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drop with steppage gait and was prescribed an articulating left
ankle foot orthosis set in slight plantar flexion to improve knee
stability.
Discussion:
Preservation of hip flexion is seen in femoral nerve
injuries below the inguinal ligament after the branch to psoas
major. The patient was placed in lithotomy positioning during
surgery with hips flexed, abducted, and externally rotated putting
the femoral nerve in a potentially unfavorable position sharply
angulated beneath the inguinal ligament. Blood is supplied to the
femoral nerve via iliolumbar artery, deep circumflex iliac artery
(in the inguinal region) and lateral circumflex artery. The right
deep circumflex artery has been found in cadaveric studies to give
more arterial branches to the nerve than the left; hence the left
femoral nerve may be more vulnerable to ischemic injury and
explain why only the left femoral nerve was compromised in this
patient.
Conclusions:
Unilateral knee extension weakness with preservation of
hip flexion is an unusual presentation of iatrogenic femoral nerve
injury which may be explained by lithotomy positioning and predi-
lection for left sided involvement due to variable blood supply to the
nerve. An additional caveat to this case was a concomitant common
peroneal nerve injury posing challenges in both diagnosis and
treatment.
Level of Evidence:
Level V
Poster 360:
Preliminary Study on the Mechanism of Repetition
Recovery in a Chinese Aphasia Patient by Combining
Resting-State fMRI and DTI: A Case Report
Wang Hong, MD (Guangzhou, China)
Disclosures:
Wang Hong: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
Case Description: This patient received
a 4-months traditional speech therapy (ST) and achieved good
speech improvement. Before and after the 4 months’ ST, Aphasia
Battery of Chinese (ABC), which is a modified Western Aphasia
Battery (WAB) adapted to Chinese culture, was applied to evaluate
the patient’s speech function. The r-fMRI and diffusion tensor im-
aging study (DTI) were performed with a 3.0T MR system. The
fractional anisotropy (FA) was calculated with the Functool 9.4.05a
software to approach the integrity of AF. The correlation co-
efficients for functional connection (FC) strength between Broca
area (BA) and Wernicke area (WA) was determined with software
DPARSF and REST.
Setting:
An academic hospital.
Results:
In the two sub-items of repetition, this patient demonstrated
remarkable improvement in the word repetition (WR), but limited
improvement in the sentence repetition (SR). The correlation co-
efficients between BA and WA showed an increase in left hemisphere,
but a slight decrease in right hemisphere. The FA value in AF was found
to have mild increase bilaterally.
Discussion:
In this patient, both the structural connection (SC)
repair of AF revealed by DTI and the increased FC between BA and
WA revealed by r-fMRI are consistent with his WR recovery. The
decrease of the FC between BA and WA in right hemisphere sug-
gested the down-regulation of the inhibition from the non-domi-
nant hemisphere may also play a role in WR recovery. The
relative limited recovery of SR may be due to the insufficient
recovery of AF.
Conclusions:
Both FC and SC between BA and WA may contribute to
WR recovery. However, SR recovery requires more complicated nerve
routes and more solid SC recovery, and possibly involving wide brain
areas.
Level of Evidence:
Level V
Poster 361:
Psychogenic Polydipsia after Pediatric Severe Traumatic
Brain Injury: A Case Report
Philip Chen, MD (University of Michigan, Ann Arbor, MI, United
States), Ryan Stork, MD
Disclosures:
Philip Chen, MD: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 16-year-old male with severe trau-
matic brain injury (TBI) after a motor vehicle collision. During the
patient’s acute rehab stay, the patient and mother described an
insatiable thirst. Oral fluid intake and urine outputs ranged from 3 to
7 liters per day. There was an initial clinical concern for diabetes
insipidus (DI). Sodium remained normal throughout his admission.
Serum osmolality remained in normal limits. Urine osmolality was
low. Patient was unable to complete a water deprivation study
during the inpatient stay due to profound thirst. After discharge, his
polydipsia continued, including reports of drinking 5 gallons of milk
per week.
Setting:
Tertiary care pediatric hospital.
Results:
A water deprivation test was performed as an outpatient
confirming appropriate concentration of urine and excluding the
diagnosis of DI. 6 months after discharge, family noted his thirst was
improving, though still increased compared to baseline. A nutritionist
assisted with behavioral management, as he also had hyperphagia
causing significant weight gain.
Discussion:
Sodium and fluid balance dysfunctions are commonly re-
ported following severe TBI, including cerebral salt wasting, diabetes
insipidus, and the syndrome of inappropriate ADH secretion. Psycho-
genic polydipsia, on the other hand, is a very rare complication after
TBI, being described in only two prior case reports to our knowledge,
and none previously in a pediatric patient. Diabetes insipidus and
psychogenic polydipsia have similar clinical presentations, but it is
important to distinguish the two because the treatments are vastly
different, and mistreatment can lead to serious consequences,
including hyponatremia or hypernatremia. A water deprivation study
should easily establish the correct diagnosis.
Conclusions:
Psychogenic polydipsia is a rare complication of TBI. It
is important to be aware of given the similarity in clinical presen-
tation to diabetes insipidus, which is a more common complication
after TBI.
Level of Evidence:
Level V
Poster 362:
Nivolumab-Induced Concurrent Guillain-Barre
Syndrome and Myasthenia Gravis in a Patient with
Metastatic Renal Cell Carcinoma: A Case Report
Isabel M. Rutzen-Lopez (UT MD Anderson Cancer Center), Jack B. Fu,
MD, FAAPMR, Jose E. Arias-Berrios, MD
Disclosures:
Isabel Rutzen-Lopez: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 67-year-old man with metastatic
renal cell carcinoma who had recently received immunomodulation
therapy with Nivolumab, presented to the Emergency Center
reporting 3 weeks of progressive diplopia, dysphagia, dysarthria,
generalized weakness, and urinary and fecal incontinence. On
admission, the patient developed rapidly progressive respiratory
failure requiring endotracheal intubation. The patient was initially
treated with high dose steroids and plasmapheresis for suspected
immunotherapy-related Myasthenia Gravis. Extensive workup was
performed, including brain imaging, EMG, lumbar puncture, and
blood tests. Electrodiagnostic and lumbar puncture findings
favored diagnosis of Miller Fisher variant of Guillain Barre Syn-
drome (GBS). Further workup revealed abnormal AchR antibody
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Abstracts / PM R 9 (2017) S131-S290