Working Diagnosis:
Paroxysmal exercise-induced dyskinesia

Treatment:
Oral hydration, food, and passive rewarming.

Outcome:
Discharged ambulatory and instructed to follow-up with his primary care physician. The patient continues to run. Given the unpredictability of his symptoms and lack of effect on daily activities, he remains off medication for dyskinesia.

Author's Comments:
Paroxysmal exercise-induced dyskinesia is an indeterminant form of a movement disorder. It involves cramping and spasm of the legs and feet after prolonged exercise. Episodes last an average of 5-30 minutes and resolve after approximately 10 minutes of rest. Onset is 1-30 years of age. Frequency ranges from 1 attack per day to 1 attack per month. This dyskinesia may be inherited or sporadic, and has been associated with mutations in glucose transporter type 1. Treatment includes physical therapy, sensorimotor retraining and medication, which could include carbamazepine, levodopa, or trihexyphenidyl.

Editor's Comments:
Teaching Points
• Cramping and spasms of legs and feet after prolonged exercise (1,2,3)
• Episodes last 5-30 minutes(1,2,3)
• Resolves after ~10 minutes of rest(1,3)
• Onset 1-30 years old (1,2,3,6)
• 1 attack/day to 1 attack/mo (1,4,5)
• Inherited or sporadic (1,3,6)
• Associated with mutations in glucose transporter type (1,6,7)
• Treatment includes physical therapy, sensorimotor retraining, and medications (2,4,5,6)

References:
1. Lance JW. Familial Paroxysmal Dystonic Choreoathetosis and Its Differentiation from Related Syndromes. Ann Neurol. 1977; 2: 285-93.
2. Demirkiran M, Jankovic J. Paroxysmal Dyskinesias: Clinical Features and Classification. Ann Neurol. 1995; 38: 571-79.
3. Bhatia KP, Soland VL, Bhatt MH, Quinn NP, Marsden CD. Paroxysmal Exercise-Induced Dystonia: Eight New Sporadic Cases and a Review of the Literature. Mov Disord. 1997; 12(6): 1007-12.
4. Bhatia KP. The paroxysmal dyskinesias. J Neurol. 1999; 246: 149-55.
5. Unterberger I, Trinka E. Diagnosis and treatment of paroxysmal dyskinesias revisited. Ther Adv Neurol Disord. 2008; 1(2): 67-74.
6. Bhatia KP. Paroxysmal Dyskinesias. Mov Disord. 2011; 26(6): 1157-65.
7. Van Rootselaar AF, van Westrum SS, Velis DN, Tijssen MAJ. “The paroxysmal dyskinesias.� Pract Neurol. 2009; 9: 102-9.

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