S228 S290
Poster 303:
A Rare Series of Events Resulting in Hemorrhagic Conversion
of Stroke Due to Levamisole-Contaminated Cocaine:
A Case Report
Khushboo Doshi, MD (McGaw MC of NW Univ NW Med Schl/RIC,
Chicago, IL, United States), Benjamin Ingraham, DO, Stacey Bennis,
MD, Jacqueline Neal, MD, MSE
Disclosures:
Khushboo Doshi: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 59-year-old man suffered a cocaine-
induced acute left middle cerebral artery (MCA) infarction, for which
he underwent a 10 day course of acute inpatient rehabilitation (AIR),
discharging to home at the modified independent level. During hos-
pitalization, he developed uptrending creatinine to 1.7. Nephrology
consult suggested a contrast-induced or chronic NSAID use etiology
prior to discharge. 16 days later, he was re-admitted to the hospital
with a creatinine of 2.7, requiring initiation of dialysis. Renal biopsy
confirmed a diagnosis of pauci-immune ANCA glomerulonephritis
(+PR3), attributed to levamisole-contaminated cocaine. During renal
workup, his course was complicated by hemorrhagic conversion of the
prior left MCA stroke with worsening deficits, requiring transfer for
additional AIR.
Setting:
Acute care hospital and acute inpatient rehabilitation unit
within hospital.
Results:
Despite treatment for glomerulonephritis, he progressed to
dialysis-dependent end-stage renal disease. After the hemorrhagic
conversion, he had significant non-fluent aphasia, right upper ex-
tremity flaccid paralysis, and cognitive impairments. He required a 65-
day AIR course with discharge to a skilled nursing facility at the mod-
max assist level.
Discussion:
Over 70% of cocaine in the U.S. is contaminated with
levamisole, a veterinary anti-helminthic medication, which has
been associated with ANCA autoimmune disease. Patients
commonly present with purpuric skin lesions, and less commonly,
acquired renal disease. Likely, the patient’s hemorrhagic con-
version was either directly, or indirectly a result of the acquired
ANCA vasculitis
e
ultimately resulting in a poorer functional
outcome. This case highlights a rare, but clinically significant
series of events that may occur in patients with cocaine-induced
stroke.
Conclusions:
Physiatrists routinely care for these patients in the
subacute period, and thus play an integral role in identifying and
potentially preventing development of these complications via early
diagnosis and treatment.
Level of Evidence:
Level V
Poster 304:
Syndrome of Irreversible Lithium-Effectuated Neurotoxicity
(SILENT) With Dysarthria and Weakness: A Case Report
Sima A. Desai, MD (Tufts Medical Center), Ariel Savitz, MD
Disclosures:
Sima Desai: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
A 54-year-old schizophrenic man pre-
sented to an outside facility nonverbal, with fever, altered mental
status, and a generalized tonic-clonic seizure. He was found to
have an elevated lithium level to 3.10 and underwent emergent
dialysis. He was diagnosed with lithium toxicity and subsequently
with SILENT. His lithium and haloperidol were immediately dis-
continued and never restarted. Instead, the patient was started on
risperidone. He was transferred to an acute inpatient rehabilita-
tion hospital with severe dysarthria, hypophonia, bradykinetic
movements, left lower extremity rigidity, left upper extremity
resting tremor, generalized upper extremity and lower extremity
muscle weakness, oropharyngeal dysphagia, dysmetria, and
catatonia.
Setting:
Acute Inpatient Rehabilitation Hospital.
Results:
The patient underwent a comprehensive neurorehabilitation
program, in a 136 day stay with daily psychiatry follow up. Upon
discharge home the patient only required moderate assistance to
ambulate with a rolling walker, supervision for upper body dressing,
minimum assistance for lower body dressing, and moderate assistance
for toileting. His dysarthria had significantly improved and conversa-
tions were completely comprehendible. He was tolerating a pureed
diet with nectar thickened liquids. His bradykinetic movements,
hypophonia, and resting tremor had resolved. Additionally, he
regained full strength in his upper extremities and lower extremities
with resolution of catatonia. Functional independence measure
increased from 28 on admission to 78 at discharge. His risperidone was
slowly titrated to receive a morning dose and an evening dose, along
with buspirone for his anxiety and schizophrenia.
Discussion:
SILENT is an extremely rare psychiatric disorder that can
be very severe and debilitating. Education of lithium toxicity to cli-
nicians which can lead to persistent cognitive and neurological
impairment is imperative for prevention of SILENT.
Conclusions:
Our case demonstrates the effectiveness of an acute
comprehensive multidisciplinary rehabilitation approach for SILENT.
By combining aggressive treatments that simultaneously addressed
cognitive and neurological impairments, achievement of dramatic
gains is possible.
Level of Evidence:
Level V
Poster 305:
Delayed Diagnosis of Traumatic Brown-Sequard-Plus
Syndrome Due to Associated Brachial Plexopathy: A
Case Report
Raul Rosario, MD (University of Puerto Rico), Carmen C. Lopez-
Acevedo, MD, Carmen E. Lo´pez Acevedo, MD
Disclosures:
Raul Rosario: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Patient: A 29-year-old man with Brown-
Sequard-Plus Syndrome (BSPS) and Left Lower Trunk Brachial Plexop-
athy secondary to gunshot wound in the left inferior neck region. Case
Description: Upon initial evaluation patient found with left hemibody
weakness that was most prominent in the upper extremity. Neck and
chest CT demonstrated a small left pneumothorax and a severely
comminuted fracture of the left T2 transverse process. Brain CT
revealed no acute intracranial pathology and spinal cord imaging was
not performed in the acute setting. Evaluation in clinics 3 weeks later
showed significant left distal upper extremity weakness with associ-
ated improvement of left lower extremity strength. Also present were
loss of pain and temperature sensation below right T2 dermatome
level with intact proprioceptive and vibratory sensation. As the patient
also presented neurogenic bowel and bladder, cervico-thoracic mag-
netic resonance imaging was requested and revealed a T2 level spinal
cord edema compatible with spinal cord contusion. Electrodiagnostic
study confirmed a lower trunk left brachial plexopathy.
Setting:
Tertiary Care Trauma Hospital.
Results:
Patient diagnosed with BSPS and associated Left Lower Trunk
Brachial Plexopathy. Ambulatory therapies were prescribed. Further
developments will be discussed.
Discussion:
This is the first reported case, to our knowledge, of a
concomitant BSPS and left brachial plexopathy in a gunshot wound
patient. Delayed or missed diagnosis of BSPS may occur in a trauma
setting for which detailed history and physical examination are
essential.
Conclusions:
Traumatic BSPS may occur associated with brachial
plexopathy in gunshot wound patients.
Level of Evidence:
Level V
S228
Abstracts / PM R 9 (2017) S131-S290