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Images in Neurology |

Ethanol Responsive Tremor in a Patient With Multiple Sclerosis

Edward R. Hammond, MD, MPH; Douglas A. Kerr, MD, PhD
Arch Neurol. 2008;65(1):142-143. doi:10.1001/archneurol.2007.13.
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A 29-year old white man presented with gait imbalance and visual disturbances 6 years ago. Evaluation of his condition led to a diagnosis of multiple sclerosis (MS). He experienced disease progression while taking 2 different conventional MS treatments that manifested as new-onset tremor in both hands, progressing to involve the hands and neck. He occasionally drinks alcohol and has no family history of tremor. Over the next 4 years, he averaged 3 relapses per year and 6 enhancing lesions per year on magnetic resonance imaging scans with gadolinium contrast (Omniscan), including 1 cerebellar lesion. Twenty-two months earlier he had been treated with high-dose intravenous cyclophosphamide (Revimmune), 200 mg/kg, over 4 days under a research study protocol at Johns Hopkins Hospital. He has not been receiving any immunomodulatory treatment since the Revimmune protocol. Over this period he has had no exacerbations or new gadolinium-enhancing lesions. His disability reduced from 4.0 to 3.0 on the Expanded Disability Status Scale1 with gait returning to normal but unable to walk in a straight line with one foot directly in front of the other, perform tandem. He showed improvement of +1.08 on the Multiple Sclerosis Functional Composite z score,2 evident in all 3 components. His tremors, however, have persisted, limiting his ability to feed himself. This is a coarse, high-amplitude, mixed kinetic/intention and postural tremor of 2 to 3 Hz. He recently reported that his tremor was significantly reduced following alcohol ingestion (Figure 1 and Figure 2).

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Figure 1.

A note written by the patient prior to the start of a party. What follows is a transcribed note of what is seen in the figure: “12/15/06 2:30 p Dr Kerr, Here is note with two hands and my chin! [with patient supporting pen with both hands and chin to keep steady] More to come[.]”

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Figure 2.

A note written by the patient after drinking alcohol at the party mentioned in Figure 1. What follows is a transcribed note of what is seen in the figure: “12/16/2006 4:05 a Dr Kerr, As promised . . . more to come! Actually the . . . Christmas was a little more laid back than last year. I had exactly a 12 pack and seem to be doing pretty well with that! As you can tell, with one hand, I’m doing much better than two hands & my chin! [with patient supporting the pen with both hands and his chin to keep steady] It's strange and I wish I could explain but I guess that's why they call it MS! Thanks,”

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