BONANNI, ENRICA

CARNICELLI, LUCA

DI COSCIO, ELISA

Iacopini E

MAESTRI, MICHELANGELO

English

M. Maestri

L. Carnicelli

E. Di Coscio

E. Iacopini

E. Bonanni

Crossref

European Journal of Neurology

Exacerbation of restless legs syndrome presenting as a psychiatric emergency

Archivio della Ricerca - Università di Pisa

LETTER TO THE EDITORExacerbation of restless legssyndrome presenting as apsychiatric emergencyM. Maestri, L. Carnicelli, E. Di Coscio,E. Iacopini and E. BonanniSleep Disorders Center, NeurologicalClinic, University of Pisa, Pisa, ItalyCorrespondence: E. Bonanni, SleepDisorders Center, Neurological Clinic,University of Pisa, Via Roma 67, 56126Pisa, Italy (tel.: +39 050 992931; fax:+39 050 992567; e-mail e.bonanni@med.unipi.it).Keywords: bipolar disorder, emergency,mirtazapine, restless legs syndromeReceived: 29 January 2013Accepted: 14 February 2013Sir,We read with great interest the casedescriptions by Mehta et al. [1] and Man-coni and Fulda [2] and appreciated thehighlight on restless legs syndrome (RLS)as a clinical manifestation in emergency.We report a similar, although less dra-matic, case. We evaluated in the emer-gency department a 60-year-old malereferred for severe worsening of RLS last-ing continuously for 2 days and leading tosevere insomnia and leg restlessness. Thepatient had a history of bipolar depressionand impulse control disorder and wastreated with valproate 900 mg/day. RLSsymptoms started 2 years before but, sincethey were mild and sporadic, no treatmentwas suggested.Owing to severe insomnia and worsen-ing of depressive symptoms, mirtazapine30 mg at bedtime was added. Immedi-ately after, RLS symptoms dramaticallyworsened. On the second night, pramip-exole 0.25 mg in the evening was startedwith no benefit. In the third afternoonthe patient came to the emergencydepartment with severe agitation andrestlessness, being unable to sit downwithout moving. We immediately decidedto stop mirtazapine and, due to the anxi-ety symptoms and previous psychiatrichistory, we preferred not to use highdosage dopamine agonists and shiftedthe treatment to tramadol 25 mg andgabapentin 300 mg. The patient refusedto be admitted into our ward. However,the next morning he reported an impres-sive improvement of the symptoms. Inthe first month, tramadol was graduallydiscontinued and gabapentin wasincreased to 600 mg/day. After morethan 4 years of follow-up, RLS andbipolar symptoms appear still controlledwith gabapentin 600 mg in the evening,valproate CR 300 mg TID and imipra-mine 12.5 mg TID.This case report is a further exampleof how RLS could become a real emer-gency. A drug-related worsening, oroccurrence, of RLS symptoms shouldalways be considered in the differentialdiagnosis of agitation. In this case,although psychiatric history andsymptoms of anxiety were confoundingfactors, correct identification of RLSsymptoms (both during the previousyears and currently) together with arecent change in antidepressant therapyled to the correct diagnosis. The success-ful treatment was based on therapy withalpha-delta ligand, but probably evenmore so on the discontinuation of mirt-azapine. It should be underlined thatmirtazapine has the highest risk for RLSamong second-generation antidepressants[3], typically within the first week, andprovokes periodic limb movements evenin healthy subjects [4]. However, a simi-lar case report had been described withcitalopram [5].Thus, we would suggest that a list ofcontraindicated drugs should be diffusedto general practitioners, other specialistsand also to patients to help the correcttreatment of comorbidities in RLS.References1. Mehta SH, Dees DD, Morgan JC, SethiKD. Severe exacerbation of undiagnosedrestless legs syndrome presenting as amovement disorder emergency. Eur JNeurol 2013; 20: e35.2. Manconi M, Fulda S. Restless legssyndrome in the emergency room. Eur JNeurol 2013; 20: e36.3. Rottach KG, Schaner BM, Kirch MH,et al. Restless legs syndrome as sideeffect of second generation antidepressants.J Psychiatr Res 2008; 43: 70–75.4. Fulda S, Kloiber S, Dose T, et al. Mirtaza-pine provokes periodic leg movementsduring sleep in young healthy men. Sleep2013; http://www.journalsleep.org/AcceptedPapers/P-319-12.pdf (accessed 25/03/2013).5. Perroud N, Lazignac C, Baleydier B,Cicotti A, Maris S, Damsa C. Restless legssyndrome induced by citalopram: a psychi-atric emergency? Gen Hosp Psychiatry2007; 29: 72–74.© 2013 The Author(s)European Journal of Neurology © 2013 EFNS e83European Journal of Neurology 2013, 20: e83 doi:10.1111/ene.12147

https://arpi.unipi.it/bitstream/11568/236332/1/exacerbation%20of%20Rls.pdf

Exacerbation of restless legs syndrome presenting as a psychiatric emergency

Abstract

Similar works

Full text

Available Versions

Crossref

Archivio della Ricerca - Università di Pisa