A 67-year-old woman with a family history of essential tremor in her father and sister.
No other relevant morbid history.
From 35 years of age, the patient presented tremor predominantly in action in the upper limbs, of moderate amplitude and worsened in stressful situations, with no functional impact on his usual activities.
Ten years ago he noticed an increase in the intensity of the tremor, so he consulted.
He started episodic treatment with propranol up to 120 mg/day and pressedna up to 250 mg/day, with partial improvement.
Three years ago, right brachial rest tremor was associated with slowing of the ipsilateral fine movements and some clumsiness in gait, greater with right deterioration.
For this reason, the patient started treatment with levodopa/carbidopa in progressive doses up to 250/25 half a tablet 3 times a day, with significant improvement in rest and decrease in tremor bradykinesia.
For 2 years she has had postural instability, especially in standing, which often relieves markedly the desire or sit down.
For this symptom, an increase in the dose of levodopa/carbidopa (250/25) to 3 tablets a day was indicated, without any improvement in postural stability.
She did not report motor fuctuations or dyskinesias associated with the use of dopaminergic medication.
At the time of our evaluation, the patient was not taking levodopa for 12 hours.
On examination, the presence of moderate muscle stiffness in extremities with Froment presence to left was highlighted, as well as mild slowing of the fine right-to-right movements without evident right-to-left branesia.
There was also low frequency right brachial and ipsilateral crural tremor at rest and moderate frequency and low amplitude bilateral brachial action tremor.
An important postural instability stood out in the standing position, which markedly relieved the fan.
No shivering was observed in the foot position; however, it was possible to separate an activity in both thighs, more intense on the right in this position.
In the 'ON' motor situation, under levodopa effect, an improvement was observed in rigidity, bradykinesia and tremor at rest, however, postural instability remained.
The retrofitting test was normal.
Attention was paid to the absence of remarkable axial manifestations, with minimal hypomymia without hypophonia.
Blood pressure was normal, with no evidence of orthostatism.
Clinically, it was interpreted as a carrier of long-standing essential family tremor, associated with a right-sided predominantly clinical picture of 3 years of evolution, good response to treatment and good response to levodopa and lower limb instability with high frequency tremor.
Faced with this last option, an electrophysiological study was requested in order to rule out tremor or episodes.
The electrophysiological study performed with surface electrodes showed a resting tremor of 4 to 6 Hertz (short for second) in the upper and lower right limbs.
In the standing position, there is a change in frequency at 16 Hz of tremor in the lower limbs, with no variations in upper limb tremor.
When the patient returned to decubitus position, tremors returned to the initial frequency of 4-6 Hz.
1.
With these elements we proposed the diagnosis of secondary tremors associated with parkinsonian syndrome, probably idiopathic PE.
We started clonazepam in increasing doses up to 2 mg a day, maintaining the levodopa dose, with an improvement in postural instability and a good response of parkinson's symptoms.
