P041: ARM ON FIRE: A COMPLEX DIAGNOSIS FOLLOWING CARDIAC CATHETERIZATION USING RADIAL ACCESS
G Perez, DO1; R Sanchez, MD1; A Labrada, MD1; K Lappin, MD1; A Alvarez, MD1; M Ramirez, MS2; K Dombrowski3; 1Palmetto General Hospital; 2Herbert Wertheim College of Medicine; 3Nova Southeastern University
Introduction: In the age of opioid addiction, recognizing signs and symptoms of a potentially chronic and debilitating disease could help a patient at risk to avoid a lifetime of analgesic dependence, inability to work, and substantial financial burden. We present a case of Complex Regional Pain Syndrome (CRPS) type I following recent radial access for cardiac catheterization in an otherwise healthy female patient in the hopes that adding this case to the current literature will allow physicians to more easily recognize this important diagnosis and avoid disastrous, lifelong disability.
Methods: A Literature review was performed on PubMed using the keywords “complex regional pain syndrome,” and/ or “Cardiac catheterization,” and/ or “radial access,” and/or “CRPS,” and/or “Complication.”
Case: A 55 year old Costa Rican female with a history of hypertension and recent positive outpatient cardiac stress test presented to the emergency department (ED) by private vehicle after being sent by her cardiologist for right arm pain and swelling approximately 1 month after cardiac catheterization utilizing the right arm for radial access. The pain began one week post procedure and gradually worsened over several weeks per ED documentation. Presentation included severe 10/10 right arm pain, limited range of motion, poor grip strength, and exquisite tenderness to touch. She was given one dose of morphine due to pain severity and associated tachycardia and hypertension.
Symptoms were localized to the right upper extremity with associated muscle weakness, decreased grip strength, limited ROM, and exquisite tenderness to palpation inconsistent with any particular plexopathy or peripheral pattern as well as dermatomal or myotomal distributions. Flexion of the metacarpal phalangeal and proximal interphalangeal joints produced intense pain. She was unable to tolerate even light touch to the area of the C5 dermatome, though the pain did not radiate and was not characteristic of radicular symptoms. Abduction of the arm was within normal limits. There was no history of prior cervical disc disease, myelopathy, trauma to the arm, or similar symptoms. After considering a broad differential, including cervical disc disease, myelopathy, trauma and conversion disorder, the identification of CRPS I was made. The patient ultimately underwent right stellate ganglion nerve block for long term pain control which provided eventual improvement of symptom severity.
Discussion: There are few case reports in current literature that describe CRPS I or II. Though guidelines exist to aid CPRS diagnosis, the rarity of these cases has led to the lack of standardization on the management of this syndrome as well as the development of formal methods to decrease the risk of complications. CRPS is a rare but existing complication of procedures requiring radial access. This diagnosis should be suspected in patients with complaints of severe, out of proportion arm pain that does not follow specific dermatomal pattern or expected plexopathy findings. Neurology should be consulted for evaluation and prompt treatment to minimize the risk of morbidity in these patients.