Bilateral spontaneous carotid-cavernous fistulas, associated with systemic hypertension and generalised arteriosclerosis: a case report.

A 65 year old previously healthy farmer was brought to the emergency room 18 hours after the acute onset of symptoms. There was no family history of movement disorders, or of neuroleptic-induced extrapyramidal reactions. Four days before admission, he experienced mild epigastric distress and abdominal fullness, for which 2 days later, he took one tablet, 5 mg of oral metoclopramide, dextromethorphan, and Gasgel (simethicone, aluminum magnesium hydrate and magnesium oxide). Some 30 hours after the first dose, and 2 hours after the second dose, he developed irregular, intermittent muscle jerking, most obviously in the face, mouth, and limbs (fig, a). The jerks could be initiated when the patient began to speak or to move a limb, but were not affected by external stimuli such as pinprick, touch, vibration, light, or sound. The jerks disturbed speech and swallowing. There was no change in the level of consciousness. Obvious irregular independent flapping tremors were observed in both outstretched hands when the wrists and fingers were extended (fig, b). There was involuntary hyperextension of the neck and forceful opening of the mouth. Routine laboratory studies were all normal including liver function tests. A chest radiograph was normal. EEG (awake) revealed no abnormality. The asterixis, myoclonus, and acute dystonic reactions cleared within 12 hours. On follow-up 6 months later the patient was normal. Myoclonus has been described in association with the acute hyperkinetic syndrome