LETTER TO THE EDITOR Restless legs syndrome in the emergency room M. Manconi and S. Fulda Sleep and Epilepsy Center, Neurocenter of the Southern Switzerland, Civic Hospital (EOC) of Lugano, Lugano, Switzerland Correspondence: M. Manconi, Sleep and Epilepsy Center, Neurocenter of Southern Switzerland, Civic Hospital (EOC) of Lugano, Via Tesserete 46, 6900 Lugano, Switzerland (tel.: +41 91 811 6825; fax: +41 91 811 6915; e-mail: mauro.manconi@eoc.ch). Keywords: neurological disorders, restless legs syndrome, sleep disorders, Willis-Ekbom disease Received: 15 October 2012 Accepted: 16 October 2012 We have read with great interest the case description of Mehta et al. [1] that high- lighted an unusual clinical manifestation of restless legs syndrome (RLS) in the neurology intensive care unit. RLS is a still underdiagnosed chronic sleep-related movement disorder with a wide range of severity, including uncommon cases with severe and abrupt clinical presentation. The presentation of RLS in an emer- gency room setting has been almost neglected in the literature. The case reported by Mehta et al. concerns a patient with a history of undiagnosed RLS and an acute exacerbation of symp- toms likely secondary to promethazine. Herein we report a similar case that underlines the possibility that RLS can present as an acute emergency, and adds the observation that this may even occur in patients with a well-established RLS diagnosis and treatment for RLS. A 57-year-old man with chronic renal failure due to inherited collagenopathy underwent renal transplantation after 1 year of peritoneal dialysis. Two years before, RLS associated with renal insuffi- ciency had been diagnosed and treatment with pramipexole was initiated. The patient had suffered from RLS since the age of 10 years and reported a positive family history of RLS. Before surgery he was successfully treated with extended release pramipexole 1.125 mg plus clonazepam 0.5 mg, because of progres- sive worsening of the symptoms during the past year. For reasons that were not well specified, probably related to stan- dard safety pre-surgical procedures, the surgeons decided to withdraw pramipex- ole and clonazepam the day before the operation. Surgery proceeded without complications, but about 2 h after awak- ening from anesthesia the patient started to show severe ‘akathisia’ characterized by continuous leg and arm stretching movements associated with confusion. Symptoms worsened during the following 2 h, and the patient started to insist that he needed to move and repeatedly tried to stand up and walk to relieve symp- toms. Physicians and nurses attempted to restrain him in order to avoid post-surgi- cal complications due to the intense motor activity. Physicians then decided to inject haloperidol 10 mg intra-muscu- larly, which worsened the symptoms and induced an unusual aggressive behavior in the patient. Main hemodynamic and laboratory parameters were within the normal range, and a diagnosis of psycho- motor agitation due to an abnormal response to anesthesia was suspected. Although confused, the patient screamed repetitively the name of the sleep expert who was treating him for RLS. Finally, physicians contacted the sleep expert who advised against giving any other neuroleptic, and suggested to administer morphine intravenously (10 mg), and to subsequently continue with the pre-sur- gery RLS treatment. With morphine, RLS symptoms rapidly resolved and the patient was able to stay in bed. We think that in this case the complete and rapid RLS drug withdrawal before surgery and possibly the anesthesia trig- gered RLS symptoms, and that haloperi- dol with its anti-dopaminergic effect significantly worsened the symptoms. Anesthesia might trigger new or worsen a pre-existing RLS [2], and already Karroum et al. [3] described a series of patients who experienced a perioperative acute exacerbation of their RLS symp- toms with negative consequences and complications during surgery and follow- up. In our case, we decided to administer opioids and observed an immediate effect, which had previously also been described by Vahedi et al. [4] in another case of severe RLS admitted as an emer- gency. This case and others described in the literature are in support of a recent pro- posal of the Medical Advisory Board of the RLS Foundation that suggested to provide all patients with RLS with a pocket card containing information regarding the diagnosis, its treatment and the contact details of the treating physi- cian in case of emergencies. Finally, we think that increased knowledge of and attention to RLS symptoms by emer- gency room personnel may disclose a sig- nificant number of diagnosed or undiagnosed exacerbated RLS cases otherwise misdiagnosed as unknown psychomotor agitation. References 1. Mehta SH, Dees DD, Morgan JC, Kapil D, Sethi KD. Severe exacerbation of undi- agnosed restless legs syndrome presenting as a movement disorder emergency. Eur J Neurol 2013; 20: e35. 2. H€ ogl B, Frauscher B, Seppi K, Ulmer H, Poewe W. Transient restless legs syndrome after spinal anesthesia: a prospective study. Neurology 2002; 59: 1705–1707. 3. Karroum EG, Raux M, Riou B, Arnulf I. Acute exacerbation of restless legs syn- drome during perioperative procedures: case reports and suggested management. Ann Fr Anesth Reanim 2010; 29: 920–924. 4. Vahedi H, K€ uchle M, Trenkwalder C, Krenz CJ. Peridural morphine administra- tion in restless legs status. Anasthesiol In- tensivmed Notfallmed Schmerzther 1994; 29: 368–370. © 2013 The Author(s) European Journal of Neurology © 2013 EFNS e36 European Journal of Neurology 2013, 20: e36 doi:10.1111/ene.12035