900 - Neurogenic heterotopic ossification in the setting of COVID induced critical illness myo-neuropathy

A 59-year-old found to have neurogenic heterotopic ossification 7 months following COVID infection.

Case Description:

A 59-year-old male presented with a history of critical illness myo-neuropathy after a one-month ICU hospitalization secondary to COVID in 2021. He received limited physical and occupational therapy during his prolonged hospital course and was not an inpatient rehab candidate at that time. He was incidentally found to have extensive heterotopic ossification (HO) of the bilateral hips 7 months after his ICU course. He developed contractures in the bilateral upper and lower extremities that progressed over several years with minimal therapy. The patient presented to inpatient rehab four years later and was limited in therapy due to chronic hip pain. Hip x-ray at that time demonstrated significant progression of bilateral hip HO.

Discussions: HO is a pathological formation of bone within soft tissue, usually occurring in the periarticular location. It is frequently observed in patients with spinal cord injury, traumatic brain injury, or stroke.  Most recently, HO has been reported in individuals with prolonged hospitalization following severe COVID infections. Established risk factors include immobilization, hypoxia, mechanical ventilation, and tracheostomy, all of which may contribute through a sustained proinflammatory state. It is believed that COVID infections trigger an uncontrolled systemic inflammatory response, further increasing the risk of HO.  In this case, the patient did not receive intensive rehabilitation during hospitalization or post-discharge due to loss to follow-up. The development of HO is likely multifactorial, with COVID and associated risk factors playing contributory roles in our case.

Conclusions:

HO should remain a key differential diagnosis in patients with prolonged ICU stays related to COVID who present with joint pain and restricted range of motion. Early recognition, along with timely initiation of mobilization and intensive rehabilitation is essential to minimize functional impairment and other complications associated with HO.