A 42-year-old right-handed male was evaluated for episodes of twitching movements of the right hand that began 2 weeks earlier. He had a 3-year history of bipolar disorder, which was well controlled on valproate 1500 mg/day. He was moderately overweight and had a history of sleep apnea treated with continuous positive air pressure (CPAP).
The episodes were stereotypic, beginning with numbness of the left hand and arm and a flushed feeling in his face. This was followed by uncontrollable twitching movements of the right hand. The episodes lasted from 10 minutes to 4 hours and occurred an average of four times a week. Lorazepam 2 mg/kg intravenously had been administered at another hospital during a prolonged episode but had no effect. All episodes occurred while the patient was awake and there were no precipitants such as sleep deprivation.
Previous diagnostic testing included normal magnetic resonance imaging, EEG, complete blood count and blood chemistry as well as a negative Lyme titre.
Video-EEG monitoring revealed stereotyped sensorimotor episodes beginning with a sensation of numbness in the left hand and in the neck and face. Subsequently, right-sided flexion—extension movements occurred. These movements involved the second, third, fourth and fifth digits at the metacarpophalyngeal joints or the entire hand. The movements were usually arrhythmic but were sometimes rhythmic at 1—3 Hz. Movements would intermittently stop for several seconds. The episodes lasted 7—10 minutes and did not occur during sleep.
The episodes stopped briefly when the patient's attention was diverted while performing a left upper extremity task. There was no weakness during or between episodes. The patient appeared to be in no emotional distress during the
Alan B Ettinger
Was this article helpful?