A 31-Year-Old Woman With Right Arm Tremors

Heidi Moawad, MD


May 01, 2019


The patient probably has a demyelinating episode that appears to be a recurrent demyelinating condition of the central nervous system. Given her symptoms, along with saccades and dysmetria, she may have more than one lesion. Her decreased tone in the right arm, along with increased reflexes, is an unusual pattern that suggests multiple lesions.

Multiple sclerosis is the most common causes of demyelination. The patient in this case may have relapsing-remitting multiple sclerosis (RRMS), which manifests with symptoms that resemble those of a stroke or cervical spine stenosis. Parkinson disease and multiple sclerosis do not usually present with similar symptoms, but in this instance, the presence of a tremor requires considering a possible diagnosis of Parkinson disease.

RRMS is characterized by symptoms caused by episodic demyelination of the brain, spine, or optic nerves, typically of the white matter. These exacerbations can involve one or more lesions at a time and can occur at varying intervals, ranging from several times per year to only a few times in a person's lifetime. Many patients have some residual signs and symptoms between their exacerbations.

Multiple sclerosis typically manifests with motor or visual impairment. In addition, cognitive changes, mood changes, fatigue, and low energy can accompany focal symptoms or can occur independently of focal symptoms. The patient's examination findings are consistent with at least one focal lesion, corresponding to her right upper-extremity symptoms, and at least one other lesion, corresponding to the saccades.


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