S247 S290
(binding and modulating) sustained on repeated testing. EMG study
was repeated 3 weeks later and showed findings favoring a
neuromuscular junction (NMJ) dysfunction with improvement
noted in prior demyelinating findings.
Setting:
Tertiary care hospital.
Results:
Clinical and electrodiagnostic findings initially favored diag-
nosis of Miller Fisher variant of GBS. However, positive AchR antibodies
on repeated testing and electrodiagnostic findings on follow up EMG
favoring NMJ disorder, suggested co-existing Myasthenia Gravis. The
patient was treated with several sessions of plasmapheresis, high dose
steroids, IVIG, Rituximab, and Infliximab with eventual improvement
in motor symptoms and respiratory status.
Discussion:
Nivolumab is an anti-programmed death-1-specific
monoclonal antibody that may be used in the treatment of metastatic
renal cell carcinoma. Neurologic side effects are rare but include cases
of immune polyneuropathies, Guillain Barre´ syndrome, myasthenia
gravis, and immune encephalitis among others. While there have been
reported cases of Nivolumab associated GBS and Myasthenia Gravis
separately, this would be the first to describe a patient who had
findings of both neurologic conditions simultaneously.
Conclusions:
With the development of new approaches for cancer
treatment with immunotherapeutic drugs, it is essential that neuro-
logic immune-related adverse events are recognized and treated as
soon as possible, as early treatment increases the odds of recovery.
Level of Evidence:
Level V
Poster 363:
Transverse Myelitis Caused by Zika Virus Infection in
the Caribbean: A Case Report
Rafael A. Romeu-Mejia, MD (VA Caribbean Healthcare System, San
Juan, Puerto Rico, Puerto Rico), Joanne M. Delgado-Lebron, MD,
Eduardo Nadal-Ortiz, MD
Disclosures:
Rafael A. Romeu-Mejia, MD: I Have No Relevant Financial
Relationships To Disclose
Case/Program Description:
A 86-year-old man with history of
confirmed Zika viral infection presents to VA Hospital with
complaint of mild bilateral lower extremity weakness, leg pain and
difficulty walking 10 days after initial flu-like symptoms. Initial
physical examination was remarkable for a distal symmetric weak-
ness with no sensory deficits. Patient was admitted for further
workup including electrodiagnostic study, cervical, lumbar and
thoracic MRI. Lumbar puncture was performed, a presumptive
diagnosis of Guillain Barre was done and patient was treated with
intravenous immunoglobulins (IVIGs). After IVIGs patient showed
limited recovery, with progression of lower extremity weakness over
a 3-month course, with markedly limited ambulation, constipation,
sensory loss and preserved lower extremity deep tendon reflexes.
Electrodiagnostic study was performed twice showing findings
inconsistent with acute inflammatory demyelinating poly-
neuropathy. Lumbar puncture was repeated with persistence of
elevated CSF proteins. Cervical, thoracic and lumbar MRI with and
without contrast were performed.
Setting:
Tertiary care hospital.
Results:
Diagnosis of transverse myelitis causing a sensory incom-
plete paraplegia with sensory level at T6 was made. A short course
of high dose methylprednisolone was given with poor response.
Thoracic MRI was repeated 3 months after initial presentation with
evidence of mild hyperintensity of the thoracic cord from T4 to the
conus level.
Discussion:
To our knowledge this is the first case reported in the
literature about transverse myelitis associated to Zika viral infec-
tion in Puerto Rico, a U.S. territory in the Caribbean. Two cases
have been reported in the past year one in Colombia and the other
in Brazil.
Conclusions:
Transverse myelitis is a clinical syndrome, which can be
associated with a number of different viral conditions. Zika viral
infection, now an epidemic in the Caribbean, shall be considered in
the differential diagnosis of acute transverse myelitis.
Level of Evidence:
Level V
Poster 364:
Sensorimotor Polyneuropathy in a Patient with Rare
Type B Insulin Resistance and a History of Systemic
Lupus Erythematosus: A Case Report
Glenn A. Nanney, MD (Vidant Rehab Ctr/East Carolina Univ/Brod,
Greenville, North Carolina, United States), Carrie McShane, MD,
John Norbury, MD
Disclosures:
Glenn Nanney: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 43-year-old Jamaican-American woman
with a past medical history significant for systemic lupus erythema-
tosus presented as an inpatient consult for electrodiagnostic evalua-
tion of rapid onset weakness. Over the 4 months prior to admission,
the patient experienced significant weight loss, polyuria, polydipsia,
foot numbness and rapidly increasing global weakness. She was diag-
nosed with diabetes mellitus by a local provider and was prescribed
metformin. She presented to hospital with chest pain and was found to
have a blood glucose of
>
800 mg /dL. Patient was found to be positive
for antibodies to the insulin receptor and required increasing doses of
insulin, up to 1500 units three times a day with meals and 1000 units at
bedtime.
Setting:
Academic Medical Center.
Results:
Upon electrodiagnostic evaluation, the patient was found to
have electrodiagnostic evidence of a sensorimotor polyneuropathy
with prominent demyelination as well as axon loss.
Discussion:
Type B insulin resistance is a rare autoimmune disease
which results in the production of autoantibodies to the insulin
receptor. This results in very high blood glucose levels with even
minimal carbohydrate intake. The very high glucose levels rapidly
affect the myelin sheaths with a resulting sensorimotor
polyneuropathy.
Conclusions:
Rapid onset of sensorimotor polyneuropathy may be a
sign of rare Type B insulin resistance and should be carefully
evaluated.
Level of Evidence:
Level V
Poster 365:
Can Down Syndrome Predispose to Autoimmune Polyneuropathy?
A Case Report
Austin C. Myers, MD MBA (Vidant Rehab Ctr/East Carolina Univ/Brod),
Carrie McShane, MD
Disclosures:
Austin Myers: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 17-year-old male with past medical
history of Down Syndrome presented with 2-month history of pro-
gressive lower extremity weakness. Of note, patient was diagnosed
with hyperthyroidism 1 month prior. He denied viral illness, bowel
incontinence, bladder incontinence. Lumbar spine MRI showed
enhancement of cauda equina. Nerve conduction studies were inter-
preted as polyneuropathy with right prolonged F wave. Patient was
positive for Epstein-Barr virus and mycoplasma pneumoniae anti-
bodies. He was given two doses of intravenous immunoglobulin
without improvement and admitted to inpatient rehabilitation for
intensive therapies.
Setting:
Pediatric Inpatient Rehabilitation of Academic Medical
Center.
S247
Abstracts / PM R 9 (2017) S131-S290