S200 S290
Poster 212:
Spontaneous Bilateral Hip Fractures in a
Paraneoplastic Stiff Person Patient with Severe
Spasticity: A Case Report
Isabel M. Rutzen-Lopez (UT MD Anderson Cancer Center), Jack B. Fu,
MD, FAAPMR, Rajesh Yadav, MD, FAAPMR
Disclosures:
Isabel Rutzen-Lopez: I Have No Relevant Financial Re-
lationships To Disclose
Case/Program Description:
A 46-year-old woman with a history of left
breast invasive ductal carcinoma s/p neoadjuvant chemotherapy and
mastectomy. Fourteen months later, she presented with progressive
stiffening of the bilateral lower extremities causing her to become
bedbound over a 2-month period. She underwent an extensive
neurologic work-up including imaging of the brain and thoracic/lumbar
spine, EMG, rheumatologic tests, infectious disease tests (including
tropical paraparesis) and paraneoplastic antibody panel. The patient
was found to be GAD65 positive and diagnosed with paraneoplastic
stiff person syndrome (PSPS). The patient was treated with several
rounds of IVIG with partial response. Due to poorly controlled lower
extremity muscle spasms she eventually suffered bilateral hip
fractures.
Setting:
Tertiary care hospital.
Results:
The patient underwent left hip hemiarthroplasty due to
femoral neck fracture. Two weeks later she complained of worsening
pain of the right hip. She was found to have an acute right hip fracture
and underwent right hip hemiarthroplasty. The etiology of her bilat-
eral hip fractures is believed to be secondary to severe spasms as there
was no history of trauma and pathology was negative for metastatic
disease. The patient was subsequently transferred to the acute inpa-
tient rehabilitation unit and achieved improvements in her Functional
Independence Measure scores.
Discussion:
PSPS is a rare disease process that can lead to significant
physical impairment. In this case, uncontrolled spasms likely contributed
to her bilateral hip fractures. Musculoskeletal pain in PSPS patients should
be investigated radiographically to rule out metastases and fractures.
Conclusions:
PSPS is an uncommon manifestation of cancer. Severe
muscle spasms may lead to complications including fractures. Reha-
bilitation interventions improved patient function and should be
considered an integral part of the management of this condition.
Level of Evidence:
Level V
Poster 213:
A Case Report of Hypercoagulability Presenting as
Acute Radiculopathy, Leading to an Above Knee
Amputation: A Zebra in the Musculoskeletal and
Electromyography Clinics
Lauren S. Rudolph, MD (Univ of Utah Med Ctr), Susan V. Garstang, MD,
Laura Waller, MD/MPH, Michael R. Ortiz, MD
Disclosures:
Lauren Rudolph: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 60-year-old female smoker with chronic
low back pain presented to MSK clinic with left lower extremity (LLE)
numbness, weakness, and cramping for 3 weeks. Additional history
revealed patient taking high dose estrogen therapy for menopause
symptoms. Physical exam significant for tenderness over left para-
spinal muscles, positive straight leg raise and slump test. No swelling
or erythema. She had left dorsiflexion, EHL, and plantar flexion
weakness. Sensation to light touch decreased over left anterior leg and
dorsum of foot. We suspected a left lumbar radiculopathy, EMG was
performed and MRI was ordered.
Setting:
Outpatient musculoskeletal clinic.
Results:
EMG showed evidence of acute left L5 and chronic left S1
radiculopathy. Limb temperature 31.4 degrees Celsius. MRI of lumbar
spine showed mild degenerative changes without spinal canal or neural
foraminal narrowing. She subsequently presented to PCP and ED
multiple times for shortness of breath and progressive LLE weakness.
Two weeks after clinic visit she developed Rutherford Class III ischemia
with absent pulses of the LLE. CTA chest revealed bilateral multi-
segmental pulmonary emboli. Arterial duplex revealed thrombi in left
common femoral and superficial femoral arteries, distal aorta and left
femoral and popliteal veins. She underwent AKA and subsequently
completed rehabilitation on our inpatient unit.
Discussion:
Initial presentation of acute radiculopathy was actually
subacute limb ischemia secondary to clots in the setting of hyperco-
agulability in a smoker on high dose estrogen therapy. Additional
workup for cancer, vasculitis and hereditary coagulopathy was nega-
tive. We suspect the abnormal MUAP morphology and spontaneous
activity on EMG was due to limb ischemia in the setting of muscle
denervation from hypoperfusion.
Conclusions:
Acute on chronic lower extremity ischemia may be the
underlying cause of a patient presenting to MSK clinic for clinical (and
EMG verified) radiculopathy, and should be included in the differential
diagnosis if neuroimaging does not reveal another etiology.
Level of Evidence:
Level V
Poster 214:
Diagnosing POEMS Syndrome in Acute Rehabilitation:
A Case Study
Leia Rispoli, MD (NY Presby Hosp/Columbia/Cornell, Jersey City, NJ,
United States), Brandon Garcia, BA, Akinpelumi Beckley, MD
Disclosures:
Leia Rispoli: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
The patient presented with progressive,
ascending lower extremity paresthesias and weakness. EMG showed
conduction slowing, lumbar puncture showed cytoalbuminologic
dissociation, leading to an initial diagnosis of CIDP. Lumbar MRI and
bloodwork were unremarkable. Patient was treated with intravenous
immunoglobulin with no clinical response. His symptoms progressed
and accompanied by a weight loss and fine motor skill decline. Patient
was started on plasma exchange and IV dexamethasone, with no
clinical improvement. Patient was admitted to acute rehabilitation for
management of his functional deficits. Due to his lack of response to
IVIG and PLEX, a further inpatient workup was initiated while in acute
rehabilitation. Findings revealed elevated ESR/CRP, monoclonal IgG on
serum protein electrophoresis, low total testosterone, and normal
vascular endothelial growth factor. Bone marrow biopsy showed
increased megakaryocytes and osteosclerotic trabecular changes.
Imaging revealed a large, expansile lytic lesion in T10 vertebral body,
which was biopsied and determined to be a lambda-restricted
plasmacytoma.
Setting:
Inpatient.
Results:
The patient was determined to meet diagnostic criteria for
POEMS syndrome (polyneuropathy, organomegaly, endocrinopathy,
monoclonal PCD, and skin changes), a rare paraneoplastic syndrome
secondary to an underlying plasma cell disorder. The patient was
transferred to bone marrow transplant unit for autologous stem cell
transplantation with planned return to rehabilitation after
remission.
Discussion:
Although POEMS syndrome is most commonly misdiagnosed
as CIDP, it can be distinguished by a lack of response to IVIG and PLEX and
the presence of additional symptoms. Minimally-invasive testing such as
EMG, serum VEGF, and radiographic bone scans can provide clues leading
to early treatment for a debilitating and potentially fatal disease.
Conclusions:
The complex, multisystem presentation and low inci-
dence of POEMS presents a diagnostic challenge, however a high index
of suspicion and close collaboration between neurology, endocrinology
and physiatry teams may warrant a more extensive workup, allowing
for a relatively earlier diagnosis and treatment.
Level of Evidence:
Level V
S200
Abstracts / PM R 9 (2017) S131-S290