S250 S290
Poster 371:
The Course of Recovery in a Patient with Anti-NMDA
Receptor Encephalitis: A Case Report
Max B. Hurwitz, DO (Univ of WA Med Ctr), Denise Li Lue, MD
Disclosures:
Max Hurwitz: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 22-year-old woman with anti-NMDA
receptor (NMDAR) encephalitis. The patient presented to a tertiary
care hospital with progressively worsening neurologic and psychiatric
symptoms. Initially she demonstrated insomnia, anxiety and vision
changes. She rapidly developed frank psychosis, mania and general-
ized seizures and ultimately progressed to a minimally conscious
state. She was found to have CSF positive for anti-NMDAR antibodies
and started on initial immunotherapy with high-dose steroids, IVIG
and plasma exchange without improvement. Following a second stage
of treatment with 4 planned weekly infusions of rituximab and 1 out
of 6 planned monthly cyclophosphamide treatments she began
showing clinical improvement. At that time, she was admitted to
acute inpatient rehabilitation to address deficits in balance, speech,
memory, attention, processing speed, motor planning and urinary
incontinence.
Setting:
Tertiary Care Hospital and Acute Inpatient Rehabilitation.
Results:
2 weeks following completion of immunotherapy the patient
showed progress in motor function and communication in the acute
inpatient rehabilitation setting. Upon discharge she was able to
ambulate without an assistive device, complete self-care with only
contact guard assistance, but continued to have deficits in balance,
coordination, speech, memory, attention and language. We will
monitor and report on functional progress as the patient continues
therapy over the next few months.
Discussion:
Anti-NMDAR encephalitis is a rare autoimmune encepha-
lopathy. Antibodies are known to target specific brain regions with
higher density of the NR1 subunit of the NMDA receptors: hippocam-
pus, frontal lobes and basal ganglia. This leads to characteristic find-
ings of movement disorders, seizures, autonomic instability, cognitive
and psychiatric symptoms.
Conclusions:
Prolonged functional and cognitive deficits can persist in
patients with anti-NMDAR encephalitis, despite response to medical
treatment. This population benefits from close monitoring by a reha-
bilitation medicine physician and long-term therapies.
Level of Evidence:
Level V
Poster 372:
Delayed Inpatient Rehabilitation Leads to Significant Debility
in Charcot Marie Tooth Patient Status Post Fall
Rene C. Ruggiero, MD (Oakwood Heritage Hosp)
Disclosures:
Rene Ruggiero: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
The patient is an 81-year-old woman
with CMT whom presented to inpatient rehab 6 days after a ground
level fall with a R scapular fracture (NWB in RUE) and multiple
right rib fractures 3-9. Patient’s baseline prior to fall was inde-
pendent with all ADLs and most IADLs, she uses a hemi walker for
ambulation. She wears bilateral AFOs for ambulating as well. Pa-
tient worked with PT 45 mins per day starting 2 days after fall,
they did not have patient ambulated. Patient was planned for IPR
on day 3 but was delayed due to holiday closures, under-staffing
and other admissions accepted prior to hers. On IPR initial evalu-
ation (7 days post fall) patient ambulated 10 ft w/ walker. One
year prior patient had a laminectomy done, she was admitted to
IPR 4 days after surgery and walking 200 ft with walker on her
initial evaluation.
Setting:
Acute inpatient rehabilitation.
Results:
11 days post fall patient is ambulating 40 ft with hemi-
walker, she has become very frustrated with her progress. New
AFOs have been ordered for patient in hopes to progress
ambulation.
Discussion:
Charcot-Marie-Tooth (CMT) disease is an inherited
neuromuscular disorder affecting at least 1 in 2,500. The primary
treatment for CMT is rehabilitation therapy and surgical proced-
ures for skeletal deformities. There are many studies that
emphasize the benefits of muscle strengthening and gait training
for CMT patients. This case report shows how quickly decondi-
tioning can occur in a CMT patient and supports the importance of
gait training.
Conclusions:
This case enlightens us to consider the effects of
immobilization in patients with hereditary neuromuscular diseases. In
this patient specifically, due to the admission process and delay, a
triage system should be in place for admissions and/or an emphasis
on early gait training should be acknowledged for neuromuscular dis-
ease patients.
Level of Evidence:
Level V
Poster 373:
Rehabilitation Course Following Fat Emboli Syndrome:
A Case Report
Erica Seidel, MD (Univ of Minnesota), Mary Himmler, MD
Disclosures:
Erica Seidel: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 22-year-old man was involved in a
motorcycle accident with multiple fractures and a brief LOC at the
scene. Initial head CT was negative. He underwent emergent operative
repair of fractures and on postoperative day 2 had a decreased level of
consciousness. He extended one extremity to pain and was unre-
sponsive in other extremities. MRI was consistent with fat emboli
syndrome. His acute care hospitalization was complicated by venti-
lator associated pneumonia, cholecystitis, and multiple pressures ul-
cers. At the time of admission to acute rehab he would startle to
auditory and visual stimuli and open eyes spontaneously. He partici-
pated in intensive therapies and underwent trials of various neuro-
stimulant medications.
Setting:
Acute rehabilitation unit.
Results:
At time of discharge, 5 months later, he had made some
improvements although he remained significantly impaired. He
displayed reproducible movement to command, visual pursuit,
automatic motor responses, vocalization/oral movement, and eye
opening without stimulation. He was able to eat orally with
supplemental tube feedings, would vocalize spontaneously, and
would inconsistently show appropriate emotional responses to
environmental stimuli. He had significant issues with apraxia and
aphasia.
Discussion:
Fat emboli syndrome is a rare disorder that presents as
a triad of neurological dysfunction, respiratory problems, and a
petechial rash, often in the setting of a long bone fracture. We
describe the rehabilitation course of a patient with concurrent fat
emboli syndrome and TBI, who progressed from a persistent
vegetative state to a minimally conscious state. While this is a very
rare disorder, one case series found a good prognosis in the ma-
jority of patients even among those who were comatose initially.
Despite our patients’ young age and premorbid function, he
remained significantly impaired, likely due to his large burden of
emboli.
Conclusions:
Fat emboli syndrome can lead to significant long term
disability, but intensive rehabilitation can lead to some improvement.
Level of Evidence:
Level V
S250
Abstracts / PM R 9 (2017) S131-S290