Parker Nguyen, MD
Resident Physician
NewYork-Presbyterian
New York, New York, United States
Richard Tran, MD
Resident Physician
NewYork-Presbyterian Hospital -- Columbia & Cornell
New York, New York, United States
Renee Li, BS
Medical Student
Jefferson Medical School
NYC, New York, United States
Matthew Brandenburg, BA, MS
Medical Student
New York Medical College
New York, New York, United States
Kaile Eison, DO
Attending Physician
NewYork-Presbyterian
New York, New York, United States
Neuropathic pain after diagnosis of multiple acyl-CoA dehydrogenase deficiency (MADD)
20-year-old female college student with type 1 diabetes mellitus and anxiety was admitted to the ICU for diabetic ketoacidosis. Initial physical examination after resolution of DKA revealed 2/5 strength in bilateral hip flexion and knee extension, as well as 9/10 pain in bilateral feet. Thigh MRI was significant for evidence of myositis, with findings of vacuolar myopathy on biopsy. Further testing was consistent with multiple acyl-CoA dehydrogenase deficiency (MADD). She was started on a low fat diet with vitamin supplementation, and discharged to acute inpatient rehabilitation (AIR) on celecoxib, duloxetine, pregabalin, and lidocaine cream.
In AIR, she continued to have 9/10 plantar pain, limiting her sleep, participation in therapies, and severely exacerbating her anxiety. Her pain regimen was optimized and Ativan was added for the co-treatment of sleep and anxiety. Although these changes initially helped, the 9/10 pain returned within the next week. Capitalizing on a multidisciplinary approach, pain psychology, psychiatry, palliative care, and spiritual care were consulted. She was taught guided meditation techniques, which she used daily. Occupational therapy also incorporated walks outside the hospital and play therapy. Within the next week, her pain improved to 3/10, her sleep drastically improved, and she made notable functional gains, including the ability to ambulate with modified independence. She was discharged with plans to follow with pain psychology, attend pain support groups, and continue outpatient therapy services for strength, gait, and endurance training.
There is limited literature on management of neuropathic pain in MADD. Existing case reports describe improvement of muscle weakness after dietary changes and vitamin supplementation, but minimal improvement of neuropathic pain. This case highlights the complexity of managing MADD neuropathic pain, emphasizing the utility of a multimodal approach to pain management and the importance of a tailored rehabilitation course.
