Case-1
25-year-old woman presented to ED with progressive weakness in both legs for 3 weeks. Neurologic exam showed dysarthria, weakness and hyperreflexia in both legs with normal muscle tone. MRI with and without contrast for brain and spine was normal. Three days after admission she developed progressive painful paroxysmal dyskinesia beginning in both legs and progressively involving her abdomen, chest, back, arms, and neck over the following week. These episodes lasted 20-40 seconds and were triggered by emotional stress, touch and movement and did not impair consciousness. Symptoms of dysautonomia including persistent tachycardia (120s-140s), episodes of hypertension, and urinary retention were present. CSF studies demonstrated elevated white cell count (490) with lymphocytic predominance, elevated protein, elevated albumin and positive anti-GAD antibody. Patient showed improvement in weakness and paroxysmal dyskinesia after treatment with IVIG, solumedrol and rituximab.
Case-2
61-year-old man presented to neurology clinic for evaluation of paroxysmal movements. Patient had a history of a left hemispheric stroke in 2009. He developed right-arm paroxysmal dyskinesia in 2010. Initially these episodes were infrequent and lasted between 30 seconds and 4 minutes. The episodes progressively worsened over 9 years progressing to involve right-leg in addition to arm, increasing in duration to 15-60 minutes and recurring several times per week. Neurology exam, including muscle tone, was normal. Serum anti-GAD was positive. CSF IgG-index was elevated. Paroxysmal movements resolved after a course of IVIG and solumedrol with gradually recurring in milder form 3 months after treatment.