key: cord-0794639-szrc3su2
authors: Paudel, Anish; Reggio, Christopher; Donato, Anthony; Crozier, Kelly
title: A Rare Case of COVID-19 Related Necrotizing Myopathy
date: 2021-10-31
journal: Archives of Physical Medicine and Rehabilitation
DOI: 10.1016/j.apmr.2021.07.561
sha: 726f3fead8ad6c93ed54e863bc9fb673a448a6e8
doc_id: 794639
cord_uid: szrc3su2

Research Objectives To report a case of COVID-19 associated necrotizing myopathy. Design Case report. Setting Following the patient through acute hospitalization, acute rehab to outpatient therapy follow up. Participants A 76-year-old man with known hypogammaglobulinemia on monthly IVIG infusions who presented to the hospital with 1 week of dyspnea and myalgias. He was a former athlete who participated in daily cardiovascular workouts before admission. He was found to have COVID-19 pneumonia. Interventions Patient was treated with remdesivir and oral dexamethasone. He was transferred to the ICU for 9 days where he received convalescent plasma, intravenous methylprednisolone, and high flow oxygen. He did not require intubation nor sedatives. Main Outcome Measures Following transfer to the floor, he reported new-onset muscle weakness. Physical examination revealed symmetrical proximal upper and lower extremity weakness with elevated CK at 3665 IU/L. His atorvastatin was held, and steroids were tapered. However, his creatinine kinase continued to rise, peaking at 8335 IU/L. High dose methylprednisolone was resumed with improvement in creatinine kinase. Extensive myositis panel and Anti HMGCR antibody were normal. Thyroid studies revealed transient thyroiditis thought to be induced by COVID-19 infection that did not require treatment. Results Right thigh MRI revealed edema of the lateral thigh muscles. Biopsy of the quadriceps showed necrotizing myopathy. Electromyography and NCS revealed inflammatory/immune myositis. Findings were not typical for a steroid, endocrine, or disuse myopathy. He was discharged to an IRF at a dependent level with bilateral hip flexor strength 2/5, triceps 3+/5, and the remainder of his extremity muscles 5/5. By day 40, he was independent with a rolling walker with significant gains in strength. Conclusions Timely recognition of COVID-19 related myopathy may prevent serious necrotizing muscle injury. Author(s) Disclosures None.

Research Objectives: To improve understanding of the unique experience of female veterans' post-traumatic brain injury (TBI) utilizing the power of storytelling. Design: Qualitative phenomenological design. Setting: TBI/Polytrauma Rehabilitation System of Care of the Veterans Affairs Palo Alto Health Care System (VAPAHCS). Participants: 10 female veterans participating in a storytelling workshop.

Main Outcome Measures: Retrospective chart review of each participant's demographic and injury information. Using storytelling an arts-based research method approach, participants' shared stories related to their injury, and their recovery experiences related to their TBI. Qualitative analysis for main themes and associated subthemes was completed using a constructivist grounded theory approach Results: Ten powerful visual stories focused on life pre and post TBI; detailing how their injuries occurred, describing the challenges of their recovery, and sharing thoughts on their life and future. Three content themes emerged from the thematic analysis: (1) psychological and emotional impacts of TBI, (2) acceptance and healing process associated with recovery, and (3) distinct individual mindsets. Negative psychological and emotional impacts identified included suicidal ideation, grief, sadness, anxiety, relationships problems, memory loss, loss of independence, and headaches Notably, all the stories acknowledged a healing process, characterized by a sense of living meaningfully with TBI . Lastly, each story contained a distinct mindset which captured a strong sense of overcoming hardships while emphasizing determination, motivation, optimism for continued recovery, and coping with their new self. Conclusions: A phenomenological examination adds powerfully to evidence-based research highlighting the distinct impact of TBI among female veterans. Each story uncovered nuanced and multifaceted issues that women uniquely experience in their TBI recovery. Our findings can guide future intervention on the care, support, and TBI recovery for the female population. Design: Prospective Case Series. Setting: Inpatient Rehabilitation. Participants: 14 persons with acute stroke stratified by the TWIST algorithm into either a "good walking prognosis" (GWP) group (n=10) or a "poor walking prognosis" (PWP) group (n=4). Interventions: The CPG for advanced rehabilitation technology was standard of care at our facility. Main Outcome Measures: Functional Ambulation Category (FAC) and 10 Meter Walk Test (10 MWT) at initial evaluation, discharge, and at 3 months. Session steps were measured via accelerometers and technology use was tracked for each patient. Results: At 3 month follow-up, 50% of the GWP group had achieved independent walking (FAC=4 and 10 MWT > .8 m/s) compared to 0% in the PWP group. However, 50% of patients in the PWP group did achieve FAC= 3 at 3 months or greater after initial stroke. Average step counts between both groups were similar: GWP group= 1469 steps, PWP group= 1296. Advanced rehabilitation technology was utilized 92% of the time in the PWP group compared to 52% for the GWP group. Most notably, the PWP group utilized robotic exoskeletons 26.8% of therapy sessions compared to 2.9% in the GWP group. Conclusions: Standardized use of advanced rehabilitation technology allowed for similar stepping repetitions between groups, although not equal walking outcomes. Interestingly, 50% of the PWP group ambulated without physical assistance, although this was not achieved until at least 3 months after stroke. A sparing of the motor pattern early in stroke recovery may have downstream affects for gait function. Research Objectives: To report a case of COVID-19 associated necrotizing myopathy. Design: Case report. Setting: Following the patient through acute hospitalization, acute rehab to outpatient therapy follow up. Participants: A 76-year-old man with known hypogammaglobulinemia on monthly IVIG infusions who presented to the hospital with 1 week of dyspnea and myalgias. He was a former athlete who participated in daily cardiovascular workouts before admission. He was found to have COVID-19 pneumonia.

