ABSTRACT
Case Diagnosis: COVID-19 antibody induced polyarthropathy Case Description or Program Description: A 71-year-old female with no medical history developed unrelenting and progressive polyarthropathy. An extensive medical workup including comprehensive rheumatologic labs, electrodiagnostic studies, and orthopedic imaging were all negative apart from a positive COVID- 19 antibody test. Furthermore, the timing of her positive COVID-19 antibody test, rather than any COVID-19 PCR test, coincided precisely with the onset of her symptoms. She completed regimens of oral steroids, NSAIDS, SSRI's, and opioids without any relief. Physical therapy provided mild relief with active movement, apart from pain upon initiation of passive movement and active exercises. Setting(s): Outpatient clinic Assessment/Results: The inter-specialty and interprofessional consensus for this patient's seronegative polyarthropathy non-responsive to medications, negative for all rheumatologic labs and orthopedic imaging, and only mildly responsive to active exercise was that the COVID-19 antibodies themselves were the likely etiologic source. Discussion (relevance): Human coronaviruses have well-documented rheumatologic and nociceptive sequelae. Viral RNA has been identified to spark novel inflammatory conditions or exacerbate preexisting autoimmune conditions. During previous outbreaks of the closely related MERS-CoV infection as well as other viruses, rheumatologic and neurologic conditions such as Systemic Lupus Erythematosus, Rheumatoid Arthritis, Guillain-Barre Syndrome, and Acute Inflammatory Demyelinating Polyneuropathy have been documented in the presence of resultant antibodies rather than viral RNA or antigens. As we progress from the current pandemic, a growing body of literature is highlighting the significant and potentially severe nociceptive effects that COVID-19 antibodies can have on patients. Conclusion(s): A physiatric approach is vital to these rising cases of polyarticular pain as many patients are not finding relief with established medications and approaches. As physiatrists, becoming familiar with the increasing prevalence of seronegative polyarthropathies in the setting of only a positive COVID antibody test is imperative to delivering timely and effective patient care.
ABSTRACT
Case Diagnosis: Parsonage Turner Syndrome Case Description or Program Description: A 34-year-old male presented with 1 month of suddenonset left neck pain radiating to the shoulder. Symptoms began upon waking from sleep without preceding triggers or infection. Pain was severe and rated 8/10. Nonsteroidal anti-inflammatories and muscle relaxants provided moderate relief, but he developed weakness weeks later manifested as difficulty with carrying his child, donning a coat, and overhead activities. Exam demonstrated decreased infraspinatus bulk and weakness with external rotation and abduction. Nerve conduction studies were normal but electromyography (EMG) demonstrated moderate supraspinatus membrane instability and severe infraspinatus instability without residual motor units or reinnervation signs. MRI of the shoulder confirmed intrinsic constriction of the suprascapular nerve consistent with Parsonage-Turner Syndrome (PTS). Subsequent autoimmune, hepatitis, Covid-19, and HIV studies were unremarkable. Setting(s): Outpatient Clinic Assessment/Results: The patient underwent several courses of physical therapy with slow progress but interval improvement in childcare and dressing capabilities. Discussion (relevance): PTS is a rare disorder that can present with a complex constellation of symptoms. PTS may mirror other pathologies including cervical spondylosis, rotator cuff tendinitis, adhesive capsulitis, or nerve compression by mass lesion. The typical pattern involves abrupt pain followed by weakness after pain has diminished. PTS is often attributed to prior viral infection, immunization, recent surgery, or heavy exercise but can also be idiopathic without identifiable triggers. EMG in conjunction with MRI can be crucial in grading severity of denervation and differentiating PTS from true compression which often requires more invasive interventions. While the majority of patients recover functionally by 3 years with conservative treatments, progress may be slow and physicians should consider long term follow-up with repeat electrodiagnostics to track recovery. Conclusion(s): In patients with abrupt shoulder or neck pain followed by progressive neurologic deficits, PTS needs to be considered. Electrodiagnostic studies can both aid in diagnosis and be used to track recovery over time.