Untreated Hypertension and Overuse of NSAIDS

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CASE REPORT

A 67-year-old woman presents with symptoms of symptoms of daytime fatigue and sleeplessness at night due to excessive nighttime movements over the course of three months. Her husband is concerned that she could be having seizures. Her past medical history is significant for hypertension, for which she has been prescribed antihypertensive medication in the past. She stopped taking the medication when she and her husband both retired two years ago; the pharmacy where she picked up her prescriptions was in the building where she used to work.

Five years ago, she slipped and fell on the ice while walking to get her mail. She sustained a herniated lumbar disk and a sprained ankle, resulting in persistent neck and back pain. Her ankle gradually improved over the course of five months after the injury, but she frequently takes generic over-the-counter non-steroidal anti-inflammatory medications (NSAIDS) for back pain, often taking up to 10 pills per day.

Physical examination

The patient was alert, oriented, cooperative, and in no acute distress. She moved her legs almost constantly during the examination. When questioned about it, both she and her husband said that these movements are typical for her, but neither could not recall when the movements began. She explained that her legs often feel an “inner itch,” and the sensation is relieved when she moves them. This sensation has never been associated with a rash or any other visible lesions.

Cardiac, respiratory, and abdominal examination were normal, but blood pressure was high (150/90). She had a normal cranial nerve examination. On neurological examination, strength, reflexes, and coordination were normal in all four extremities. Sensory examination was normal for light touch, pinprick, vibration, and proprioception. Gait was also normal, and she was able to walk heel to toe without limitations. She had a negative Romberg test.

Diagnosis: Restless Legs Syndrome, Subacute Hemorrage

An electroencephalogram (EEG) showed localized focal slowing in the right cerebral hemisphere corresponding to one lead, and there was no suggestion of an epileptic focus or post-ictal changes.

A complete blood count (CBC) and blood chemistry to explore the cause of RLS in this patient were normal. As a follow-up to the focal abnormality on her EEG, a brain MRI showed evidence of a subacute hemorrhage in the right basal ganglia.

Based on her history and physical examination, a tentative diagnosis of restless legs syndrome (RLS) was made. This patient likely had a hemorrhagic stroke due to her untreated hypertension and overuse of NSAIDS, many of which are blood thinners. FDA-approved medications for the treatment of RLS include gabapentin enacarbil (an anticonvulsant), as well as ropinirole, pramipexole, and rotigotine (dopamine agonists).

Treatment and outcome

The patient was started on gabapentin enacarbil to control the symptoms. An antihypertensive medication was resumed. She was sent for a physical therapy evaluation and advised to discontinue taking NSAIDS.

At one-month follow-up, her husband reported that the nighttime movements had improved. She reported that she was less tired during the day and she did not experience any adverse effects from the gabapentin or blood pressure medication. She continued to experience neck and back pain and was given a prescription for celecoxib.

Discussion

RLS is a condition that manifests with excessive physical movements of the arms and/or legs, and rarely, other parts of the body. Uncomfortable sensations or an urge to move can occur during the day or night, generally when a patient is physically at rest. These symptoms are often relieved with action of the restless extremities or body parts. Most of the time, people with this condition experience leg movements that interfere with restorative sleep. The movements are generally involuntary, but they can sometimes be voluntarily inhibited for a brief period of time. Most people who have this disorder feel sleepy and irritable during the day. 

This condition usually begins in when patients are in their mid-40s, especially when there is a family history of RLS. It is often associated with Parkinson disease or another movement disorder, as well as renal failure, iron deficiency, and peripheral neuropathy. RLS is rarely associated with a brain lesion, as in this case, but lesions have been localized in the pons, centrum semiovale, thalamus, putamen, medulla, or occipital lobe.¹ RLS after a stroke is more commonly associated with difficulty falling asleep than with daytime sleepiness.²

The condition may progressively worsen over time. However, if the cause is related to kidney failure or iron deficiency, it can improve with management of these causative etiologies. For this patient, because the etiology of her condition was a stroke, she is not expected to experience progressive symptoms over time.

Take Home Points

• RLS can manifest with various complaints, and it is often the spouse who is most aware of excessive physical movements

• RLS can produce daytime restlessness, which is helpful in the diagnosis

• While RLS is a clinical diagnosis, tests may be necessary to identify the etiology of the disorder

References:

1. Tuo H, Tian Z, Ma X, et al. Clinical and radiological characteristics of restless legs syndrome following acute lacunar infarction. Sleep Med. 2019;53:81-87.

2. Shiina T, Suzuki K, Okamura M, et al. Restless legs syndrome and its variants in acute ischemic stroke. Acta Neurol Scand. 2018 Nov [Epub ahead of print].