1100 - When There Is A Pump To Blame

Case Diagnosis: Increased spasticity secondary to fecal impaction and urinary tract infection (UTI)

Case Description: 29-year-old female with spastic quadriplegic cerebral palsy (CP), receiving long-term intrathecal baclofen (ITB) therapy, detrusor sphincter dyssynergia, Crohn’s disease, and seizure disorder presenting with suspected ITB withdrawal. Patient developed two days of pruritus, worsening muscle spasms, and urinary retention, initially managed with 20mg of baclofen with temporary symptom improvement. On exam she was noted to be flushed and restless, with increased dystonia. Vitals noted a blood pressure of 103/63 and heart rate of 121. Labs remarkable for creatinine kinase 424 and WBC 14. Urine culture with mixed commensal microbiota. Baclofen pump interrogated and working appropriately. Patient managed with Ceftriaxone for a suspected UTI. Abdominal Xray showed radiopaque device overlying the right lower quadrant and noted large stool burden, confirmed on CT abdomen/pelvis. Patient was manually disimpacted and started on an aggressive bowel regimen consisting of Miralax, Colace, Dulcolax suppositories, and enemas with symptom resolution.

Discussions: This is an interesting case of a patient with spastic quadriplegic cerebral palsy (CP) with intrathecal baclofen pump presenting with pruritus, worsening muscle spasms, and urinary retention due to fecal impaction and a subsequent UTI, not ITB pump malfunction.

Conclusions: Constipation and UTIs are common in the CP population. It is important to perform a full medical work-up including physical exam, labs, and imaging to assess for all possible causes of hypertonicity, which could mimic symptoms of ITB withdrawal. Patients with cerebral palsy should be asked about their bowel and bladder habits in order to appropriately manage potential causes for increased spasticity and prevent delay of treatment.