diabetes and glaucoma, chronic kidney disease, and hyper-tension. Initial management consisted of optimization ofcomorbidities, physical and occupational therapies, pred-nisone 5 mg daily, and azathioprine 25 mg daily. Minimalimprovement of elbow flexion and extension from 1/5 to 2/5was observed on this regimen over the first 2 weeks, there-fore, prednisone was increased to 60 mg daily. In 3 days,improvement of elbow flexion and extension were observed,thus prednisone was increased to 100 mg daily. After 5 days,left and right elbow flexion and extension improved to 4/5and �3/5, respectively. After 2 weeks of this regimen, hebegan to experience adverse effects; therefore, the dose wasdecreased to 80 mg daily.Setting: Spinal cord injury rehabilitation facility.Results: Treatment consisting of high dose corticosteroids,Disease-modifying antirheumatic drugs, and intensive reha-bilitation program showed promising, but modest improve-ment of motor strength in this patient with neurosarcoidosisafter decompressive laminectomy.Discussion: Treatment of spinal cord invasion of neurosar-coidosis can be very difficult. Promising improvement ofstrength with the combination therapy of high-dose steroids,DMARDs, and rehabilitation program showed promise in thiscase for future treatment of patients with neurosarcoidosis.Conclusions: Close monitoring and prompt managementof the adverse effects of this combination therapy is crucial,for the adverse effects could be the limiting factor in thispromising treatment regimen.

Poster 285Motor Inhibition With Use of Topiramate inSetting of Severe Neuropathy: A Case Study.Phong Kieu, MD (Johns Hopkins University, Balti-more, MD); Sandeep Singh, MD; Argyrios Stampas,MD.

Disclosures: P. Kieu, None.Patients or Programs: A 36-year-old woman contractedan extensive meningoencephalomyelitis of unclear etiology,which left her functionally as a C3 ASIA A. During her stay ona neurorehabilitation floor, she slowly gained strength in herbilateral upper extremity flexor from 0/5 to 1/5. Unfortu-nately, she had severe neuropathic pain in her bilateral upperextremities.Setting: Tertiary care center, Inpatient rehabilitation unit.Results: The patient’s neuropathic pain was difficult to con-trol on various treatments including gabapentin, pregabalin,and amitriptyline, frequently rated at 10/10. Adverse effectslimited their usage including dizziness with gabapentin, up-per extremity swelling with pregabalin, and hypotensionwith amitriptyline. Topiramate was then started at a dose of100 mg BID, and the patient’s pain improved to 7/10. Overthe next few days, she developed increasing weakness andconfusion. Topiramate was discontinued, and patient’sstrength and pain returned. She was then restarted on topira-

mate at a dose of 50 mg PO BID with a decrease in her pain to8/10, but again noticed a decline in her strength. Topiramatewas discontinued a second time, and her strength returned.Discussion: Topiramate is an anticonvulsant that can beused to treat neuropathic pain, but it is not considered a firstline treatment due to numerous adverse effects. One adverseeffect not usually mentioned is the inhibition of motor neu-rons. There have been several small studies using topiramateon animal models showing no effects on motor functioning.However, in this case, there was a strong correlation of motorinhibition with the use of topiramate. It is unclear whetherher comorbidity with a severe neuropathy contributed.Conclusions: Topiramate is useful as an adjunct treat-ment for neuropathic pain if other first-line treatments areineffective. However, in patients with spinal cord injuries orother comorbid neuropathy, there may be an adverse effectcausing inhibition of motor neurons. Further research intoadverse effects with topiramate is warranted.

Poster 286Outbreak of Herpes Simplex Virus 2 AfterTransforaminal Epidural Steroid Injection:A Case Report.Henry Huie, MD (Stanford, Redwood City, CA);Raj Mitra, MD.

Disclosures: H. Huie, None.Patients or Programs: The patient was a 67-year-oldwoman with a history of shingles, childhood chickenpox(VZV) and viral meningitis who presented with radicular lowback pain.Program Description: The patient presented to the in-terventional spine clinic with a 3-month history of 6/10, lowback pain radiating to the right leg. Physical examination wassignificant for 4/5 weakness in the right L4 myotome. MRI ofher lumbosacral spine showed grade 1 anterolisthesis of L4-5and a broad-based disk protrusion causing right sided neu-roforaminal stenosis. She was diagnosed with a right L4radiculopathy. After no relief with physical therapy, thepatient underwent a right L4 transforaminal epidural steroidinjection (ESI) with 60 mg triamcinolone (1.5 mL) and 1%lidocaine (1.5 mL). At one-month follow-up, the patient’slow back pain had decreased to a 1/10. Six weeks after herinjection, the patient developed painful, clustered vesicles onher right buttocks in a dermatomal distribution, subse-quently diagnosed to be VZV.Setting: Academic tertiary care center outpatient clinic.Results: Scrapings of the lesions were culture positive forherpes simplex 2 (HSV-2). Viral serologies showed that thepatient was seropositive for VZV, HSV-1, and HSV-2. Thepatient was referred to the infectious disease clinic for furthermanagement, and they concluded her skin lesions weresecondary to HSV-2.Discussion: The patient’s ESI may have caused local im-munosuppression near the lumbosacral dorsal root ganglia

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