Holmes tremor in multiple sclerosis: clinical characterization as a diagnostic tool

Abstract

Case presentation. 32-year-old male who presented four years of tremor predominantly in the lower limbs, activated by standing and walking, improved at rest and lying down. Over the course of disease, he developed intention tremor, ataxic dysarthria, and gait ataxia. Physical examination revealed ataxic dysarthria, quadriparesis, pelvic hyperreflexia, bilateral dysmetria and dysdiadochokinesia, as well as a dystonic tremor at rest, posture, and intention, predominantly in the right side. Symptomatic treatment for tremor started with clonazepam 2 mg half a tablet every 12 hours and gabapentin 300 milligrams one capsule at night, with symptomatic improvement. Electromyography confirmed tremor of 9 Hertz in quadriceps, 7 Hertz in the biceps brachii; Brain MRI revealed hyperintense demyelinating lesions on T2 and FLAIR sequences with involvement of cerebellar output pathways and cortical-subcortical regions suggestive of a demyelinating disease, Multiple Sclerosis type. Treatment. After establishing a diagnosis, acute flare treatment was initiated, with significant improvement in tremor and motor coordination, reinforcing the link between demyelinating inflammatory activity and clinical expression of tremor. Outcome. This case highlights the importance of a phenomenological characterization of tremor in Multiple Sclerosis, highlighting atypical presentations such as Holmes tremor, the identification of which improves clinical-radiological correlation and the therapeutic approach.