418 - A Case of a Delayed Diagnosis of Acute Motor Axonal Neuropathy in the Setting of a Misdiagnosis of Functional Neurological Disorder

Case Diagnosis: Acute motor axonal neuropathy, systemic lupus erythematosus, dysphagia

Case Description: 29-year-old woman with depression and anxiety presented to a hospital with a two-week history of progressive weakness and difficulty eating. Imaging was unremarkable, inconsistencies were noted on neurological exam, and she was discharged with a diagnosis of functional neurological disorder (FND). Ten days later, she presented again, unable to ambulate or eat. Evaluation favored FND, but rule-out testing revealed acute motor axonal neuropathy with underlying systemic lupus erythematosus. She received intravenous immunoglobulin, but no restrictions were made to her diet before transferring to an inpatient rehabilitation facility (IRF). There, she failed her swallow study and was transferred back to acute care. In the hospital, it was determined that her condition had not progressed and she was discharged back to IRF. Two days later, she suffered respiratory failure from aspiration pneumonia. Once stabilized, she was offered plasma exchange therapy but declined before being transferred back to IRF to complete her rehabilitation.

Discussions: Atypical neurological diagnoses in IRF present unique challenges in coordination of care, especially when colored by a prior diagnosis of FND. Misdiagnosis of FND can permeate the medical record and damage patient trust in the medical team. Physiatrists must be on guard to independently assess neurologic presentations, maintain ethical principles, and preserve the unique physician-patient relationship essential for effective patient care in rehabilitation.

Conclusions: The delayed diagnosis of uncommon neurological disorders in the setting of FND labeling can lead to poor patient outcomes. Patients presenting to IRF often carry with them both clinical and psychological complexity. Great care must be taken by physiatrists to confirm diagnoses and preserve the ethical foundations of patient care to facilitate optimal rehabilitation care.