S253 S290
Poster 380:
Progressive Proximal Muscle Weakness in a 61-Year-Old Man:
A Case Report
Molly E. Schill, DO (Vidant Rehab Ctr/East Carolina Univ/Brod)
Disclosures:
Molly Schill: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 61-year-old man presented to his pri-
mary care doctor outpatient with proximal muscle weakness and was
diagnosed with polymyalgia rheumatica, started on prednisone, and
referred to neurology for further work-up. Electromyography (EMG)
revealed irritability and fibrillation potentials with reduced recruit-
ment patterns. He was diagnosed with polymyositis and continued on
low dose prednisone 20 milligrams daily as he had improved to base-
line. He presented one year later to the hospital with progressively
worsening proximal muscle weakness, rendering him wheelchair
bound, and dysphagia. Creatine kinase was elevated. Anti-Jo-1 anti-
body, signal recognition particle antibody, and thiopurine methyl-
transferase were negative and muscle biopsy was not done. He was
treated with high dose steroids and azathioprine but had little func-
tional improvement. Physiatry was consulted and he was admitted to
inpatient rehabilitation.
Setting:
General Inpatient Rehabilitation Center.
Results:
On admission to rehabilitation, he was unable to stand inde-
pendently and had a nasogastric tube in for nutrition. He worked
intensively with physical therapy and occupational therapy for 3 weeks.
By discharge, his hip flexor strength increased from 2/5 to 4/5 and his
elbow flexion and extension strength increased from 2/5 to 4/5. He was
ambulating 50 feet with contact guard assist. After working with speech
therapy on dysphagia exercises and receiving neuromuscular electrical
stimulation, he was able to transition to a regular diet.
Discussion:
Polymyositis is an idiopathic inflammatory myopathy that
should be considered when patients present with proximal muscle
weakness. Dysphagia occurs in about a third of severe cases. EMG may
show increased insertional activity and spontaneous fibrillations.
Treatment usually consists of steroids.
Conclusions:
The clinical course for polymyositis is very unpredict-
able in terms of improvement in function. Although pharmacologic
therapy should be started immediately, initiating therapies with the
patient early on in the course can hasten their recovery.
Level of Evidence:
Level V
Poster 381:
Incomplete Recovery of Post-Sternotomy Plexopathy: A Case
Report
Mariko Kubinec, MD (University of Louisville, Louisville, Kentucky,
United States), David Haustein, MD, Brenton C. Bohlig, MD
Disclosures:
Mariko Kubinec: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 60-year-old woman reported
decreased sensation in left digits four and five, and clumsiness /
weakness of the left hand following a median sternotomy for open
heart surgery. An electrodiagnostic study demonstrated sponta-
neous activity in the left first dorsal interosseous, left flexor carpi
ulnaris, and left extensor digitorum communis that was originally
interpreted as a left C8 radiculopathy. She continued to have left
hand tingling, numbness, and weakness for seven years and was
referred for repeat electrodiagnostic evaluation. Left arm sensory
and motor nerve conduction studies were normal, but EMG
demonstrated decreased recruitment of long duration, large
amplitude potentials in the left extensor digitorum communis.
Needle study was abbreviated due to bleeding.
Setting:
Academic VA Medical Center.
Results:
Combined with clinical history of sternotomy and initial EMG
findings, this patient appears to have experienced sternotomy related
plexopathy with denervation then reinnervation in the left lower trunk
distribution affecting C8-innervated muscles.
Discussion:
The incidence of brachial plexus injury following open
heart surgery ranges from 2% to 38%. Patients most commonly present
with medial hand sensory complaints. Electrodiagnostics can confirm
decreased ulnar SNAP and CMAP amplitudes and axonal loss in muscles
innervated by the C8 nerve root. Prognosis is usually excellent with an
overwhelming majority of patients making a full recovery within one
month of surgery.
Conclusions:
This is an unusual case of incomplete recovery of lower
trunk brachial plexopathy secondary to open heart surgery in which
the lower trunk was re-innervated, but the patient continued to have
sensory complaints seven years later.
Level of Evidence:
Level V
Poster 382:
Ischemic Stroke due to Pituitary Adenoma Occluding
the Internal Carotid Artery: A Case Report
Vincent Y. Ma, MD (VA Greater LA Hlth Care Sys/UCLA, Los Angeles,
CA, United States), Mary Nasmyth, MD, David N. Alexander, MD
Disclosures:
Vincent Ma: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
LB is a 56-year-old right-handed man
who presented with right occipital headache, confusion, left prona-
tor drift, no motor deficits. MRI/MRA showed a complete occlusion of
the right ICA from the carotid bifurcation as well as a large supra-
sellar mass identified as a non-functioning pituitary adenoma without
apoplexy. He was started on levothyroxine with plans for elective
trans-sphenoidal resection after sufficient stroke recovery. On Hos-
pital Day 5 (HD-5), the patient felt unwell during a bowel movement
and became unresponsive with right eye deviation and new left leg
and arm weakness. Vitals were notable for BP 80/29 and heart rate
of 37. The event was attributed to cerebral hypoperfusion secondary
to a vasovagal episode. He was started on fludrocortisone and
midodrine to maintain a target systolic blood pressure goal of 120-
160 mmHg.
Setting:
Acute rehabilitation hospital.
Results:
The patient had no further signs of stroke re-expression for
the remainder of his 15-day rehabilitation course and was discharged
at stand-by-assist levels for self-care and mobility.
Discussion:
Pituitary adenoma leading to ICA occlusion is exceedingly
rare, with just 14 cases identified since 1952. Of those, 11 presented
with cerebral ischemia. This case highlights the rare association be-
tween pituitary macroadenoma and ischemic stroke, linked by the
internal carotid artery’s vulnerability to occlusion around the supra-
sellar region. The patient’s transient stroke re-expression due to an
episode of hypotension after physical therapy both supports the
occlusive etiology, and demonstrates the need for vigilance against
cerebral hypoperfusion in managing and rehabilitating such patients,
with appropriate interventions including mineralocorticoid therapy
and liberalization of dietary salt restrictions.
Conclusions:
In the rare case of ischemic stroke due to pituitary ad-
enoma, the risk of symptom progression due to hypotension must be
carefully managed to prevent complications that may worsen symp-
toms and interfere with rehabilitation.
Level of Evidence:
Level V
Poster 383:
No Smiling Matter: An Unusual Presentation of Guillain Barre
Syndrome
Kadir J. Carruthers, BS (Univ Med Cntr of Pittsburgh),
Mary Ann Miknevich, MD
Disclosures:
Kadir Carruthers: I Have No Relevant Financial Re-
lationships To Disclose
S253
Abstracts / PM R 9 (2017) S131-S290