85-year-old woman • insomnia • abdominal discomfort • urge to move at night • Dx?

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doi:doi: 10.12788/jfp.0572

Case Reports

85-year-old woman • insomnia • abdominal discomfort • urge to move at night • Dx?

J Fam Pract. 2023 April;72(3):E1-E3 | doi: 10.12788/jfp.0572

By

Ryuichi Takimiya, MD

Hirohisa Fujikawa, MD

Ryo Hoshino, MD

Daigo Hayashi, MD, PhD

► Insomnia
► Abdominal discomfort
► Urge to move at night

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References

1. Hening WA, Allen RP, Washburn M, et al. The four diagnostic criteria for restless legs syndrome are unable to exclude confounding conditions (“mimics”). Sleep Med. 2009;10:976-981. doi: 10.1016/j.sleep.2008.09.015

2. Innes KE, Selfe TK, Agarwal P. Prevalence of restless legs syndrome in North American and Western European populations: a systematic review. Sleep Med. 2011;12:623-634. doi: 10.1016/j.sleep.2010.12.018

3. Bogan RK, Cheray JA. Restless legs syndrome: a review of diagnosis and management in primary care. Postgrad Med. 2013;125:99-111. doi: 10.3810/pgm.2013.05.2636

4. Silber MH, Buchfuhrer MJ, Earley CJ, et al. The management of restless legs syndrome: an updated algorithm. Mayo Clin Proc. 2021;96:1921-1937. doi: 10.1016/j.mayocp.2020.12.026

5. Aquino CC, Mestre T, Lang AE. Restless genital syndrome in Parkinson disease. JAMA Neurol. 2014;71:1559-1561. doi: 10.1001/jamaneurol.2014.1326

6. Pérez-Díaz H, Iranzo A, Rye DB, et al. Restless abdomen: a phenotypic variant of restless legs syndrome. Neurology. 2011;77:1283-1286. doi: 10.1212/WNL.0b013e318230207a

7. Sforza E, Hupin D, Roche F. Restless genital syndrome: differential diagnosis and treatment with pramipexole. J Clin Sleep Med. 2017;13:1109-1110. doi: 10.5664/jcsm.6736

8. Wang XX, Zhu XY, Wang Z, et al. Restless abdomen: a spectrum or a phenotype variant of restless legs syndrome? BMC Neurol. 2020;20:298. doi: 10.1186/s12883-020-01875-1

9. Esaki Y, Kitajima T, Tsuchiya A, et al. Periodic abdominal movements. Psychiatry Clin Neurosci. 2014;68:167. doi: 10.1111/pcn.12095

10. Baiardi S, La Morgia C, Mondini S, et al. A restless abdomen and propriospinal myoclonus like at sleep onset: an unusual overlap syndrome. BMJ Case Rep. 2015;2015:bcr2014206679. doi: 10.1136/bcr-2014-206679

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THE CASE

An 85-year-old woman with hypertension presented to our hospital with a 10-month history of insomnia along with abdominal discomfort. Several months prior, the patient had undergone an esophagogastroduodenoscopy, the results of which were normal, and had received diagnoses of psychogenic insomnia and abdominal pain from her previous physician. At that time, she was prescribed eszopiclone, but her insomnia did not improve. She did not complain of any other gastrointestinal symptoms.

On examination at our hospital, the patient’s abdomen was soft and nontender. Laboratory results were unremarkable. Abdominal computed tomography was performed to exclude obvious malignancy and showed no remarkable findings.

Additional history taking and physical examination were performed. The patient reported that she could sleep for only about 2 hours per night due to persistent severe discomfort around the umbilicus, which she described as “itching.” The discomfort occurred along with an urge to move while she laid in a state of relaxed wakefulness. This discomfort occurred no matter what position she laid in and improved if she walked or tapped around the umbilicus for a while. She denied any unusual or uncomfortable sensations in her lower extremities.

Her symptoms were absent during the daytime and not related to diet. Furthermore, she did not have any symptoms of anxiety and/or depression; a detailed neurologic examination, including cognitive assessment and extrapyramidal system, yielded unremarkable findings. Additional laboratory tests showed a mild iron deficiency (ferritin, 52.6 µ g/L; iron, 10.7 µ mol/L) without anemia.

THE DIAGNOSIS

Given the patient’s presentation and clinical history, the differential diagnosis included restless abdomen (which is a spectrum or a phenotypic variant of restless legs syndrome [RLS]) and its mimics, which include fibromyalgia and gastrointestinal tract diseases. We considered the characteristic symptoms of this case (ie, irresistible symptoms, lengthy duration of symptoms, and sleep problems) to better support the diagnosis of restless abdomen than its mimics.¹ In particular, abdominal discomfort that led to insomnia was characteristic of restless abdomen, helping to pinpoint the diagnosis.

DISCUSSION

RLS is a common sensorimotor disorder that is characterized by an unpleasant urge to move the legs.² RLS may manifest as an idiopathic condition, or it can be secondary to medical conditions such as iron deficiency and Parkinson disease.^3,4 Because the unpleasant symptom is exacerbated in the evenings, patients with RLS frequently complain of sleep disturbance.

Cases of RLS-like sensory disorders, with symptoms involving sites other than the lower extremities (eg, arms, mouth, trunk, and genitals) recently have been reported.^5-7 Among them is restless abdomen, a rare disorder that manifests with a restless abdominal sensation and worsens the quality of sleep and life.⁶

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85-year-old woman • insomnia • abdominal discomfort • urge to move at night • Dx?

References

THE DIAGNOSIS

DISCUSSION

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