Late onset of atypical paroxysmal non-kinesigenic dyskinesia with remote history of Graves’ disease
A 66-year-old right-handed female with a history of Graves’ disease and total thyroidectomy at the age of 30 was referred to our clinic with the chief complaint of abnormal movements of the left hand. She reported intermittent abnormal posturing and tightening of her left hand. These movements started 6-7 years before she presented to the neurologist. They occurred twice per week and lasted from 1 to 2 min. Furthermore, these movements tended to be unilateral and involuntary, with no change in her level of consciousness during attacks. She reported no aura prior to the episode, while at other times she sensed them coming. She did not specifically recall any triggers that may have preceded the attack, such as sudden movement, substance, or stress, but had experienced that these attacks were much more often than baseline after fatigue or lifting heavy objects. Although she experienced discomfort with these events, she did not experience pain, numbness, weakness, or tingling. She dealt with attacks by spreading her fingers and pushing them against a surface. She had no difficulty performing daily activities, and during episodes, she was able to communicate and was perfectly coherent. There was no family history of movement disorders. Her neurological examination was completely normal.\nFurthermore, laboratory investigation including complete blood count, sedimentation rate, renal and liver function tests, thyroid profile, growth hormone, cortisol, and ceruloplasmin levels did not reveal any abnormality. A magnetic resonance imaging (MRI) of brain and a 48-h ambulatory electroencephalogram (EEG) with two clinical episodes were normal.