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Poster 218:
Musculocutaneous Neuropathy Due to PICC Line
Insertion: A Case Report
Maria Janakos, MD (University of Louisville Physical Medicine,
Louisville, KY, United States), David Haustein, MD, Preeti Panchang, MD
Disclosures:
Maria Janakos: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 55-year-old man with uncontrolled
diabetes mellitus developed a diabetic foot ulcer and osteomyelitis
requiring intravenous antibiotics. He underwent sonographically
guided PICC line placement using a 5-French catheter with radio-
graphic confirmation of the tip at the cavoatrial junction. The patient
recalls terrible pain and extensive ecchymoses of his right arm and
lateral thorax in the days following the procedure as well as weakness
with right elbow flexion and paresthesias over the lateral forearm. He
was seen 2 months later by a physiatrist at the VA hospital and found to
have weak right elbow flexion and diminished sensation in the right
lateral antebrachium; otherwise normal strength and sensation
throughout the bilateral upper limbs. An abbreviated electro-
diagnostic study was performed that day for further evaluation.
Setting:
VA hospital.
Results:
A limited EMG of the right upper limb demonstrated a right
musculocutaneous neuropathy at least proximal to the fascicles to the
biceps characterized by at least partial axonal loss. Also noted was an
underlying peripheral polyneuropathy characterized by sensorimotor
axonal loss and demyelination.
Discussion:
Given its deep location, musculocutanous nerve injuries
are rare but have been reported in athletes performing repetitive
overhead activities as well as a complication of direct trauma,
shoulder dislocations, and surgery. Symptoms include arm pain,
weakness with elbow flexion and/or supination as well as sensory loss
over the lateral aspect of the forearm. Differential diagnoses include
brachial plexopathies and cervical stenosis. Spontaneous recovery is
possible but may take months to years.
Conclusions:
A musculocutaneous nerve injury is an unusual compli-
cation of upper extremity vascular access; given the close proximity of
nerve and vascular structures in the limbs, close monitoring for neu-
ropathy symptoms during and after the procedure is warranted.
Level of Evidence:
Level V
Poster 219:
Male Infertility Treatment Leading to Cerebellar
Cerebrovascular Accident: A Case Report
Hanzla Quraishi, MD (Marianjoy Rehab Hosp)
Disclosures:
Hanzla Quraishi: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 47-year-old man with a past medical
history of asthma, hypertension, and male infertility presented with a
complaint of acute vertigo for 6 days. He stated that it came on suddenly
with concurrent nausea, emesis and diplopia. Brain MRI was positive for
acute right posterior inferior cerebellar artery occlusion and right
vertebral occlusion. He subsequently underwent a midline suboccipital
craniectomy with durotomy and resection of infarcted brain. The pa-
tient was seen by neurology and it was determined that his cerebro-
vascular accident was secondary to hCG injections for male infertility.
Prior to presenting, the patient had no history of atherosclerotic disease
or hypercoagulable state predisposing patient to stroke.
Setting:
Acute Rehabilitation Hospital.
Results:
The patient completed a course of comprehensive inpatient
rehabilitation including physical, occupational, and speech therapies.
Discussion:
There is a known link between spinal cord injury and
stroke with infertility, specifically in the male population. This case
appears to be the first known event of male hCG treatments directly
leading to cerebrovascular accident. Prior cases of hormone therapy
leading to stroke involved either female hormonal therapy or testos-
terone treatment. In the younger rehabilitation population, fertility
and the ability to bear children are a distinct concern of many pa-
tients. Given this, there is merit to educating patients about risks of
fertility therapy as well as monitoring patients actively undergoing
fertility treatment. Comorbidities in the rehabilitation population may
further predispose patients to adverse outcomes regardless of gender.
Conclusions:
Treatment of male infertility can be associated with
increased risk of stroke, even in the absence of testosterone therapy,
specifically with hCG or Clomiphene. Given the biopsychosocial profile
of rehabilitative medicine, fertility concerns can often be of para-
mount importance in this population. Accordingly, it is the re-
sponsibility of the physician to educate patients in regards to risks and
benefits of potential therapy regardless of gender.
Level of Evidence:
Level V
Poster 220:
The Psychosocial Impact of Rehabilitation Services as
Highlighted by the Care of a Patient with Multiple
Epiphyseal Dysplasia: A Case Report
Charles P. Scott, MD (New York Presbyterian Hosp), Nasim Chowdhury, MD
Disclosures:
Charles Scott: I Have No Relevant Financial Relationships
To Disclose
Case/Program Description:
The patient was diagnosed with MED at
age 7 after 2 years of progressive gait impairment. Her father, paternal
uncle, and paternal grandmother were previously diagnosed with MED;
her father and uncle had each undergone bilateral hip replacements.
Neither she, nor her family, has yet undergone genetic testing; all
diagnoses were made clinically with plain film radiographs. She
described feeling increasingly socially isolated as a teenager, largely
due to her inability to participate in activities such as athletics and
casual play, given chronic joint pain and severe fatigue within several
minutes of activity onset. With progressive gait impairments causing
her to limp, she began physical therapy as a young adult, allowing her
to remain independent and to participate in academic, professional,
and social pursuits. After graduating from college, she completed a 26-
month engagement with the Peace Corps in the developing world,
remaining ambulatory with use of a cane. Due to progressive disease
and functional deficits, she underwent bilateral hip replacement at
age 29. Post-operatively, rehabilitation focused on retraining gait
mechanics and increasing independence with household tasks.
Setting:
In-patient rehabilitation unit of a tertiary care hospital.
Results:
The patient made rapid progress with ambulation and func-
tional tasks, and returned to full-time work 45 days after surgery.
Discussion:
Rehabilitation medicine played an integral role
throughout the care of this patient by helping to maintain mobility and
range of motion and through introduction of specific interventions
such as teaching the use of a cane and retraining gait mechanics.
Conclusions:
MED patients face a variety of physical limitations that
may have a marked impact on psychosocial functioning. Rehabilitation
strategies play an integral role in management of MED and can help
patients overcome significant physical barriers to social and profes-
sional integration.
Level of Evidence:
Level V
Poster 221:
Rehabilitation Considerations in a Patient With
Klippel-Feil Syndrome: A Case Report
Grace L. Maloney, MD (Marianjoy Rehab Hosp, Naperville, IL, United
States), Anjum Sayyad, MD
Disclosures:
Grace Maloney: I Have No Relevant Financial Relation-
ships To Disclose
Case/Program Description:
A 55-year-old man with Klippel-Feil syn-
drome, morbid obesity (BMI 47.8), type II diabetes, and asthma
S202
Abstracts / PM R 9 (2017) S131-S290