Gilbert Siu

Sympathetic storming in a patient with intracranial basal ganglia hemorrhage.

Neurologic deficits and medical complications are common sequelae after intracranial hemorrhage. Among the medical complications, sympathetic storming is relatively rare. We describe a case of a patient with an acute right basal ganglia hemorrhage. During the patients hospital course, he developed tachypnea, diaphoresis, hypertension, hyperthermia, and tachycardia for three consecutive days. A complete laboratory work-up and imaging studies were unremarkable for infectious etiology, new intracranial hemorrhage, and deep vein thrombosis. The patient was diagnosed with sympathetic storming, a relatively uncommon cause of these symptoms. The storming was secondary to a kinked Foley catheter, and subsequent placement of a new catheter resulted in the resolution of his symptoms.

Purple Urine Bag Syndrome in Rehabilitation

ehabilitation physicians will occasionally encounter patients with urine discoloration. The pectrum of discoloration can vary from a red to orange to purple, and these discolorations ay indicate a benign condition or potentially serious medical pathology. For example, reen discoloration may indicate urinary tract infection, bile problems, or excess of B itamins, whereas red discoloration may indicate acidic urine caused by certain foods, edications (eg, rifampin and doxorubicin), or a primary urological pathology [1-3]. Brown rine can represent a serious medical condition, such as liver disease, acute renal failure, elanoma, or copper and phenol poisoning [1-3]. Purple discoloration is a rare phenomnon and may be alarming to the patient, patient’s family members, and rehabilitation staff. tiologies include medications with iodine-containing compounds, consumption of beets, orphyria, methylene blue, and pseudomonas bacterial infection [1,3]. One uncommon linical entity that causes purple discoloration of the plastic urinary drainage bag and tubing ithout discoloration of the urine is known as purple urine bag syndrome (PUBS). PUBS occurs predominantly in elderly women with chronic urinary catheterization and onstipation. Although this condition might be expected in a rehabilitation setting, we have ot identified any reported cases of PUBS in rehabilitation patients. This report provides a eview of the pathogenesis, clinical features, and management of PUBS, as well as rehabiltation implications.

Poster 201: Rehabilitation and Osteopathic Manipulative Medicine for a Patient With Dysphagia Secondary to a Hyoid Somatic Dysfunction: A Case Report

explorative hip surgery, reviewed and treated him unsuccessfully. Given the family’s frustration and fear of an unnecessary operation they explored a fourth opinion at our hospital with a spine surgeon. A lumbar spine magnetic resonance imaging (MRI) study was organized and the patient was subsequently referred to our clinic. After a careful neurologic examination a radicular pattern of pain and weakness after the L5 distribution was discovered. The MRI demonstrated a large cyst extending posteriorly from the L4-5 disk. At first, it was difficult to ascertain the origin of the cyst, but with the assistance of a radiology consultation the cyst was confirmed to extend from the disk itself. Setting: Outpatient interventional physiatry clinic. Results: The L5 radicular symptoms were treated successfully with a transforaminal epidural corticosteroid injection. The patient was able to return to sport and is currently being followed up with serial MRI studies to determine the rate and extent of disk resorption in the adolescent spine. Discussion: To our knowledge, there are only a handful of case reports with radicular symptoms secondary to diskal cyst. Furthermore, none of these have been described in the adolescent population. It is important to consider lumbar etiology for hip and lower extremity pain in young patients. This etiology can be easily missed leading to inappropriate therapies and interventions, which can be time consuming, costly, and detrimental. Conclusions: Diskal cysts are rare, particularly in the adolescent population. They can contribute to extensive radicular symptoms. It is important to consider an appropriate trial of conservative management, especially in the young population.

