Case 39 - 75 y/m with involuntary movements

A 75 year old male shopkeeper by occupation presented to the casuality with Altered sensorium
History of 4 episodes of seizures since morning 4 am 
Each episode lasting for a period of 5 minutes 
Seizures- involving left upper limb and lower limb tonic clonic type associated with facial deviation and frothing not associated with urinary incontinence and tongue bite

Patient was apparently asymptomatic 6 months back 
Then patient developed tingling sensations of left upper and lower limb and was taken to local practioner and given unknown medications 
Later patient was unable to move his left lowerlimb ,was Intitally able to move lt ul which then progressed to Inability to move lt ul and was taken to neurologist and was diagnosed as CVA 
Ct brain done showing acute infarct in Rt frontal cortex
Patient found to have GRBS 480 mg/dl and started on GlimiM2 twice daily
During hospital stay patient developed frequent eye twitches  and was started on ? Anti epileptic for 6 weeks 
Patient is started on dual antiplatelet( aspirin,clopidogrel ) therapy, atorvastatin,levatiractetram, amitriptyline 10mg, zolpidem 

Patient is non alcoholic
Known smoker from age of 15 years  tobacco 2 times a day (50years)
Diet mixed
Bowel and bladder regular
Sleep decreased

Family history : No relevant family history

General examination :




72 year old male Moderately built and nourished
Pallor present
No icterus, cyanosis , edema and lymphadenopathy
Thyroid normal



Vitals :
Pulserate -82 bpm , regular in rate rhythm and normal volume , bilaterally present
Bp:110/90 mm of Hg
Temp :99 F

SYSTEMIC EXAMINATION:

CNS :





Right Handed person


MMSE could not be assessed 

speech : could not be assessed 

Behavior : irritable 


   
   MOTOR 
    TONE : 
Left Upper limb Hypertonic 
        Lower limb Hypertonic 
Right Upper limb Normotonic
         Lower limb  Normotonic

   SUPERFICIAL REFLEXES:
                    Right.                       Left
   CORNEAL present.            present       

   CONJUNCTIVAL present   present

   ABDOMINAL present

   PLANTAR withdrawal.         extensor 

   DEEP TENDON REFLEXES:
                 Right.        Left
   BICEPS +              +++

   TRICEPS +             +++

   SUPINATOR +         +++

   KNEE +                    ++++

   ANKLE +                 ++++



    

SENSORY EXAMINATION:  
              Rt.     Lt
pain  UL+       +
          LL +     +


SIGNS OF MENINGEAL IRRITATION: present

Gait : Patient couldn't walk

 



RESPIRATORY SYSTEM:

Inspection: 
Barrel shaped chest
No scars and sinuses
Respiratory movements equal on both sides
Abdominothoracic type
Mediastinum central

Palpation:
Inspectory findings are confirmed
No palpable sounds 

Percussion: 
Resonant note present in all lung areas
Vocal Fremitus normal 

Auscultation:
Normal vesicular breath sounds heard
Vocal resonance normal
No pleural rub or crepts

CVS :

Inspection : Bilaterally symmetrical chest present 
No scars sinuses
No visible pulsations
No visible mediastinal shift

Palpation:
Inspectory findings are confirmed
Apex beat normal
No palpable heart sounds or murmurs

Percussion  :
Heart borders within normal limits

Auscultation : 
S1 S2 heard
No murmurs or additional heart sounds

Git: 
Inspection - scaphoid 
No scars sinuses masses visible
No visible peristalsis 
Umbilicus normal

Palpation:
Inspectory findings are confirmed 
No Tenderness, masses 
No organomegaly

Percussion : Resonant note

Auscultation: Normal bowel sounds heard
No bruit heard


PROVISIONAL DIAGNOSIS:
Involuntary movements under evaluation


INVESTIGATIONS:
Ct brain done on 7/12/2021


Discussion:
Icu Bed no:2
Day 3 of admission
S: Involuntary movements of lower jaw decreased
 No seizure episodes today
O: Patient conscious,non coherent
 PR-64/min
BP-130/70mm Hg
RR-20cpm
Cvs-s1s2+
RS-Bae+,NVBS
CNS- 
GCS E4V2M4
cranial nerves: Not elicitable
motor system:
Tone
Right 
upper limb Normal
lower limb hypotonia
left:
upper limb hypotonia
lower limb hypotonia
Power
Rt
UL 5/5
LL 2/5
Lt 
UL 1/5
LL 1/5
Reflexes
Rt 
 B+
 T +
 K ++
 A ++
 P flexion
Lt
 B +++
 T +++
 K +++
 A +++
 P extension
sensory system intact
A 
Focal seizures with dyselectrolytemia(?Post stroke seizure)
Paraparesis secondary to hypokalemia
with old cva(Left hemiparesis)
P
Inj levipil 1gm iv bd
Inj kcl 2 amp in 500ml ns iv
Inj piptaz 2.25gm iv bd
Inj Neomol I gm iv sos




The Link Between Amitriptyline and Movement Disorders: Clinical Profile and Outcome

AMT-associated movement disorders that were diagnosed in patients included MCL (n = 26), DKN (n = 11), DTN (n= 8), stuttering (n = 5), AKT (n = 3) and restless legs syndrome (n = 1). In less well-defined cases (Table 2), they included DKN (n = 99), psychomotor disturbances (n = 19), Parkinsonism (n = 12), DTN (n = 11), MCL (n = 3), AKT (n = 1) and extrapyramidal symptoms (n = 1).

For well-defined cases, 54 patients were identified and their mean and median ages were 45.40 years (SD 16.78) and 40 years (range 3.7–82 years), respectively. Over half of them were women (58.13%). Indications for AMT included depression (79.54%), insomnia, migraine, neuropathic pain and tension-type headache. Mean and median AMT dose were 126 mg (SD 128.76) and 75 mg (range 15–800 mg), respectively. 

ime of onset of AMT-associated movement disorders was indicated in 44 patients. Mean and median time of onset was 40.95 days (SD 78.08) and 21 days, respectively; in 30 patients, it was <1 month. Duration from AMT withdrawal to complete recovery was described in 37 participants; it was <1 month in 26 patients and >1 month in remaining patients. A weak negative linear correlation (r = −0.0904) was found between start of AMT intake and onset of movement disorders (P = 0.04).

The treatment for AMT-associated movement disorders in 84.44% of patients was withdrawal of AMT. Other interventions included an increase or a reduction in AMT dose and the prescription of medications such as biperiden, diazepam, diphenhydramine, methylphenidate and phenobarbital. Reintroduction of AMT was attempted in 5 patients, but only 1 patient recovered without withdrawal. 

Conclusion AMT is associated with various movement disorders, particularly DKN, DTN and MCL. Stutters and RLS are some of the less common associations. The pathophysiological mechanism of AMT-induced AKT is likely related to norepinephrine; in RLS, it is attributed to norepinephrine and serotonin; in DTN and MCL, it is ascribed to serotonin; and in DKN, histamine and acetylcholine. AMT is the most commonly prescribed TCA, which explains the large number of adverse effects reported from its use in the literature. A correlation between AMT dose and onset of movement disorders has been suggested. Findings on AMT-induced movement disorders can enrich the understanding of the effects of other TCA. More studies are needed to understand the pathophysiology of AMT and other TCA in movement disorders.

https://pubmed.ncbi.nlm.nih.gov/32419008/

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