A 31-Year-Old Woman With Right Arm Tremors

Heidi Moawad, MD


May 01, 2019

This patient seems to have an episodic condition or a systemic illness. Her bout of fatigue improved without any intervention. Because she was not examined at the time, whether she had focal findings is unclear. Typically, focal symptoms prompt an urgent medical visit. Patients with multiple sclerosis who do not have focal symptoms on the first event may not seek medical attention, delaying the diagnosis. Multiple sclerosis is also often worse during hot weather. The fact that her episode of fatigue and low energy and her episode of tremors both occurred during the warm summer months supports multiple sclerosis as the likely etiology. 

Tremors are not common in multiple sclerosis, and when they occur, they manifest as intention tremors, rather than resting tremors. Evidence suggests that lesions in the pons and cerebellum are correlated with an intention tremor in multiple sclerosis.[1] Pharmacologic and surgical approaches specifically focused on managing tremors are used to improve quality of life for patients with multiple sclerosis who have persistent tremors, if treatment for an acute multiple sclerosis exacerbation and disease-modifying therapy do not alleviate the tremor. 

Cervical spine stenosis may cause spinal cord and/or nerve root impingement, which can produce focal symptoms. Symptoms may include weakness and/or sensory loss, with increased or decreased reflexes, depending on peripheral nerve or cervical spine impingement. Some of this patient's physical examination findings may be explained by cervical spine stenosis; however, it would not explain her saccades or intermittent intention tremor. Her unusual bout of fatigue would also not be explained by cervical spine stenosis. 

Stroke can cause focal weakness and increased reflexes and is a rare cause of tremors as well. The patient's examination findings suggest at least one focal lesion, which could be consistent with one or more ischemic brain lesions. Although she may have several ischemic brain lesions, the bout of fatigue that she experienced more strongly suggests a systemic or episodic condition. 

Parkinson disease often manifests with tremors. However, this patient clearly has an intention tremor, as opposed to the resting tremors that are more typical of Parkinson disease. Her symptoms and signs are focal, which is not typical of Parkinson disease. Her upper-extremity reflexes are brisk, which is also an atypical finding in Parkinson disease. She also has decreased muscle tone with an absence of the muscle rigidity that would be expected to accompany Parkinson disease. Eye movement abnormalities can occur with Parkinson disease, but they are usually limitations of eye movement, rather than saccades. Her signs and symptoms are suggestive of one or more focal lesions rather than a degenerative disease process, such as Parkinson disease.


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