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अमूर्त

The Importance of Managing Coexisting Anxiety Disorder and Polysubstance Abuse at the Acute Inpatient Rehabilitation of a patient with Lance-Adams Syndrome (LAS): A Case Report

Roderick N. Sembrano

Abstract:

PATIENT: A 43-year-old female with hypoxic ischemic encephalopathy related to a cardiac arrest status post cardiopulmonary resuscitation with subsequent development of LAS.

CASE DESCRIPTION: The patient became unresponsive and suffered a pulseless electrical activity with cardiorespiratory arrest related to overdose of fentanyl and cocaine in the community with successful cardiopulmonary resuscitation and return of spontaneous circulation.  On arrival to the emergency department patient underwent extensive work-up including imaging studies without any spinal fractures or intracranial pathology with CT scans. Stimulus-induced myoclonus was noted a few weeks during the hospitalization.  Patient had a brain MRI as part of the work-up and at that time did not show any evidence of anoxia.  Neurology diagnosed the patient with LAS and treated with valproic acid, levetiracetam and intermittent use of benzodiazepines with note of relative improvement of myoclonus.

ASSESSMENT/RESULTS: She was transferred to inpatient rehabilitation hospital for intensive rehabilitation management. The patient’s action myoclonus initially responded quite well with improved functional transfers mobility and ADLs with continued medications of Valproic Acid and Levetiracetam and addition of low-dose clonazepam.  However the patient's myoclonus and functional mobility declined with correlation of anxiety exacerbation and intake of nonprescriptive medication found to have positive fentanyl on urine toxicology.  Due to this finding and patient's unwillingness to further participate in inpatient rehab despite encouragement, goalsetting strategies, and reassurance of plan of care, patient was discharged against medical advice.

DISCUSSION: Post-hypoxic myoclonus (PHM) is a rare complication after a successful cardiopulmonary resuscitation. LAS is a chronic type of PHM with usual onset within days to weeks and is typically characterized by action myoclonus.  Significant comorbidities such as anxiety disorder and polysubstance abuse can be a barrier to optimize post-acute management and rehabilitation.

CONCLUSION: This highlights the importance of addressing significant comorbidities of mental health conditions such as anxiety disorder and polysubstance abuse in order to provide and have a better chance of successful medical and rehabilitation care for those with LAS. 

Biography:

Dr. Roderick Sembrano has completed his Medical Degree from the University of the Philippines, College of Medicine, in Manila, Philippines. He completed his residency training in Physical Medicine & Rehabilitation (PM&R) at East Carolina University, Pitt County Memorial Hospital, in Greenville, North Carolina USA. Currently, he serves at the Medical Director of the Brain Injury Program at Northeast Rehabilitation Hospital Network in Salem, New Hampshire USA.