Poster 109 Unusual Cause of Quadrilateral Space Syndrome: A Case Report

on a steroid taper was initially admitted to the intensive care unit (ICU) for acute respiratory distress syndrome secondary to pneumonia versus acute amiodarone toxicity. He was intubated by using vecuronium and was started on high-dose intravenous steroids. After extubation, he had severe right-sided weakness and was diagnosed clinically with a stroke despite imaging of the head negative for acute pathology. Initial examination after transfer to inpatient rehabilitation illustrated proximal weakness that started improving after electrodiagnostic evaluation performed within 72 hours of admission. Setting: An electrodiagnostic center at a tertiary rehabilitation hospital. Results: Distal sensory and motor latencies were prolonged in the lower limbs with absent motor response in the peroneal nerve. Duration of the tibial response was prolonged. Median nerve minimum F latency was normal, with prolonged mean latency and chronodispersion. Recruitment was increased with profuse brief, small polyphasic potentials in the proximal muscles. Computerized interference pattern analysis of iliopsoas motor unit potentials showed increased ratio of amplitude per turn and turns per second. These findings suggest both myopathy and peripheral polyneuropathy. Discussion: Neuromuscular blocking agents and high-dose steroids alone or in combination can lead to a primary ICU myopathy. The history of proximal weakness after vecuronium, steroids, and critical illness suggest acute quadriplegic myopathy as the most likely diagnosis. Confirmation by repetitive nerve stimulation that showed a decremental response could not be done, because the patient had a defibrillating pacemaker. Conclusions: Acute quadriplegic myopathy is a rare complication of prolonged ICU stay that may be confused with many diagnoses, including stroke. When clinical examination findings do not correlate fully with the initial suspected diagnosis, electrodiagnostic studies should be performed to look for other explanations.

Poster 494 An Unusual Cause of Ischemic Stroke in a Patient With Hermansky-Pudlak Syndrome: A Case Report

functioning at maximal assistance level for self-care. Discussion: ODS is a demylating disease that involves pontine and extrapontine sites associated with alcoholism and hyponatremia. Oligodendrocytes are vulnerable to apoptosis during sodium correction, which leads to demyelination. Magnetic resonance imaging changes may be delayed, and imaging has no prognostic features. Functional outcome over time does not appear to be uniformly bad, as illustrated by a 34 case series: 2 acute deaths, 10 dependent, 11 with some deficits but independent, and 11 completely recovered. Conclusions: ODS may have a better functional recovery than once thought, but scientific investigation is needed on long-term functional outcome after ODS.

Poster 58 Rehabilitation After Central Pontine Myelinolysis Induced From Beer Potomania: A Case Report

acute inpatient rehabilitation facility. On admission, she had severe weakness in the extremities and facial muscles, which required maximum assistance, but had no sensory abnormalities. Electrodiagnosis was consistent with AMAN, and anti-GM1 ganglioside antibodies were positive. AMAN is an axonal variant of GuillianBarré syndrome, thought to be due to the production of antibodies to gangliosides on the axolemma. The differential diagnosis of acute motor weakness is vast, and the rehabilitation physician must be aware of other possible etiologies, including acute poliomyelitis, botulism, and myasthenia gravis. This case warrants review because there is little published on the rehabilitation of AMAN syndrome. Conclusions: This case demonstrates the successful and ongoing rehabilitation of a patient with AMAN syndrome and contributes to the literature on this topic.

Poster 281 Functional and Cognitive Outcomes in Survivors of Emergency Department Thoracotomy

Results: After 2 weeks of acute inpatient rehabilitation, which included daily repetitive passive range of motion, stretching, moist heat, hydrotherapy, and use of a stretcher chair, the patient’s axial and limb stiffness and functional mobility improved. She was able to ambulate with a rolling walker from 20-150 ft and stair climbing improved. Discussion: Stiff person syndrome is a rare neurologic condition characterized by symptoms of muscle stiffness and spasms usually starting axially. The involuntary contractions of agonist and antagonist muscles caused by motor unit activity are the key clinical and electrophysiological markers. Anti-GAD75 antibodies are positive in 65% of cases and are associated with other autoimmune conditions. The chronic, progressive, and variable nature of the disease indicates the need for life-long management and an individualized rehabilitation program. Conclusions: Awareness of this rare condition in addition to a comprehensive history and physical examination could avoid unnecessary invasive procedures. This case illustrates that intensive rehabilitation with physical therapy and occupational therapy can improve the functional outcome and quality of life of individuals with stiff person syndrome.

