S227 S290
Poster 300:
Acute Onset of Psychotic Symptoms Following Abrupt
Discontinuation of Hormone Replacement Therapy in
a Trangendered Woman with Traumatic Brain Injury:
A Case Report
Yu M. Chiu, DO (NYU Rusk Institute of Rehabilitation Med, NY, NY,
United States), Baruch Kim, resident, Xuemue Qu, MD,
Prin X. Amorapanth, MD, PhD
Disclosures:
Yu Chiu: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
We present the case of a 35-year-old
transgendered woman undergoing acute rehabilitation for traumatic
brain injury and associated orthopedic polytrauma who experienced
the onset of acute psychotic symptoms during her rehabilitation
course. In the course of her evaluation and treatment, it was deter-
mined that her acute behavioral dysregulation and mood disorder
were likely due to the abrupt discontinuation of hormone replacement
therapy (HRT).
Setting:
Level I Trauma Center, Acute Inpatient Rehabilitation Center.
Results:
The patient displayed multiple episodes of behavioral and
mood disturbance that were marked by the presence of psychotic
symptoms.
Discussion:
To our knowledge, this represents the first documented
case of acute onset of psychotic symptoms due to acute discontinua-
tion of HRT (in this case, estrogen) in a transgendered woman with TBI.
Due to insurance qualifications and restrictions regarding the off-label
use of HRT, especially for Cross-Sex Hormone Treatment (CHT), HRT is
not generally approved in the acute inpatient rehabilitation setting.
However, hypo-estrogenic states have been shown to be associated
with occurrence of psychotic disorders in women, termed estrogen
withdrawal associated psychosis (EWAP). Furthermore, given the
known neuroprotectant effects of estrogens in animal models of TBI, it
may be reasonable to continue HRT in transgendered patients.
Conclusions:
Serious adverse events may occur with abrupt discon-
tinuation of HRT in transgendered patients, leading to the develop-
ment of psychotic symptoms. Optimal management of mood and
behavioral disturbances is a major goal of TBI rehabilitation due to
implications for patient and caregiver health, but is challenging due to
the sheer multitude of possible etiologies. As the use of CHT in
transgendered women is likely to continue to increase in the future
with increasing awareness and access, rehabilitation physicians should
be aware of the risk of the development of psychotic symptoms with
the abrupt discontinuation of CHT.
Level of Evidence:
Level V
Poster 301:
Baclofen Desensitization for Hypersensitivity Reaction:
A Case Report
Brittany A. Snider, DO (Mayo Clinic of Rochester), Ryan Woods, MD,
Brennan Boettcher, DO, Ronald K. Reeves, MD
Disclosures:
Brittany Snider: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 60-year-old man with a presumed bac-
lofen allergy and paraplegia due to human T-cell lymphotropic virus
type 1 (HTLV-1)-associated myelopathy has experienced progressive
spasticity since his diagnosis 4 years ago. He previously used oral
baclofen for spasticity management but developed a Type 1 hyper-
sensitivity reaction with urticaria and pruritus almost immediately
following baclofen administration. Upon discontinuation of baclofen,
his lower extremity tone became intractable, and other pharmaco-
logical interventions including diazepam and tizanidine were ineffec-
tive. Due to multiple medical comorbidities, the patient declined a
dantrolene trial. Spasticity remained 3-4 on the Modified Ashworth
Scale (MAS). Pain and spasticity limited his functional mobility,
prompting admission to inpatient rehabilitation after an acute care
hospitalization for a myocardial infarction and heart failure. In concert
with an Allergist, a baclofen desensitization protocol was developed
using an oral suspension. The initial baclofen dose was 0.002 mg. The
dose was doubled every 15 minutes for a total of 12 steps and cumu-
lative dose of 10 mg. Close observation was required, and nursing
remained at the patient’s bedside for the 3-hour process. The risk of
an anaphylactic reaction was low, yet IV methylprednisolone, IV
diphenhydramine, and IM epinephrine were available if needed.
Setting:
Academic medical center and acute rehabilitation hospital.
Results:
The patient tolerated the desensitization without an adverse
reaction and was started on a standard baclofen regimen. He subse-
quently experienced a considerable reduction in tone.
Discussion:
Baclofen hypersensitivity reactions are rare, and there is
a paucity of literature on baclofen desensitization. This case provides
a unique clinical example of a successful desensitization protocol in a
patient with a baclofen allergy.
Conclusions:
Baclofen desensitization may be a viable option in
allergic patients with recalcitrant spasticity that impacts function and
is unresponsive to other pharmacological interventions. Once desen-
sitized, patients should continue regular use of the medication to
maintain tolerance.
Level of Evidence:
Level V
Poster 302:
Treatment with Onabotulinum Toxin A for Post-Traumatic
Oromandibular Dystonia: A Case Report
Amar M. Mangalapudi (Sinai Hospital of Baltimore PM&R Program,
Adelphi, MD, USA), Amanda K. Morrow, MD, Lynn Staggs, MD, MS
Disclosures:
Amar Mangalapudi: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 43-year-old woman with a history of
facial trauma and temporomandibular joint (TMJ) displacement
complicated by chronic pain, muscle spasms, and difficulty opening
her mouth had undergone three surgeries to correct TMJ displace-
ment, four stellate and sphenopalatine blocks, and several modalities
with minimal relief. She continued to experience severe pain, spasms
and restriction of jaw motion. She became opiate dependent and
could only tolerate a liquid diet. Lidocaine and steroid injections
temporarily relieved symptoms. Given improvement with lidocaine, a
multidisciplinary team consisting of orofacial pain specialist, dentist,
and physiatrist decided to trial injection with onabotulinumtoxinA
(OTA). 100 units of OTA were reconstituted with 1 mL of preservative
free saline. After initial injection with 2mL of 1% lidocaine to the distal
condyle, 25 units of OTA were injected into to each left lateral pter-
ygoid and right masseter. She tolerated the procedure well without
complications.
Setting:
Outpatient Clinic.
Results:
Prior to injection she was able to open her mouth 6 mm,
immediately post injection it was 31 mm. At 6-week follow-up, range
of motion was 20 mm voluntarily and 30 mm with active assist. She
reported decreased pain with reduced opiate requirement, improved
facial spasms, ability to eat solid food, and improved quality of life
with plan to return to work. She continues to follow up for repeat OTA
injections to control her symptoms.
Discussion:
Previous case studies have demonstrated use of OTA in
treatment of dystonia due to neurogenic TMJ dislocation, cervical
dystonia, myofascial pain, facial spasticity secondary to cerebral
palsy, and migraine headaches. This is a case where OTA substantially
improved symptoms in a patient for 6 weeks.
Conclusions:
Treatment with onabotulinumtoxinA may be used for
mandibular and cervical dystonia and pain caused by traumatic TMJ
dislocation and can substantially alleviate pain, increase range of
motion and improve quality of life.
Level of Evidence:
Level V
S227
Abstracts / PM R 9 (2017) S131-S290