Restlessness in right upper limb as sole presentation of restless legs syndrome
A 28-year-old female was presented with a 7-month history of tickling sensation, felt deep inside the muscles of right upper limb. The symptoms started slowly over a period of 1 month and progressed gradually. The arm and the forearm were affected in equal magnitude. The sensations appeared during night and were associated with an urge to move the affected extremity. Movement of the right arm and forearm brought relief but the symptoms recurred with the cessation of movements. Typically, symptoms lasted for 4-6 hours/day for at least 4 nights a week. She also complained of daytime symptoms like lethargy and somnolence on almost all days. These symptoms were not following any dermatomal pattern; not associated with any motor weakness; never experienced during the day; and never interfered with the use of any of the upper limbs in daily chores. She did not notice any aggravating factor for the symptoms except the diurnal variation. The patient did not report any history to suggest medical, surgical or psychiatric illness before the onset of these symptoms. Similarly, onset of symptoms was not associated with any drug intake or any stressful life event. As reported by her, none of the family members had RLS or any psychiatric disorder.\nShe had been taking treatment (Diclofenac 50 mg orally twice a day and Vitamin B complex formulation orally once a day) for 15 days, without any improvement. Her X-ray neck AP view depicted bilateral cervical ribs []. Mental status examination showed decreased psychomotor activity and depressed anxious affect. Neurological assessment-motor power, deep tendon reflexes and sensory examination (touch, pain, pressure, temperature, graphesthesia) of all the limbs did not show any abnormality. Specifically, in both the upper limbs, power in abductors, adductors and rotators of shoulder; flexors and extensors of arm, forearm and hand; and hand grip was adequate (Grade 5) and bilaterally equal. Provocation tests for the disputed thoracic outlet syndrome were done.[] Elevated arm stress test, Wright's test, Cyriax test and cervical rotation lateral flexion test were performed, which were negative.[] Her radial pulses were of equal volume on both the sides and she was not having any sensory or vascular symptoms on movement of either of the shoulders. Considering the clinical features and clinical examination, further examination through radiological investigation of cervical spine or level-1 polysomnography was not considered.\nDiagnosis of the RLS was made. Severity of the symptoms was adjudged with the help of IRLS Hindi version[] and Insomnia Severity Index (ISI) Hindi version.[] IRLS score was 34 and ISI score was 14. Her total iron binding capacity (TIBC) was 526 μg/dl (range = 274-385 μg %) and serum ferritin was 4.02 ng/ml (range = 22-112 ng/dl). She was given tablet pramipexole 0.25 mg once a day in the evening along with the oral iron therapy (ferrous sulfate 150 mg twice a day).\nShe was followed up after 2 weeks. She reported a significant improvement in RLS (IRLS score 7). Despite improvement in RLS, she had difficulty in falling asleep and non-refreshing sleep persisted (ISI score = 10). Her clinical history was reviewed, which revealed that sleep problems and sadness of mood were present since past 6 months, i.e., after the onset of RLS symptoms. Her diagnosis was reviewed and major depressive disorder with co-morbid insomnia was added to the initial diagnosis of RLS. Hamilton rating scale for depression (HAM-D) was administered (Score = 23). Duloxetine 20 mg once a day orally along with clonazepam 0.125 mg twice a day orally was added to the pramipexole and oral iron therapy.\nFollow-up after 3 weeks showed a substantial improvement in the mood (HDRS = 11) and the sleep (ISI = 4) with almost complete remission of RLS symptoms (IRLS = 2).