Poster 203: Rehabilitation of a Patient With Morel-Lavallee Lesion Secondary to an Improvised Explosive Device Blast: A Case Report

multilevel somatic dysfunctions. The patient underwent osteopathic manipulative medicine, consisting of myofascial release and muscle energy to the hyoid and anterior neck muscles with cervical high velocity low amplitude manipulation. After 3 sessions of osteopathic manipulative treatment and a home rehabilitation program consisting of anterior cervical muscle stretching, range of motion, and strengthening, the patient was re-examined and found to have decreased tissue texture changes, less restriction of motion and improved range of motion accompanied by an improvement in swallowing. Discussion: Whiplash injuries usually lead to soft-tissue injury, where most clinicians focus on the posterior neck as the cause of the pain symptoms. The anterior neck, however, is often overlooked. Soft-tissue injuries and somatic dysfunctions in the anterior neck, particularly the hyoid bone, may result in dysphagia. To our knowledge, this is the first reported case of hyoid somatic dysfunction causing dysphagia. Conclusions: Clinicians should be aware of this etiology, especially if imaging and electrodiagnostic studies are normal.

Poster 449: Cerebral Autosomal Dominant Arteriopathy With Subcortical Infarcts and Leukoencephalopathy (CADASIL) Mimicking Multiple Sclerosis: A Case Report

micturition and bowel movements. No fever, chills or trauma. During his admission to inpatient stroke rehabilitation program, 2 months before this admission, he complained of mild hip pain; x-ray film of hip showed moderate arthritis. Upon admission to medicine service, left lower extremity examination revealed spasticity with tenderness and painful ROM of hip. Blood cultures were negative, no leucocytosis, elevated C-reactive protein-1.553 and ESR-91. Septic arthritis of hip was suspected but CT scan showed no joint effusion. MRI of pelvis showed enlarged left piriformis 5 cm in size, with mass effect on rectum suspicious for inflammatory/infectious process. Examination by infectious disease revealed positive piriformis test; the diagnosis of pyomyositis was made. Setting: VA hospital. Results: Interventional radiology aspirated 5 mL of cloudy fluid from piriformis muscle, which grew Clostridium perfringens. Empiric cefazolin was switched to IV clindamycin and penicillin-G for 2 weeks, later penicillin-G was continued for 2 more weeks, and then 2 additional weeks of PO penicillin-V. Repeated CT scan at 4 weeks revealed 2-cm Piriformis muscle and at 8 weeks completely resolved pyomyositis, ESR-37, and patient was asymptomatic. Discussion: Pyomyositis is a suppurative infection of skeletal muscle that can mimic musculoskeletal pain or septic arthritis. Muscle injury is a predisposing factor for infection with associated bacteremia. Stroke patients are exposed to aggressive rehabilitation therapy and prone to injuries. Clostridium perfringens pyomyositis is a rare serious complication of trauma if not detected early. Conclusions: This is the first reported case of Clostridium perfringens piriformis pyomyositis. A high index of suspicion is required to detect and treat this condition early.

Poster 209: The Other White Coat Syndrome: Somatic Dysfunctions in Medical Students Wearing White Coats (A Case Series)

ROM, ADLs, and ambulation. Discussion: This is a case of severe and rapid onset of extraintestinal manifestations of Crohn disease not diagnosed until her rehabilitation admission. In a patient previously independent in ADLs and ambulation, this case demonstrates unusually rapid functional decline that may have been mitigated with earlier physiatric intervention. Conclusions: Physiatrists must have a high index of suspicion for potentially debilitating outcomes when encountering patients with Crohn disease accompanied by musculoskeletal complaints. Early diagnosis and treatment are essential in preventing joint deformity and destruction, and preserving maximal function.