Interventions: Patient was treated with remdesivir and oral dexamethasone. He was transferred to the ICU for 9 days where he received convalescent plasma, intravenous methylprednisolone, and high flow oxygen. He did not require intubation nor sedatives. Main Outcome Measures: Following transfer to the floor, he reported newonset muscle weakness. Physical examination revealed symmetrical proximal upper and lower extremity weakness with elevated CK at 3665 IU/L. His atorvastatin was held, and steroids were tapered. However, his creatinine kinase continued to rise, peaking at 8335 IU/L. High dose methylprednisolone was resumed with improvement in creatinine kinase. Extensive myositis panel and Anti HMGCR antibody were normal. Thyroid studies revealed transient thyroiditis thought to be induced by COVID-19 infection that did not require treatment. Results: Right thigh MRI revealed edema of the lateral thigh muscles. Biopsy of the quadriceps showed necrotizing myopathy. Electromyography and NCS revealed inflammatory/immune myositis. Findings were not typical for a steroid, endocrine, or disuse myopathy. He was discharged to an IRF at a dependent level with bilateral hip flexor strength 2/5, triceps 3 +/5, and the remainder of his extremity muscles 5/5. By day 40, he was independent with a rolling walker with significant gains in strength.

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Research posters Participants: Eleven adults (n = 11) with unilateral lower extremity weakness following chronic stroke and eleven healthy adults (n = 11) participated in this study.

Interventions: Surface electromyographic electrodes were positioned on bilateral gluteus maximus muscles to capture activation variables. Kinetic and kinematic measurements were taken to quantify chair-rise phases. Participants stood independently with arms crossed at self-selected natural and fast speeds four times each with averages used for statistical analysis. Main Outcome Measures: Normalized root mean square (RMS) values of bilateral gluteus maximus muscle activation were measured during natural and fast-speed chair-rising. Additionally, onset of gluteus maximus activation was used to quantify neuromuscular control during chair-rising.

Results: Individuals post-stroke displayed prolonged chair-rise times compared to healthy controls during natural-speed conditions (p = .001) with no differences during fast-speeds (p = 0.124). Decreased gluteus maximus magnitudes were noted bilaterally post-stroke compared to healthy adults for both speeds (p = .007). Increased magnitudes (p < .001) and earlier onset times (p < .001) were noted during fast-speeds for both groups. No magnitude differences were noted between paretic and non-paretic extremities post-stroke (p = .846). A unique delayed onset of the paretic gluteus maximus was evident during both speed conditions (p = .029) in adults post-stroke. Conclusions: Results indicate bilateral spatiotemporal gluteus maximus muscle activation deficits during chair-rising with improved activation during faster speeds. This study contributes evidence toward the use of high-intensity chair-rise training to improve spatiotemporal gluteus maximus muscle activation post-stroke.

Author ( Results: Forty-one percent of survivors demonstrated a positive history of IPV-related TBI. Fifty-five percent reported needing an emergency room visit; 42.5% reported loss of consciousness; 45% sustained symptoms consistent with mild TBI such as headaches or fatigue. In multivariate models, after controlling for race, female sex (p=0.003) and refugee status (p=0.002) were strongly associated with the number of previous brain injuries (PBI). No other demographic variables were significantly related to the number of PBI.

Conclusions: Congruent with previous findings,1,2 our data indicated a high prevalence of IPV-related TBI (about two in five survivors) in New York. Notably, our sample comprises a higher percentage of African Americans and refugees compared to the County's demographics. We found that being a female or a refugee increases the risk of sustaining IPVrelated TBI. Though shown as high, IPV-related TBI prevalence varies among samples.3,4 Future research must determine better nationwide estimates of brain injury prevalence in the IPV population as recommended by the recent GAO4 report to improve resource allocation and clinical management.

Author ( 

Design: Cross-sectional observational study. Setting: Research gait laboratory. Participants: Ethics approval and informed consent were obtained prior to data collection. Participants included 30 pwMS and 29 controls matched for age ( §3 years) and sex. All participants were ≥ 18 years of age, and able to walk 10 m without support

Inertial sensors (Mobility Lab, APDM) measured stride length1, gait speed2, percentage double support/stride (%DS)3, mediolateral trunk range of motion (ML-tROM)4, and lateral step variability (LSV)5. Repeated measures ANOVA examined withinand between-group differences. Results: Group effects showed PwMS spent significantly greater time in %DS and had more LSV compared to controls. All participants spent less time in %DS in the 4WW-W condition compared to the other forms of haptic input. Both 4WW conditions and the haptic anchors reduced ML-tROM compared to NT. LSV was reduced with 4WW-LT and 4WW-W compared to HA and NT conditions. All participants walked significantly faster using 4WW-LT compared to all conditions. Conclusions: PwMS walked with more caution and less consistent foot placement than controls. Adding only haptic input (anchors and 4WW-LT conditions) reduced ML