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Journal of General Internal Medicine ; 37:S358, 2022.
Article in English | EMBASE | ID: covidwho-1995588


CASE: The patient is a 47-year-old woman with a history of hyperlipidemia, asthma, and psoriatic arthritis (on adalimumab) who presented to clinic with 4 weeks of "sawing" left dorsoradial wrist pain, associated with tingling in the fingers and significant finger, hand and wrist weakness. Exam was notable for full strength and range of motion bilaterally. Tinel's and Phalen's sign were positive for mild tingling radiating to left hand fingers and wrist, and Finkelstein test was positive with significant pain on pinch grasp. An ultrasound was sent to evaluate for de Quervain's tenosynovitis;radiographic imaging was deferred by the patient. Ultrasound did not show evidence of de Quervain's tenosynovitis or radial nerve injury. There was significant delay between the initial visit and imaging, and ultimately the patient was referred to an Orthopedic Hand specialist. Magnetic resonance imaging (MRI) of the wrist was ordered, which showed abnormal signal throughout the lunate sparing the radial aspect, consistent with early osteonecrosis. Follow up radiographs demonstrated lunate sclerosis consistent with osteonecrosis. The patient was diagnosed with Kienbock's disease. IMPACT/DISCUSSION: Unilateral wrist pain in the primary care setting has a wide differential including mechanical causes (e.g. De Quervain's tenosynovitis, fracture, joint instability, neoplasm, or avascular necrosis of the scaphoid (Kienböck's disease) or lunate (Preisers' disease)), neurologic causes (e.g. nerve injury or compression) or systemic causes. While detailed history/exam can help narrow down the diagnosis, radiographs are often necessary to make a definitive diagnosis. Computed tomography (CT) is used to evaluate osseous lesions, whereas MRI is used to evaluate soft tissues of the wrist, and ultrasound can show tendonitis, arthritis, or nerve entrapment. Early referral to a hand surgeon is indicated when pain persists despite splinting for bony fractures, recurrent lesions, or avascular necrosis of the scaphoid or lunate. This case underscored Kienbock disease which is a rare but urgent etiology of wrist pain due to lunate osteonecrosis and can require immediate casting or surgical decompression. A key aspect to the case was the 1 month delay from first visit to initial ultrasound, 1 month delay to specialist evaluation and 1 month delay until final diagnostic MRI, primarily due to the impact of the COVID epidemic on the health care system. As the epidemic ebbs and flows with new variants, we can expect further delays in care, making the initial clinical evaluation even more critical to reduce unneeded imaging. CONCLUSION: -When evaluating wrist pain, if exam and first line images are inconclusive and pain persists, it is key to expedite workup with advanced imaging (MRI or CT) and refer to a specialist. In the primary care setting, it is critical to set realistic expectations with our patients regarding timeline of imaging and workup to maintain the therapeutic alliance and continue to build trust.

Neurology ; 98(18 SUPPL), 2022.
Article in English | EMBASE | ID: covidwho-1925285


Objective: Determine neuromuscular manifestation incidence in COVID-19 patients from the longitudinal electronic health record database Optum. Background: Both central and peripheral nervous system (PNS) manifestations of COVID-19 have been reported. A Chinese retrospective case series, on 214 hospitalized COVID-19 patients, found that 8.9% presented with peripheral nerve disease and 7% had muscular injuries. Other studies looking at the prevalence of PNS manifestations are limited and have significantly lower numbers. Design/Methods: The COVID-19 data is sourced from more than 700 hospitals and 7000 clinics in the US. Patients with numerous neuromuscular diagnoses were identified based on ICD-10 coding. Examples include carpal tunnel syndrome, radial nerve lesion, sciatic nerve lesion, myasthenia gravis, acute transverse myelitis, Bell's palsy, and trigeminal neuralgia. Results: We reviewed a total of 598,847 patients with positive COVID-19 PCR and/or diagnosis coding. Neuromuscular complications must have been within 45 days of diagnosis to be included. Incidence of similar neuromuscular complaints was evaluated in 3,001,153 controls without COVID-19. Critical illness neuropathy was found in 35,782 COVID-positive patients and 6,281 of those without. Retrospective study limitations include temporal relationship to COVID-19 does not necessarily indicate causality and inability to confirm the coding by record review or EMG/NCS. Conclusions: Incidence of neuromuscular disorders is generally lower or equivalent in COVID19 patients than in the general population, except for critical illness neuropathy and myopathy. This finding may be explained by more COVID-19 patients being in the intensive care unit and bedbound for longer periods. It is worth noting that a small case series of COVID-related critical illness neuropathy and myopathy patients showed no histopathological or clinical differences compared to non-COVID patients. To our knowledge, this report includes an analysis of neuromuscular manifestations in one of the largest cohorts of COVID-19 patients. This can assist with risk-benefit discussions regarding treatment initiation, etiology of diagnoses, and counseling for COVID-19 questions.

Cureus ; 14(2): e22212, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1732462


Compressive peripheral nerve injury can be observed as a long-term outcome during the treatment of severe COVID-19 pneumonia. In this case study, we report a man with bilateral wrist drop due to prolonged noninvasive blood pressure monitoring. A 52-year-old man who had undergone invasive ventilation because of severe COVID-19 pneumonia was admitted with bilateral loss of function of the wrist, digital, and thumb extensors and hypoesthesia in the dorsum of the forearm and hand. The patient had not been treated with prone positioning respiratory therapy. However, he had undergone bilateral automated sphygmomanometry that measured his blood pressure every ten minutes during his ICU stay. His electrophysiological findings were compatible with the presence of bilateral radial nerve compression at the level of the spiral groove. Awareness of potential compressive peripheral nerve injury is important for rehabilitation after the treatment of COVID-19-associated pneumonia.