Avascular necrosis of bilateral knees secondary to corticosteroid enemas

Avascular necrosis (AVN) is a devastating adverse effect of corticosteroid therapy rarely reported in the setting of inflammatory bowel disease. We describe a 48-year-old woman with 6 weeks of progressive bilateral knee pain resulting in the inability to ambulate. Her symptoms developed suddenly, 9 months after treatment with hydrocortisone enemas for ulcerative proctitis. On physical examination, the patient had knee tenderness, decreased range of motion, and flexion contractures. Magnetic resonance imaging showed multiple bony infarcts in bilateral distal femora and proximal tibias, consistent with advanced AVN. Initial therapy included pain management, serial casting, gentle flexibility and strengthening, and limited mobility training. The rehabilitation efforts led to functional improvement. Ultimately, bilateral total knee arthroplasties were recommended to treat her advanced AVN. This is the first reported case of AVN secondary to hydrocortisone enemas. We review the literature and discuss the pathophysiology and management of corticosteroid-induced AVN.

Multiple sclerosis presenting as a spinal cord tumor

Multiple sclerosis, a disorder of central nervous system demyelination, is a leading cause of disability in young people. Lesions of the spinal cord are usually less than two vertebral body segments long, peripherally located, and found in the cervical region. A 30-year-old woman had a 2-month history of back pain, urinary incontinence, and bilateral lower extremity weakness. Magnetic resonance imaging (MRI) of the spine showed an intramedullary spinal cord tumor from T4 to T8 with an intramedullary cyst from T1 to T4. After thoracic decompressive surgery, findings from biopsy of the cord lesion were consistent with multiple sclerosis. Postoperatively, the patient required an intensive rehabilitation program. This is the first reported case of histopathologically confirmed spinal cord demyelination presenting as an intramedullary thoracic cord tumor. Physiatrists should be alerted that demyelinating disease can mimic a spinal cord tumor, even on MRI, and must be considered in the differential diagnosis of a symptomatic spinal cord mass.

Increased phantom limb pain as an initial symptom of spinal-neoplasia

Phantom limb pain is a common sequela of amputation. Studies suggest that over time, there is a decrease in frequency and intensity of phantom pain. Persistently increased phantom pain has been seen in benign lesions affecting the peripheral and central nervous system. We present a 74-year-old woman who had a left above-knee amputation for leiomyosarcoma of the foot 24 years previously. She had been free of disease and ambulated independently until 1 month before hospitalization, when she noted increasing pain in her phantom foot. At the time of admission, she had developed increasing low back pain and was diagnosed with adenocarcinoma of unknown primary. Work-up confirmed involvement of the L4 vertebral body with epidural and paraspinal disease. We believe this is the first reported case of worsening phantom limb pain resulting from a spinal metastasis. We review the literature on the potential implications of increased phantom pain.

Cerebral diaschisis following cerebellar hemorrhage

In 1914, Von Monakow described diaschisis, the recovery of lost cortical function in regions positionally distant from, but linked by neuronal tracts to, the primary site of cortical damage. Cerebellar diaschisis after cortical insult is detailed in the literature; however, cortical diaschisis after cerebellar insult remains a rarely reported occurrence. We describe a 36-year-old woman with rupture of a right-sided cerebellar arteriovenous malformation who developed such expected cerebellar signs as ataxia, dysmetria, and nystagmus. Days later, the patient developed profound impulsivity, disinhibition, and psychomotor agitation. Single photon emission computed tomography (SPECT) showed decreased perfusion of the bilateral frontal and temporal lobes, consistent with regional loss of neural activity. Eventual clinical improvement corresponded with reperfusion of those regions, identified on follow-up SPECT. This case documents cortical diaschisis following cerebellar insult and shows that diaschisis must be considered in patients with cerebral injury manifesting cortical deficits remote from the site of primary pathology.

Selective language aphasia from herpes simplex encephalitis

We report the case of a 16-year-old right-handed Chinese/English bilingual patient who developed herpes simplex encephalitis involving the left temporal lobe, with resultant aphasia. His native language was Mandarin, but he had received extensive training in English for 6 years after moving to the United States and was fluent in English. One week after admission, he could not speak, comprehend, repeat, name, read, or write in English, but he had relative preservation of most of these facilities in Mandarin. He could not write in Mandarin, and his syntax was simplified. Two months later, along with intensive bilingual speech therapy, his reading, writing, and naming in English had almost recovered.

Balint's syndrome arising from bilateral posterior cortical atrophy or infarction: rehabilitation strategies and their limitation

Balint's syndrome is characterized by faulty visual scanning, dysmetria secondary to a visual perceptual deficit, and an inability to recognize more than one object at a time. We report three cases of Balint's syndrome and the individualized rehabilitation they received. One patient developed symptoms of Balint's syndrome caused by bilateral occipitoparietal infarcts. In the two other cases the symptoms arose secondary to posterior cortical atrophy, a slowly progressive dementia with alexia and agraphia. All three patients initially responded to a multicontext treatment approach with intensive verbal cueing and organizational strategies with subsequent improvement in visual recognition, reaching and scanning. Continued deterioration from posterior cortical atrophy or a second infarction resulted in worsening dementia in two patients. Cognitive remediation was required as visual perceptual rehabilitation became ineffective. Clinicians should be familiar with Balint's syndrome and its various aetiologies. Lack of awareness of this syndrome may lead to a misdiagnosis and resulting inappropriate or inadequate treatment.

Delayed femoral nerve palsy following femoral vessel catheterization

We report two cases with a delayed complication of femoral vessel catheterization: femoral nerve entrapment by iliacus hematoma. Both patients had femoral artery catheterization and postoprocedural anticoagulation, followed by iliacus hematoma eruption on the side of catheterization. Diagnosis was confirmed by computed tomography and electrodiagnostic studies. The pathogenesis of iliacus hematoma-induced femoral neuropathy has been studied in detail; however, the authors could find no previous reports of catheterization causing this phenomenon. The association is probably under reported because of the delayed manifestation. Awareness of this complication could (1) minimize the neuropathy, by insuring early diagnosis and treatment and (2) reduce its incidence, by avoiding trauma to the iliacus muscle during catheterization.

Complications associated with intermittent pneumatic compression

The intermittent pneumatic compression device (IPCD) is prophylaxis for prevention of deep-venous thrombosis (DVT). This pneumatic leg sleeve has been used extensively in high-risk surgical patients, without complication. We describe two cases, one with peroneal neuropathy and the other with compartment syndrome, associated with IPCD use during surgery. Case 1 involves a patient with pancreatic cancer and weight loss who developed bilateral peroneal nerve palsies during surgery. Case 2 involves a patient with bladder cancer who developed lower leg compartment syndrome during prolonged surgery in the lithotomy position. These cases are unusual for several reasons. First, patients wearing IPCDs during surgery are at increased risk of neurovascular compression. Second, significant weight loss may predispose the peroneal nerve to injury from intermittent compression garments. Third, patients undergoing surgery in the lithotomy position are at risk of compartment syndrome. Therefore, physicians may wish to use another method of DVT prophylaxis in surgical patients with cancer or significant weight loss, or those who are undergoing procedures in the lithotomy position.