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

Abstract

TH E PA TI EN T 85-y ea r-o ld wo m an SI G NS & SY M PT O M SIns om nia-Ab do m ina l dis co m fo rt-Ur ge to m ov e at nig ht 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 µg/L; iron, 10.7 µmol/L) without anemia.