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history of lymphoma did provide a hint to the source. It was assumed
that the patient was in remission, but recognition of the HOA did lead
to the discovery of his lymphoma.
Conclusions:
Although the intent of the x-ray was to investigate local
pathology, the findings were related to his lymphoma. Careful consid-
eration of the locations of the cortical thickening at the tibia and fibula
suggested HOA in this setting. HOA is rare, but its finding can be
indicative of malignant or pulmonary processes. Further investigation
was warranted, revealing the recurrence of lymphoma that produced
the secondary hypertrophic complications seen on the knee x-ray. Un-
usual radiographic findings like this remind us to be cognizant of
possible systemic manifestations from remote sources in our imaging.
Level of Evidence:
Level V
Poster 184:
An Unusual Presentation of HIV Myelopathy: A Case
Report
Ammon A. Hills, DO (UT Southwestern Medical Center, Garland, TX,
United States), Jennifer Yang, MD
Disclosures:
Ammon Hills: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
This previously healthy 53-year-old
Caucasian man developed headache and fever not responsive to anti-
biotic treatment. Approximately 10 days later he experienced numb-
ness in his feet which progressed proximally. He was diagnosed with
Guillain-Barre Syndrome (GBS) and was treated with intravenous (IV)
antibiotics and five rounds of IV Immunoglobulin before admission to the
Inpatient Rehabilitation Unit. His ascending symptoms worsened and he
developed new truncal and upper extremity paresthesias. Magnetic
resonance imaging of his lumbar spine revealed enhancement of the
dura and cauda equina. Repeat lumbar puncture and electrodiagnostic
studies were inconsistent with the diagnosis of GBS. The patient was
ultimately diagnosed with human immunodeficiency virus (HIV), and
started on highly active antiretroviral therapy (HAART), followed by a
short course of IV steroids with improvement of paresthesias and motor
function. He was discharged at a modified independent level using a
wheelchair, and with home health therapies.
Setting:
University Medical Center Inpatient Rehabilitation Unit.
Results:
At his 2-month follow-up visit he had regained bowel and
bladder continence. He was able to ambulate with a rolling walker at his
5-month follow-up, and progressed to a single-point cane at one year.
Discussion:
HIV-associated neurological symptoms can be challenging
to diagnose at the time of presentation. Neurological symptoms are
typically seen in advanced stages of HIV, and rarely present with
myelopathy at the time of diagnosis. Only three case reports have
been described where primary HIV presents with myelopathy, with two
of the cases improving after receiving IV steroids.
Conclusions:
Acute myelopathy is rarely seen with primary HIV.
Neurologic involvement can occur in the early stages of HIV making the
diagnosis challenging. Evidence on the management of HIV myelopathy
is lacking, but should include the consideration of antivirals, and high
doses of corticosteroids.
Level of Evidence:
Level V
Poster 185:
Essential Cryoglobulinemia Vasculitis Leading to
Bilateral Above-Knee Amputations: A Case Report
Simon M. Willis, MD (WA Hosp Cntr/Georgetown Univ, Washington,
District of Columbia, United States), Michele Anderson, BSc,
Howard A. Gilmer, DO
Disclosures:
Simon Willis: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
A 63-year-old man with history of type 2
diabetes mellitus, hypertension and obstructive sleep apnea who
presented as a transfer from an outside hospital (OSH) with subacute
progression of skin lesions over 4 weeks that began as tiny red spots on
the backs of his fingers and the tops of his ankles that developed into
painful, broad desquamation of skin worse in the lower extremities.
Setting:
Inpatient.
Results:
Skin biopsies performed at the OSH were non-diagnostic and
rheumatologic workup was negative except for low C4, elevated
anticardiolipin IgM, and elevated ESR and CRP. Upon transfer to the
university hospital he was found to be positive for cryoglobulin of 4%
with a normal peripheral blood smear. Subsequent medial leg biopsy
revealed vasoocclusive thromboembolic vasculopathy affecting small
size superficial blood vessels and he was diagnosed with essential
cryoglobulinemia vasculitis. He was treated with high dose IV steroids,
plasmapheresis, and rituximab without response. Eventually he was
taken to the operating room for bilateral above-knee amputations for
treatment of severe refractory lower-extremity gangrenous changes.
Discussion:
Cryoglobulinemia is a rare condition that involves the
small-medium sized vessels with three main variants existing: type I,
II, and III. Generally, it is associated with other disease processes, but
is considered “essential” when there is no underlying disease associ-
ation. Most patients that have cryoglobulinemia have varying amounts
of cutaneous involvement from pruritic lesions to gangrene, which can
lead to amputations. Patients with essential cryoglobulinemia often
have a very quick progression of the disease process.
Conclusions:
As gangrene and small pruritic lesions can be associated
with a variety of diseases, cryoglobulinemia should be included in the
differential, as these cases of essential cryoglobulinemia have a
particularly quick clinical presentation with poor response to thera-
pies. Early identification and intervention may help to prevent sub-
sequent morbidity and reduction in the need for amputations.
Level of Evidence:
Level V
Poster 186:
First Successful Bipolar Osteochondral Allograft
Transplantation in the Ipsilateral Knee of a
Transtibial Amputee: A Case Report
Christopher F. Ketcham, DO (University of Missouri, Columbia, MO,
United States), Joseph E. Burris, MD, James L. Cook, DVM, PhD,
James P. Stannard, MD
Disclosures:
Christopher Ketcham: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
The patient is a 52-year-old female
transtibial amputee who ambulated at the K3 level with a below knee
prosthesis for almost 10 years, she then developed progressively
worsening ipsilateral knee pain with ambulation. Arthroscopy dis-
played large articular cartilage lesions within the patellofemoral joint.
With a short tibial segment the patient was not a candidate for knee
arthroplasty. The decision was made for fresh bipolar osteochondral
allograft transplantations of the right patella and trochlea.
Postoperatively the patient was admitted to an inpatient rehabilitation
hospital where she focused on transfer and balance training along with
contralateral lower extremity strengthening prior to discharging home.
She required a 6-week period of non-weight-bearing followed by pro-
gressive weight-bearing. At 6-month orthopedic follow-up the patient’s
grafts had integrated well with patellofemoral alignment, tracking and
joint space maintained. She is currently ambulating with prosthesis up
to 12 hours per day utilizing a single axillary crutch for assist while
advancing with therapy to regain full ambulatory independence.
Setting:
Inpatient Rehabilitation Hospital.
Results:
Successful osteochondral allograft in ipsilateral transtibial
amputee.
Discussion:
There have been only four case reports in published
literature of total knee arthroplasty of an ipsilateral transtibial
amputee. Up to 88% of ipsilateral knees demonstrate osteoporosis and
many simply are not candidates for arthroplasty due to a short residual
limb. Osteochondral allograft transplantation may be an option for
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Abstracts / PM R 9 (2017) S131-S290