Faculty Bibliography

Case/Program Description: A 23-year-old woman with history of asthma who presented with gradual onset polyarticular pain and swelling causing difficulty walking, along with skin lesions, dysphagia, dyspnea and weight loss. Patient was noted to have hemolytic anemia, transaminitis, multifocal pneumonia, along with both proximal and distal muscle weakness. Workup included liver and muscle biopsies. Priortobiopsy results being available, patient was treated with steroids. Patient was transferred to acute inpatient rehab without a known etiology of her symptoms. Physical exam at rehab revealed dry skin and icteric sclerae. Active and passive range of motion were decreased in all extremities due to weakness and pain, respectively. Motor testing revealed diffuse weakness, specifically 3/5 bilateral shoulder abduction, 3/5 bilateral elbow extension, 3/5 bilateral hip flexion; otherwise, 4/5 throughout. Elbows tender to palpation with moderate effusions. Right thigh hematoma at the site of muscle biopsy. MRI Femur revealed diffuse symmetric myositis. Muscle biopsy confirmed dermatomyositis. Setting: Inpatient. Results: Patient was admitted to acute inpatient rehabilitation requiring moderate assistance for transfers and ADLs, and minimal assistance with rolling walker for ambulation. Despite patient's rehab course being limited by persistent severe pain, patient did make significant gains in functional mobility such as: sit-to-stand with minimal assistance and ambulation with supervision without assistive device. Discussion: Dermatomyositisisarare, acquired inflammatorymyopathy that affects 4-10/1,000,000 annually. Symptoms include skin changes and proximal and pharyngoesophageal muscle weakness. Dermatomyositis maybeassociated with interstitial lung disease andmalignancy. Diagnosis is confirmed with muscle enzyme levels, autoimmune antibodies, elec-tromyography, and muscle biopsy. Treatment involves immunosuppres-sion. In this case, we encountered an atypical presentation which included polyarticular pain and swelling, distal muscle weakness in addition to proximal, transaminitis and hemolytic anemia. Conclusions: While dermatomyositis is uncommon, the physiatrist should be conscious of the associated risks and impairments of ADLs and functional mobility it may cause

Case/Program Description: The patient is a 64-year-old woman with history of HTN who presented to the ER with worsening extremity weakness. Of note patient had recently returned from a trip to the Dominican Republic 2 weeks prior. Patient reported significant amount of mosquito bites sustained while abroad. Upon return, the patient noted fevers, rash, joint pain and flu-like symptoms which then progressed to numbness and lower extremity weakness. EMG/NCS showed diffuse demyelination, sparing of the sural nerves and involvement of the median nerves supporting the diagnosis of GBS. Zika infection was confirmed with PCR and lumbar puncture which showed albu-minocytologic dissociation. During acute hospitalization, the patient was noted to have worsening dysphagia, dyspnea and respiratory fatigue and was admitted to the MICU service for respiratory monitoring and eventual intubation. Gradual improvement of respiratory function was noted after treatment with IVIg and patient began a bedside rehabilitation program until admission to acute inpatient rehabilitation. Setting: Acute Rehabilitation Hospital, outpatient ambulatory clinic. Results: Initially, the patient was noted to be max to total assist for ambulation, transfers and portions of self-care. A comprehensive rehabilitation plan was implemented to address her functional impairments. on discharge to home the patient was noted to be modified independent to with transfers and self-care. She continued with outpatient therapy and has progressed to full functional independence. Discussion: A recent editorial was published by the New England Journal of Medicine which showcased an association of GBS with Zika infection. To our knowledge, this is the first case of successful ongoing rehabilitation management of Zika virus associated GBS. Conclusions: With further study the Zika virus and advocation for rehabilitation management, this may assist with improving functional outcomes for patients presenting with Guillain Barre syndrome associated with Zika infection

Case Description: A 45-year-old woman with three weeks of worsening vertigo, altered tongue sensation and horizontal diplopia leading to inability to walk, traveled from Congo to the United States for treatment. Initial workup including CT and MRI was inconclusive. Para-neoplastic workup was initiated and patient was treated with steroids with limited improvement. Autoimmune workup was positive for the following markers: GAD65, OCB IgG in CSF, Lyme IgM, Parietal Cell Ab, Striational Cell Ab and VGKC Ab patient was diagnosed with Autoimmune Cerebellitis and treated with IVIG and plasma exchange with minimal improvement. Program Description: Inpatient Rehabilitation. Setting: Inpatient Rehabilitation. Results or Clinical Course: The patient was admitted to the acute inpatient rehabilitation unit with deficits caused by truncal ataxia including imbalance, inability to ambulate and deficits in activities of daily living (ADLs). Her vision remained impaired due to diplopia. Despite intensive Physical and Occupational Therapy she did not improve during her rehabilitation stay. She was discharged home requiring moderate assistance for ambulation with a weighted cane and modified independence level for ADLs due to persistent ataxia. Follow up MRI showed atrophy of vermis. Discussion: Autoimmune cerebellitis is rare, and presents with symptoms of ataxia. To our knowledge no documented cases of autoimmune cerebllitis in a rehabilitation setting have been described. The patient's symptoms did not resolve despite aggressive treatment and rehabilitation. On follow up visit the patient's diplopia and truncal ataxia had not improved. She remained at a moderate assistance level for ambulation with use of a weighted cane and required moderate assistance for ADLs. Conclusions: Autoimmune cerebellitis is a rare occurrencewhich is poorly understood. Despite early appropriate medical treatment and aggressive inpatient rehab this patient remained with ataxia and diplopia which caused functional deficits. This case h!

