![]() ![]() A repeat sleep EEG study was inconclusive because of excessive movement. Subsequent investigations were positive for delirium (a score of 23 on the Delirium Rating Scale) ( 1) and peripheral neuropathy, with electromyography showing a bilateral decrease in peroneal nerve compound motor action potential amplitude. The treatment team pursued a new differential diagnosis: mental disorders secondary to intracranial infection, neoplasm, or a substance or toxin and sleep disorder related to psychomotor seizures. ![]() He reported that he largely believed all these events to be true, which caused concern about a new onset of delirium or psychosis. For example, he recalled having seen a cat taking his money and running off, foxes transforming into clothing, and people in his village scolding him. He even conversed a little with clinicians during these sleep talks, and he recalled such exchanges, as well as various dream content, when he awoke. X continued to have narcoleptic attacks and unusual movements, postures, and sleep talking. Repeat cranial and lumbar spine MRIs were normal. The patient also had mild dyslipidemia and slightly low total serum protein and albumin levels, and his EEG showed increased theta activity and decreased alpha activity. Routine urine analysis showed a protein level of 1+, at 3.3 g/L. Touch and temperature sensation tests were normal, as were ECG, chest X-ray, blood count, electrolyte levels, and thyroid, liver, and kidney function tests hepatitis B and C screens were negative. His medical history was positive for chronic psoriasis (for the past 10 years) he had taken daily Chinese herbal decoctions for 3 months from a private clinic before admission 5 months ago.įindings from physical examination included mild oral mucosal ulcers and swelling of the gums scattered crusted papules on the head, face, and truncal areas, moderate scaling of the skin in the truncal areas mild hand tremors and weakness (grade IV, bilaterally) visible atrophy and weakness (grade III, bilaterally) in the lower extremities weak knee and ankle reflexes (grade 1) poor accuracy in finger-to-nose and heel-to-toe walk tests unsteady gait and a positive Romberg test (worse with eyes closed). He smoked occasionally and drank socially he denied any other substance use. His relationships were harmonious and his life was free of significant stressors. X had no previous personal or family psychiatric history and no history of epilepsy, infectious diseases, or sleep or pain disorders. He was not too concerned about the hypersomnia, the odd behavior during sleep, or the newly reported sensation of having, imbedded in his back, four balls that further divided into smaller ones. Well-oriented and generally cooperative, he was euthymic, with intermittent attention and focus, and his main complaint was his unsteady gait. X was noted to be a thin, neatly dressed man, ambulating with his wife’s help. Other sleep-related disorders included hypersomnia, narcolepsy, sleep talking, and vivid dreams that the patient believed were real events. An Example of the Patient's Unusual Sleeping Postures After Mercury Poisoning aĪ The patient maintained awkward postures such as this one for 1 to 2 hours. Given the complexity of the case, the patient was transferred to a psychiatric teaching hospital, with diagnoses of pain somatoform disorder and sleep disorder, 5 months after the initial presentation.įIGURE 1. More remarkably, during supine sleep, his hands and feet were raised up in the air, and he maintained these awkward postures for 1 to 2 hours ( Figure 1). He had also started to have dizziness, nausea, ataxia, blurred vision, and further sleep problems-sleeping up to 15 hours a day, falling asleep during conversations or meals, and exhibiting pronounced sleep talking. X’s lower joint pain had disappeared, but the tremulous sensation in his limbs persisted. After physical examination, laboratory studies, an X-ray of the affected joints, and MRI of the brain and spine showed no obvious abnormalities, the emergency department referred the patient to a psychiatric hospital with a diagnosis of pain somatoform disorder.Īfter 2 months of psychopharmacotherapy that included duloxetine (60 mg/day) and mirtazapine (45 mg/day), Mr. Treatment with a nonsteroidal anti-inflammatory drug was ineffective. ![]() X,” a 42-year-old married taxi driver from Beijing, came to the emergency department with insomnia, a severe and constant burning sensation and pain in the lumbar spine, hip and knee joints, and soles of the feet, and a sense of tremor in his limbs. ![]()
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