"Bring Your Own Patient" Video presentation

An 86-year-old right-handed man started five days before admission with involuntary hyperkinetic movements He had a history of essential hypertension, chronic renal failure and an isolated report of elevated blood glucose. The movements occurred 15 to 20 times a day and lasted from 30 seconds to 1 minute They affected his left arm The episodes were precipitated by arm movements or object grasping The abnormal movement disappeared when he grasped firmly his left forearm with the other hand.

Abnormal movements were characterized by arrhythmic shaking and jerking movements of the left arm, resembling myoclonic muscle contractions at an approximately frequency of 1 Hz. The amplitude seemed to increase as the movement evolved and then decreased more rapidly.

He had not complained of polyuria or polydypsia. He was only taking 120 mg/day of nifedipine extended release. No history of seizures, stroke or myocardial infarction was reported

PHYSICAL EXAMINATION Normal vital signs. No fever. He was alert and oriented. Muscle strength was normal. There was no rigidity, bradykinesia, or tremor. Deep tendon reflexes were symmetric and decreased. Plantar reflexes were flexor. The patient reported no paresthesias or dysesthesias during or between attacks.

focal paroxysmal kinesigenic myoclonic jerks affecting the left arm, in the emergency department.

Laboratory findings serum glucose concentration = 640 mg/dl BUN = 30 mg/dl Creatinine = 2.4 (basal range = 1.9). Calculated serum osmolarity = 310 mOsm No serum ketones were detected. Serum calcium, magnesium and phosphate levels were normal.

CT It showed no evidence of basal ganglia infarcts, hemorrhage or calcification, and was considered normal for an elderly person.

Treatment He was treated with intravenous fluids and parenteral insulin. The abnormal movements subsided over the next 12 hours, after hyperglycemia was corrected. This rapid resolution did not allowed us to perform an EEG during the clinical setting.

His abnormal movements disappear over the next 12 hours, after his hyperglycemia was controlled.

This is a case of paroxysmal kinesigenic myoclonic jerks in a patient with nonketotichyperglycemia as the initial manifestation of diabetes mellitus.