S195 S290
Poster 196:
Electrophysiologic Study on Bilateral All-Ulnar
Innervated Hands with Symptoms of Carpal Tunnel
Syndrome: A Case Report
Norr Santz (State University of New York Downstate Medical Center,
Brooklyn, NY, USA), Arpit Arora, MD, Marcel G. Bayol, MD,
Sanjeev Agarwal, MD
Disclosures:
Norr Santz: I Have No Relevant Financial Relationships To
Disclose
Case/Program Description:
This is a 78-year-old woman with diabetes
mellitus and hypertension who was referred by Geriatrics for elec-
trodiagnostic evaluation for suspected carpal tunnel syndrome. The
patient presented with a several-year history of decreased sensation in
the distal third and fourth digits of her right hand, difficulty picking up
small objects, and atrophy of the right thenar eminence. We per-
formed the standard nerve conduction and electromyography screen
for carpal tunnel syndrome.
Setting:
Outpatient physical medicine and rehabilitation clinic.
Results:
On the nerve conduction studies, stimulation of both median
nerves at the wrist and stimulation of both ulnar nerves at the wrist,
while recording over the abductor pollicis brevis, resulted in the same
compound muscle action potential waveform (ie, the waveform
typical of the ulnar nerve stimulation at the wrist). The amplitude of
the ulnar nerve CMAPs was higher than that of the median nerve CMAPs
when stimulated at the wrist, suggesting the median nerve response
was a volume-conducted one. Stimulation of the median nerve at the
antecubital fossa resulted in no response. No typical anastomosis
patterns were identified. Needle EMG of the bilateral abductor pollicis
brevis (APB) muscles revealed normal insertional activity without
spontaneous activity, normal interference pattern, and normal
recruitment.
Discussion:
Ulnar innervation of typically median innervated muscles
is rare. This case presents a rare example of bilateral ulnar-dominated
motor innervation with a clinical presentation consistent with median
neuropathy [eg, marked atrophy of thenar eminence], but without any
typical forearm or hand anastomosis.
Conclusions:
Physiatrists and electromyographers should keep a
broad differential in patients presenting with signs and symptoms of
median neuropathy, including an ulnar nerve-dominated hand, to
prevent ineffective treatment strategies and inappropriate surgical
referrals.
Level of Evidence:
Level V
Poster 197:
Early and Aggressive Management of Extracorporeal Membrane
Oxygenation (ECMO) Related Complications on the Inpatient
Rehabilitation Unit: A Case Report
Jennifer L. Weekes, MD (Wm Beaumont Hosp)
Disclosures:
Jennifer Weekes: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 54-year-old man with no significant past
medical history was admitted to a small regional hospital after five
days of fevers, myalgias and dry cough. He began to decompensate
and required intubation due to severe hypoxemic respiratory failure.
Despite mechanical ventilation his respiratory status worsened
requiring transfer to a large tertiary care facility and initiation of
extracorporeal membrane oxygenation (ECMO). He was ultimately
diagnosed with H1N1 influenza and superimposed Pseudomonas bac-
terial pneumonia.
Setting:
Tertiary Care Hospital.
Results:
The patient remained on ECMO for approximately 2 months
and was subsequently transferred to the inpatient rehabilitation
(IPR) unit. In addition to numerous medical complications he was
diagnosed with major depression/post traumatic stress disorder
(PTSD) secondary to his prolonged hospitalization and the use of
ECMO. Early management of his PTSD by psychiatry and other sup-
porting staff allowed for effective therapy on IPR. After only 11 days
he was discharged home at a modified independent level for activities
of daily living and ambulating greater than 120 feet without an assis-
tive device.
Discussion:
The use of ECMO has been associated with long-term
complications that can be seen in patients on IPR. It has been reported
that patients treated with ECMO for acute respiratory distress syn-
drome (ARDS) experience decreased mental and social health as well
as have an increased likelihood for PTSD compared to other ARDS
survivors. These complications, if not addressed, hinder a patient’s
progress on IPR and delay restoration of their previous level of func-
tional health.
Conclusions:
As the utilization of ECMO continues to rise, physiatrists
must become more cognizant of the challenges faced by this patient
population during their rehabilitation course. ARDS treated with ECMO
is associated with increased prevalence of long-term psychiatric dis-
orders. Addressing these risk factors with comprehensive psychiatric
care in addition to inpatient rehabilitation may minimize the long-
term sequelae of ECMO.
Level of Evidence:
Level V
Poster 198:
Autoimmune Necrotizing Myopathy Following Statin
Use: A Case Report
Wyatt Kupperman, DO (Schwab Rehabilitation Hospital, Chicago, IL,
United States), Theresa J. Lie-Nemeth, MD, Jenny Yin, DO,
Roger R. Wang, DO
Disclosures:
Wyatt Kupperman: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 50-year-old man with diabetes mellitus,
hypertension, and hyperlipidemia with statin use for “years” pre-
sented with generalized weakness and pain in his back and lower
limbs, worsening over the last 5 months. He had multiple falls over the
last year and eventually became dependent for self-care and mobility.
On exam, he was noted to have symmetric proximal weakness of lower
limbs worse than upper. Cervical MRI showed multilevel degenerative
changes of the cervical spine, worse at C4-C5 with moderate to severe
spinal canal stenosis, but no definite cord signal abnormality. Rheu-
matologic workup included negative GAD antibody, positive HMG CoA
reductase inhibitor antibody, and elevated CPK. Muscle biopsy
revealed active inflammatory myopathy with focal necrosis and mini-
mal perimysial lymphocytic infiltrate. Patient was started on steroids
and transferred to acute inpatient rehabilitation.
Setting:
Tertiary Care Hospital/Acute Inpatient Rehabilitation
Hospital.
Results:
He completed acute inpatient rehabilitation and was dis-
charged to a skilled nursing facility needing supervision for eating,
minimum to moderate assistance for ADLs and transfers, and super-
vision for wheelchair propulsion.
Discussion:
Statins are generally well tolerated; however, 1 in 10,000
per year may experience weakness, elevated CK levels, and muscle
damage. Patients normally recover with discontinuation. Rarely, an
estimated 2 or 3 out of 100,000 may develop muscle necrosis and
antibodies against 3-hydroxy-3methylglutaryl coenzyme leading to
autoimmune myopathy. The etiology remains under investigation.
Treatment consists of discontinuation of the statin, oral prednisone,
and possible immunosuppressants. Strength generally improves.
Conclusions:
This case illustrates a rare side effect to commonly
prescribed medications for cholesterol management. It highlights the
importance for treatment in the event of a known side effect to
commonly prescribed medications. Continued research is needed to
understand the etiology of autoimmune myopathy to enhance treat-
ment and recovery.
Level of Evidence:
Level V
S195
Abstracts / PM R 9 (2017) S131-S290