21. Movement disorder/tremor

Question 1

causes tremor?

Answer 1

Parkinsonism
Benign essential tremor
Cerebellar disease
Liver failure
CO2 retention
Salbutamol tremor
Lithium and lithium toxicity
Thyrotoxicosis
Drug Withdrawal/opiates/alcohol

Question 2

features parkinsonism tremor

Answer 2

resting tremor
pill rolling

Question 3

features cerebellar tremor

Answer 3

intention tremor
past pointing

Question 4

features benign essential tremor

Answer 4

postural tremor (worse if arms outstretched)

Question 5

management besnign essential tremor

Answer 5

propranolol is first-line

primidone is sometimes used

Question 6

causes of cerebellar syndrome

Answer 6

neoplastic: cerebellar haemangioma
stroke
alcohol
multiple sclerosis
coeliac

hypothyroidism
drugs: phenytoin, lead poisoning
paraneoplastic e.g. secondary to lung cancer
Friedreich’s ataxia, ataxic telangiectasia

Question 7

what is asterixis? causes?

Answer 7

flapping tremor

• encephalopathy
• CO2 retention

Question 8

what drugs cause tremor

Answer 8

beta agonist eg salbutamol

lithium - fine tremor

lithium toxicity - coarse tremor

Question 9

what is chorea? cauases?

Answer 9

uncontrollable purposeless fitting movements

• Huntington’s chorea
• Wilson’s disease (see parkinsonism chapter)
• Sydenham’s chorea (rheumatic fever)

Question 10

genetics huntingtons

Answer 10

autosomal dominant

more than 38 repeats of the CAG trinucleotide in the gene encoding the huntingtin protein.

Question 11

triad for huntingtons

Answer 11

Dominant inheritance
Choreoathetosis
Dementia

Question 12

imaging huntingtons interpretation

Answer 12

loss of striatal volume and increased size of the frontal horns of the lateral ventricles.

(MRI shows atrophy of the caudate nucleus and putamen)

Question 13

what drug is used to manage chorea in huntingtons

Answer 13

tetrabenazine

Question 14

chorea in a child - first differential?

Answer 14

rheumatic fever - sydenham’s chorea

Question 15

what is rheumatic fever

Answer 15

Rheumatic fever develops following an immunological reaction to recent (2-6 weeks ago) Streptococcus pyogenes infection.

This cross-reactivity is a Type II hypersensitivity reaction and is termed molecular mimicry.

Question 16

diagnostic criteria rheumatic fever

Answer 16

evidence of recent strep infection plus:
2 major criteria
1 major with 2 minor criteria

Major criteria
- erythema marginatum
- Sydenham’s chorea: this is often a late feature
- polyarthritis
- carditis and valvulitis (eg, pancarditis)
- subcutaneous nodules

Minor criteria
- raised ESR or CRP
- pyrexia
- arthralgia (not if arthritis a major criteria)
- prolonged PR interval

Question 17

management rheumatic fever

Answer 17

antibiotics: oral penicillin V

anti-inflammatories: NSAIDs are first-line

treatment of any complications that develop e.g. heart failure

Question 18

what is myoclonus? differentials?

Answer 18

Sudden brief involuntary twitching or jerking of a muscle or group of muscles

Myoclonic seizures
Juvenile myoclonic epilepsy
creutzfeldt-Jakob disease

Question 19

features CJD

Answer 19

dementia (rapid onset)
myoclonus

Question 20

MRI CJD

Answer 20

hyperintense signals in the basal ganglia and thalamus

Question 21

causes CJD

Answer 21

Sporadic 85% of cases - cause unknown

Variant CJD - mad cow disease

Question 22

what is dystonia? causes?

Answer 22

Dystonias describe a prolonged, often painful, muscle contraction.
dystonia= abnormal posturing due to agonist and antagonist co-contraction

usually an acute dystonic reaction eg antipsychotics or metoclopramide - treat with procyclidine

Writer’s cramp is the most common form of occupational focal dystonia.

Question 23

what movement problems can you get in wilsons disease

Answer 23

Parksinonsom, Asterixis, Chorea