Description: A 55-year-old AA female with past medical history of substance abuse (cocaine use, alcohol abuse, and nicotine dependence), depression, chronic pain, Sjogren’s syndrome, osteomalacia, hypothyroidism and recently diagnosed stage IV abdominal neuroendocrine tumor with liver masses presented with complaints of bilateral leg pain and difficulty ambulating. Initial CPK was >44,000, and within a short time patient noted increased extremity pain; pulses became non-detectable, and emergency fasciotomy was performed on bilateral lower extremities and left upper extremity. With aggressive fluid management, CPK began trending down, but severe weakness remained. No specific etiology was ever determined for severe rhabdomyolysis and compartment syndrome, but was thought to be secondary to statin use and possible drug interaction e either from prescription medication (possibly PPI) or illicit drug. Setting: Inpatient Rehabilitation of Academic Medical Center. Results: Patient was admitted to inpatient rehab, and at that time she was able to ambulate 6’ with rolling walker and contact guard assist; she was also required maximum assistance with dressing. She made significant functional gains during rehab stay, and was able to ambulate independently well over 300 feet, and was independent with dressing. Surgery team followed with wound monitoring, and these healed well. Discussion: Compartment syndrome is typically seen after a specific inciting event such as trauma. This patient did not have a traumatic injury, however she was recently diagnosed with a neuroendocrine tumor, and had a history of illicit drug abuse with alcohol and tobacco use concomitantly. All of these factors could have been contributory to development of compartment syndrome in this patient. Conclusions: This patient’s case is unique in that no traumatic event occurred, and she developed compartment syndrome in three extremities. No definitive etiology has been discovered; however, patient did demonstrate significant improvement as CPK normalized, along with intensive therapy. Level of Evidence: Level V Poster 94 Mononeuritis Multiplex Secondary to HCV Cryoglobulinemia and Rheumatoid Vasculitis: A Case Report Abhishek Patel, DO (University Medical Center of Pittsburgh, Pittsburgh, PA, United States) Disclosures: Abhishek Patel: I Have No Relevant Financial Relationships To Disclose Case/Program Description: This is a 71-year-old woman with a past medical history of rheumatoid arthritis and untreated hepatitis C virus who presented with a new right foot drop and generalized pain. On examination she had weakness in the right dorsiflexors and on further exam patient had weakness in the right wrist extensors. MRI of the brain and lumbar spine was unremarkable for stenosis or herniation. Work up was revealing for ANA+ and above normal Rheumatoid Factor. She was started on Rituximab infusion. The patient was sent for NCS/ EMG showed evidence asymmetric generalized sensory motor
polyneuropathy with conduction blocks involving right fibular nerve, right tibial nerve, and right superficial radial mononeuropathy. Nerve biopsy was performed revealing necrotizing vasculitis. The patient was started on pulse steroid therapy and completed a prednisone taper. Her foot dorsiflexion improved to a 3/5 from 0/5 on admission. She still had inability to clear the right lower extremity and thus ankle foot orthosis was recommended. She was discharged to transitional care unit for rehabilitation needs. Setting: Acute Inpatient Floor. Results: At one week, the patient was readmitted to inpatient floors possible infection at her nerve biopsy site. At that time, we reassessed the patient and she made significant recovery of her dorsiflexors to a 3/5. AFO was discontinued and she was in fact modified independent with a cane (which she used at baseline prior to admission). Discussion: Mononeuritis Multiplex is a rare neurologic/neurovascular disorder and in this particular patient the cause was thought to be untreated hepatitis C cryoglobulinemia and rheumatoid vasculitis. Her workup was consistent with chronic hepatitis C infection and cryoglobulinemia workup was positive for cryoglobulins II and III, along with low complement C4 factors. Biopsy showed vasculitis with eosinophilic infiltrates consistent with history of HCV cryoglobulinemia. However, fibularis brevis muscle biopsy showed necrotizing vasculitis consistent with rheumatoid vasculitis given. EMG findings were interesting in that right sural and bilateral superficial peroneal sensory spots were absent, right radial sensory response was low with right fibular motor response to EDB showed low amplitude and prolonged distal latency and conduction block as well as the right tibial nerve. The right ulnar motor response was slowed across the elbow needle study showed fibrillations in the right gastroc. Conclusions: Mononeuritis Multiplex has a myriad of etiologies however untreated hepatitis C and rheumatoid arthritis flares simultaneously is an unusual phenomenon confirmed by NCS and EMG findings but most notably histological studies. Both are treated and respond well with pulse steroid therapies and the patient’s function was essentially unchanged. Level of Evidence: Level V Poster 95 Oncologist’s Attitude and Knowledge about Cancer Rehabilitation Rau´l A. Rosario-Concepcio´n, MD (University of Puerto Rico, Guaynabo, Puerto Rico, Puerto Rico), Fernando L. Sepu´lveda-Irizarry, MD, Yailiz B. Calderı´n Pellot, MS4, Marı´a E. Echevarrı´a, MD, Carmen E. Lo´pez-Acevedo, MD Disclosures: Rau ´n: I Have No Relevant Financial ´l Rosario-Concepcio Relationships To Disclose Objective: To assess the awareness and referral patterns among oncologists for rehabilitation in both pediatric and adult cancer patients. Design: Cross-sectional study. Setting: Medical Oncology State Society Annual Meeting. Participants: 42 oncologists completed a 10 item questionnaire. Interventions: All willing oncologists were handed a short questionnaire focused on demographics, knowledge and clinical practices about rehabilitation in cancer patients for the past 12 months. Main Outcome Measures: Identify the frequency, reasons, at what point in the continuum of care do oncologists refer cancer patients for rehabilitation. Determine the risk/benefit perception by oncologists about rehabilitation in their patients and its correlation to patient referrals, prognosis, type of cancer and type of symptoms. Results: Up to 88% of oncologists received minimal or zero education about cancer rehabilitation, its benefits and indications. This resulted in 72% of oncologists referring less than 15% of their patients for rehabilitation with almost 1/3 of the subjects referring less than 5% of patients. However, 92% think that rehabilitation is always or frequently beneficial for their patients. Meanwhile 36% decide not to refer patients if prognosis is less than 6 months, and 40% of the