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Recurrent Involuntary Contractions of the Face, Arm, and Leg in an Elderly Man

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his 60s was evaluated in the epilepsy monitoring unit for various spells he had been having up to 5 times a day over the previous 8 months. He described transient episodes of expressive speech difficulties, paroxysmal dizziness, and involuntary nonsuppressible jerks of the right arm, which occurred without warning and were associated with mild disorientation. Video electroencephalography (EEG) captured the movements (Figure, A). They consisted of involuntary, synchronous contractions of the right face, arm, and leg that were sustained for a few seconds before muscle relaxation occurred (Figure, B and C; Video). The movements were not elicited by action or exertion. There was no epileptic abnormality that correlated with the movements on EEG, and head magnetic resonance imaging was unremarkable.

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C. Faciobrachial dystonic seizures

Paroxysmal dyskinesia (choice B) is unlikely, because the phenomena are not triggered by movement or exertion, which would suggest kinesigenic or exercise-induced dyskinesia, respectively. Paroxysmal nonkinesigenic dyskinesia may occur, but the attacks would last minutes to hours rather than seconds. Furthermore, his age at onset is late for this group of genetic disorders. A tic disorder (choice D) is also unlikely, because there is no premonitory urge that is relieved by performing the tic, and the movement is not even briefly suppressible. The movement is jerky, but contractions are sustained for a few seconds, which is too prolonged for myoclonus (choice A) and more reminiscent of dystonic posturing.

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Article Information

Corresponding Author: David Dongkyung Kim, MD, Department of Clinical Neurological Sciences, Western University, 339 Windermere Rd, London N6A 5A5, ON, Canada (david.kim@medportal.ca).

Published Online: April 1, 2019. doi:10.1001/jamaneurol.2019.0452

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
References
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2.
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