S225 S290
Poster 294:
Concurrent Tetraparesis and Cranial Nerve VI Palsy
Secondary to Adenovirus Infection: A Case Report
Douglas Verrill (McGaw MC of NW Univ NW Med Schl/RIC),
Christopher D. Reger, MD
Disclosures:
Douglas Verrill: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient was a 44-year-old man who
initially presented with severe headaches, nausea and abdominal
pain and was diagnosed with Syndrome of Inappropriate Anti-
diuretic hormone and non-ST-elevation myocardial infarction. Dur-
ing his hospitalization, he developed progressive tetraparesis with
proximal greater than distal weakness, and a left lateral gaze
deficit consistent with cranial nerve VI palsy. His weakness pro-
gressed and he required intubation for airway protection with
eventual tracheostomy placement along with gastric tube place-
ment for dysphagia. Electrodiagnostic testing was suggestive of
critical illness myopathy and neuropathy. Extensive laboratory
testing, including infectious disease testing, was significant for
elevated serum adenovirus titers. A para-neoplastic work up was
negative along with cerebrospinal fluid testing via lumbar punc-
tures. Patient received Intravenous Immunoglobulin (IVIG) for a
total of 5 days and high dose steroids with subsequent taper for
suspected adenovirus axonopathy.
Setting:
Acute Inpatient Rehabilitation.
Results:
Patient had gradual improvement of his strength in all ex-
tremities after receiving IVIG and high dose steroids. His respiratory
status also improved and his tracheostomy was able to be dis-
continued. He had persistent visual symptoms, predominately blurred
vision, that was present at time of discharge from inpatient
rehabilitation.
Discussion:
Adenovirus is a well-documented cause of both isolated
weakness and cranial neuropathies. However, this is a rare case of
concurrent gradual, progressive tetraparesis with cranial nerve VI
palsy secondary to adenovirus infection that to our knowledge has only
been seen and documented in a few isolated cases.
Conclusions:
Adenovirus infection can be a severely incapacitating
infection with variable clinical presentations. It is important to
consider that in rare cases it can cause concurrent weakness and
cranial neuropathies and should be included on the differential diag-
nosis of patients who present with both limb weakness and cranial
nerve VI palsy.
Level of Evidence:
Level V
Poster 295:
Newly Diagnosed Postural Orthostatic Tachycardia
Syndrome (POTS) in the Acute Rehab Setting in a
Patient with Recently Diagnosed Immune-mediated
Myopathy with Perimysial Pathology: A Case Report
Luis J. Soliz, MD (Rush University Medical Center, Chicago, IL, United
States), Jonathan C. VandenBerg, DO
Disclosures:
Luis J. Soliz, MD: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 38-year-old woman with a past medical
history significant for Grave’s disease and multiple sclerosis who pre-
sented to the acute hospital with progressive upper and lower ex-
tremity weakness and eventually diagnosed with immune-mediated
myopathy with perimysial pathology after muscle biopsy. Patient was
subsequently admitted to acute rehab where her course was imme-
diately complicated by severe exercise intolerance and tachycardia
into the 140s with standing. EKG revealed normal sinus rhythm. Or-
thostatics were obtained and patient met diagnostic criteria for
postural orthostatic tachycardia syndrome (POTS).
Setting:
Tertiary Care Hospital.
Results:
Compression stockings and fluid intake to 2-3 liters were
ordered. Patient was also started on metoprolol 25 milligrams twice a
day. Within 3 days the patient’s exercise tolerance had improved
greater than 50% with the patient now able to complete entire therapy
sessions. Patient’s heart rate had also dropped to the low 90s with
standing.
Discussion:
POTS is a formof dysautonomia and orthostatic intolerance
associated with severe tachycardia with standing. The current diag-
nostic criteria for POTS is a heart rate increase of at least 30 beats per
minute within the first 10 minutes of standing in the absence of ortho-
static hypotension that can easily be diagnosed at the bedside. POTS can
lead to severe exercise intolerance impacting not only a patient’s acute
rehab stay but also their quality of life on discharge. Often diagnosed in
women, POTS is often associated with auto-immune mediated diseases.
This is the first POTS case in the medical literature associated with im-
mune-mediated myopathy with perimysial pathology.
Conclusions:
Many different medications have been tried to treat
POTS with limited evidence of their effectiveness within the medical
literature. This case has demonstrated metoprolol to be an excellent
adjuvant treatment in improving exercise tolerance in newly diag-
nosed POTS patients within the acute rehab setting. Further research,
however, is needed going forward.
Level of Evidence:
Level V
Poster 296:
An 80-Year-Old Woman with Chronic Idiopathic Chest
Pain that Resolves after Resection of a Thoracic Meningioma:
A Case Report
Jonathan V. Sukumar, DO (Marianjoy Rehabilitation Hospital, Chicago,
Illinois, United States), Jeffrey Oken, MD
Disclosures:
Jonathan Sukumar: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
An 80-year-old woman who presented
with lower extremity numbness, weakness, imbalance, and falls for 6
months. MRI revealed T3 intradural extramedullary lesion of the spinal
cord with associated myelopathy and cord compression. Patient un-
derwent T2-T4 laminectomy and resection of lesion; pathology
confirmed a diagnosis of meningioma. Preceding these events, patient
had complaint of intermittent chest pain for 18 months prior. Pain was
sharp, non-radiating and localized parasternally at the right rib space
between the 3rd and 4th rib; pain was exacerbated by deep inspira-
tion, coughing, or minimal torso movement. Cardiac workup was
negative. Chest CT was negative for intra thoracic etiology. Topical
and oral pain medications also did not improve symptoms.
Setting:
Acute Inpatient Rehabilitation Hospital.
Results:
Patient’s chest pain symptoms post-operatively resolved
completely. Patient reported no pain with inspiration, expectoration,
upper extremity and torso mobilization. There was improvement in
patient’s balance, gait, and ADL enhancement with rehabilitation
course, patient was discharged with independent level of ambulation.
Discussion:
Chest pain is worked up involving an extensive cardio-
vascular investigation. If negative, the differential for chest pain
narrows quickly and may be attributed to nonspecific or idiopathic
etiology. This patient’s chest pain was likely the earliest manifestation
of her meningioma. A more comprehensive investigation of the pa-
tient’s symptoms at the onset may have revealed the neoplasm at an
earlier stage before more obvious and severe neurological symptoms
presented.
Conclusions:
Spinal meningiomas either present incidentally, as
they can be asymptomatic, or with progressive leg weakness and
numbness
e
as they did with the patient in this case. Meningiomas are
not typically aggressive but earlier diagnosis and management is
preferred. Given that the area of the lesion is on the spinal cord, it can
be proposed that radicular or referred symptoms corresponding the
spinal cord level of the lesion may be observed.
Level of Evidence:
Level V
S225
Abstracts / PM R 9 (2017) S131-S290