DT
A 34-year-old woman was admitted for urgent investigation of twitching
of the face and jerking of the legs and arms that had begun 3 weeks earlier.
On one occasion, her right arm had jerked when she was holding a glass
of water, causing her to drop it. Over the preceding 2 years, she had had multiple
episodes of stuttering speech and slight mental slowing lasting for days to
several weeks, during which she had found it difficult to function at work.
On 3 occasions, she had suffered a sudden loss of consciousness, and tonic
clonic activity associated with prolactin rise was seen on one occasion. After
each episode she had had a ‘prolonged postictal period’. Cerebral MRI had
been unremarkable. She had been prescribed carbamezepine. There was no
other past medical history and she worked as a marketing manager.
On examination, there was a fine tremor of the outstretched hands.Occasional
myoclonic jerks were seen in the face and fingers. There were no focal neurological
abnormalities on examination and general systems were normal.
Investigations showed:
● FBC, U&E, LFT, CRP, ESR, complement, immunoglobulins, vasculitic
screen: normal.
● Carbamezepine level: 35μmol/L (normal)
● MRI brain: unremarkable
● CSF examination including for oligoclonal bands: unremarkable
● EEG performed over a 4-day period with videotelemetry: paroxysms of
delta slow wave activity over the fronto-temporal regions bilaterally.No
epileptiform activity seen
● TSH 12.8mu/L (0.5–6.0mu/L), total thyroxine 55mmol/L
(70–140mmol/L).
A further test was performed and she was started on steroids and thyroxine
with good resolution of her symptoms. However, on reducing the steroids, she
became shaky and tremulous with a sensation of unsteadiness. This resolved
on increasing the steroid dose.