We report a case of a spontaneous sternal fracture secondary to idiopathic osteoporosis in a man in his late forties. His restrictive lung disorder from thoracic kyphoscoliosis was exacerbated by surgery to repair the sternal fracture. Inpatient cardiopulmonary rehabilitation helped this patient regain independence in functional status and ambulation after repair of the fractured sternum.

The case of a 28-year-old previously healthy male with a 13-year history of weight lifting is described. The patient presented to the emergency department complaining of severe anterior chest pain beginning during a workout. Following transthoracic echocardiogram and computerized tomogram the diagnosis of an ascending aortic dissection was made. The patient was taken emergently for surgical repair of an incompetent aortic valve and type II aortic dissection. Histopathologic examination of the aorta showed cystic medial degeneration. This is the first reported case of a type II aortic dissection secondary to cystic medial degeneration and the hemodynamic stresses of weight lifting. Physicians should be aware of this potentially catastrophic entity in weight lifters

OBJECTIVE: Venous thromboembolism after total-knee arthroplasty represents a common early postoperative complication resulting in significant morbidity. Despite this, the optimal prophylactic regimen is controversial. The prevalence of venous thromboembolism has been cited as high as 35% in patients receiving pharmacologic prevention alone. We investigated the efficacy of a comprehensive prevention protocol encompassing the use of epidural anesthesia, aspirin, venous foot compression pumps, and early mobilization in a series of consecutive total-knee arthroplasties. DESIGN: A series of 100 consecutive total-knee arthroplasty patients were enrolled into the prospective trial. All patients were allowed full weight bearing on the first postoperative day and ambulation as tolerated. Venous foot compression pumps and aspirin were used immediately after surgery in the totality of subjects. Seventy-five percent of the patients were transferred to an acute rehabilitation service during the first postoperative week. The presence of deep-vein thrombosis was subsequently determined with the routine use of venous duplex scans. RESULTS: Three patients (3%) demonstrated evidence of distal deep-vein thrombosis. No patient had symptomatic pulmonary embolism. CONCLUSION: The combination of epidural anesthesia, aspirin, immediate postoperative venous foot compression pumps, and early ambulation together seem to be a more effective approach to prevent the occurrence of thromboembolic events after knee replacements than pharmacologic prevention alone

OBJECTIVES: To determine (1) how many individuals with spinal cord injury (SCI) secondary to gunshot wound (GSW) had previous violent injury requiring medical professional intervention or were previously involved in the criminal justice system, and (2) how many had social service intervention initiated before their SCI to deter future injury. DESIGN: Follow-up survey of patients admitted to an inpatient SCI rehabilitation unit between 1990 and 1998. SETTING: An urban rehabilitation hospital. PARTICIPANTS: Fifty-six patients with SCI secondary to GSW. INTERVENTION: Survey questions inquired about previous GSW, violent injury, and criminal justice involvement. Subjects were queried about social service intervention. MAIN OUTCOME MEASURES: Number and percentage of respondents. RESULTS: Of the 56 respondents, 17 (30%) had a previous GSW; 9 (16%) had another violent injury requiring treatment in the emergency department; and 29 (52%) had prior involvement in the criminal justice system. A total of 55 opportunities for social service intervention were identified. Social service intervention was initiated only once. CONCLUSIONS: Most respondents had preinjury involvement in the criminal justice system and/or previous violent injury. In all of these situations except 1, there was failure to initiate social service intervention. These preliminary data suggest that criminal justice system involvement and violent injury are common among patients who have SCI secondary to GSW. More aggressive efforts at social service intervention could be an effective means to deter future disability

Hypersensitivity syndrome is a rare but potentially fatal reaction to some pharmacologic agents, including some antiepileptic drugs. Typically, the syndrome presents with fever, rash, tender lymphadenopathy, hepatitis, and eosinophilia. We report a novel case of clinical hypersensitivity syndrome secondary to gabapentin. A patient developed altered mental status, fever, diffuse macular rash, and an enlarged spleen. This constellation of symptoms and signs began 9 days after gabapentin therapy was begun. Quick resolution was noted after gabapentin was discontinued. To our knowledge, there are no reports of hypersensitivity syndrome to gabapentin