J Korean Med Sci 2008; 23: 533-6 ISSN 1011-8934 DOI: 10.3346/jkms.2008.23.3.533 Copyright The Korean Academy of Medical Sciences A Case of a Patient with Both Chorea and Restless Legs Syndrome The patient was a 44-yr-old man with end-stage renal disease who had developed chorea as a result of hypoglycemic injury to the basal ganglia and thalamus and who was subsequently diagnosed with depression and restless legs syndrome (RLS). For proper management, the presence of a complex medical condition including two contrasting diseases, chorea and RLS, had to be considered. Tra- madol improved the pain and dysesthetic restlessness in his feet and legs, and this was gradually followed by improvements in his depressed mood, insomnia, lethar- gy, and feelings of hopelessness. This case suggests that the dopaminergic sys- tem participates intricately with the opioid, serotoninergic, and noradrenergic sys- tems in the pathophysiology of RLS and pain and indirectly of depression and insomnia. Key Words : Restless Legs Syndrome; Chorea; Sleep Initiation and Maintenance Disorde; Depression; Tra- madol Yoon-Kyung Shin, Seung-Chul Hong, Yon Kwon Ihn*, Jong-Hyun Jeong, Jin-Hee Han, and Sung-Pil Lee Departments of Psychiatry and Radiology*, St. Vincent’s Hospital, The Catholic University of Korea College of Medicine, Suwon, Korea Received : 20 April 2007 Accepted : 20 September 2007 Address for correspondence Seung-Chul Hong, M.D. Department of Psychiatry, St. Vincent Hospital, The Catholic University of Korea, 93 Ji-dong, Paldal-gu, Suwon 442-723, Korea Tel : +82.31-249-7161, Fax : +82.31-248-6758 E-mail : hscjohn@hotmail.com INTRODUCTION The patient in this report was suffering from diabetic neu- ropathy, end-stage renal disease, restless legs syndrome (RLS), and depression. He had injuries of both basal ganglia and the thalamus as a result of hypoglycemia, causing chorea and more severe leg pains and dysesthetic sensations. RLS is a sensorimotor disorder characterized by unpleasant leg sen- sations together with an irresistible inner urge to move. Chorea is a neurological syndrome characterized by abrupt involun- tary movements resulting from a continuous flow of random muscle contractions. The first-line pharmacological treat- ment for RLS is a dopaminergic agent, whereas anti-dopamin- ergic drugs are the main pharmacological treatment for chorea. In general, greater D2-receptor blocking action results in greater anti-choreic efficacy (1). Dopaminergic drugs for RLS would aggravate the choreic movements, while anti- dopaminergic agents for the treatment of chorea would exac- erbate the RLS. In this report, the association between the complex medical conditions and symptoms of a patient with two coexisting, opposing diseases is discussed. This report also introduces the process through which proper diagnoses and treatments were sought. CASE REPORT A 44-yr-old man with insomnia and depression was referr- ed to the psychiatric department of our institution. He com- plained that he rarely fell asleep because of dysesthetic sen- 533 sations and pain in the lower legs and feet and that he was depressed and feeling hopeless. Although he was aware of having had a high blood sugar level for 10 yr, he never sought treatment. About 3 yr earlier, in summer 2003, he began to experience cold, numbing, and pins-and-needles sensations on his toes that eventually spread throughout his feet. About a year later, he started taking hypoglycemic agents. Howev- er, the pain in his feet became severe, and restlessness as a result of creeping sensations in his lower legs gradually start- ed to occur when he was lying down or sitting awake. He tried massaging and beating his legs and walking around. The unpleasant sensations and restlessness were temporarily relieved by massage and walking, but the pain in his feet remained little changed. These dysesthetic sensations were most severe when he lay down to sleep, increasing his sleep latency to longer than one hour. He woke repeatedly and had a difficulty falling back asleep because of further dysesthetic sensations. In July 2005, the patient received hemodialysis for end-stage renal disease. In those days his serum hemoglobin, iron, and ferritin levels were 7.4 g/dL, 29 μg/dL, and 97 ng/ mL, respectively, so oral iron supplementation was adminis- tered. He gradually became depressed, experienced feelings of worthlessness, lost his appetite, and eventually stopped eating. His speech became slow, and his arms and legs trem- bled and twitched involuntarily. Subsequently, he showed irregular, spasmodic, involuntary movements in his limbs and on his face. He was taken to the emergency center of St. Vincent’s Hospital on 26 June 2006 by his son. His blood sugar level was very low (49 mg/dL). T2- and fluid-attenuated inversion recovery (FLAIR)-weighted magnetic resonance