1153 Many Reasons for Restless Legs, Not to Rest

Abstract Introduction Restless leg syndrome (RLS) involves an urge to move the legs that is exacerbated by rest, relieved by movement, and most prominent in the evening. While RLS is commonly associated with low ferritin, here we present a complex case in a patient requiring phlebotomy for symptom control related to elevated ferritin levels. Report of case(s) A 52 year-old male presented with uncontrolled RLS diagnosed 12 years prior. Sleep history included obstructive sleep apnea (OSA) on CPAP and hypersomnolence. Diagnostic polysomnogram was notable for an AHI 36.4 events/hr with associated hypoxia. Ferritin was 374ng/mL. He presented to our clinic on melatonin and wearing socks with bars of soap atop his feet. On exam, he was obese and plethoric with significant hypersomnolence despite excellent CPAP compliance. He was previously treated unsuccessfully with a combination of phenobarbital, trazodone, and ropinirole, which exacerbated his hypersomnia. He drank 4-5 liters (L) of soda daily. In the 5 years after initial presentation, he went through periods of total cessation to drinking up to 12L a day. He eventually developed uncontrolled diabetes, hypertension, hyperlipidemia, and NASH with advanced fibrosis. He was referred to Hematology and underwent therapeutic phlebotomy every 2-4 months. He was found to have HFE-C282Y Heterozygous mutation and NASH fibrosis without iron overload on MRI. His RLS was eventually controlled with a combination of pramipexole 1.5 mg, gabapentin 1800 mg, alprazolam 0.5 mg along with therapeutic phlebotomy to maintain a ferritin level less than 250 ng/mL. His hypersomnia was managed with amphetamine-dextroamphetamine. Conclusion RLS has been associated with high serum ferritin, iron, and saturation transferrin index levels with a low transferrin level due to impaired mobilization of stored iron. Iron deposits can be seen on MRI in the globus pallidus, dentate, red nuclei and substantia nigra. In this patient, soda cessation would help improve his diabetes, thereby decreasing chronic inflammation and lowering ferritin levels. Chronic liver disease, HFE C282Y mutations, and hypoxia from OSA can also contribute to increased ferritin levels. Abstaining from caffeine can likewise improve symptoms of RLS as caffeine is known to heighten proprioceptive awareness and increase neuromuscular reactivity which may include myoclonus. Support (if any)