Case Study 2: Mother with a Twitchy Baby

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Headshot of Dawn Elise DeWitt, MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
Dawn Elise DeWitt
MD, MSc, CMedEd, MACP, FRACP, FRCP-London · Senior Associate Dean, Collaboration for InterProfessional Health Education Research & Scholarship (CIPHERS)
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Case study 2: Macrena—Mother with a twitchy baby

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A 32-year-old college history professor is admitted to L&D in labor with her first child. The baby is born and is generally healthy but is very “twitchy.” The doctors are worried because the mother also has a notable tremor on examination (most noticeable in her head and hands).
She reports being otherwise healthy; takes no medications; has no medical issues; and denies alcohol use, smoking, or drug use. She has no known exposures but grew up in a town known for water contamination from pesticides, pulp mills, and fire retardants (PFAs), though she moved away at age 18.
Examination shows normal vital signs, and neurological examination is non-focal except for a relatively slow tremor of the head and left > right hand (patient is ambidextrous) without exacerbation with intention. Gait is normal. There is no cogwheeling.

Question

The most likely diagnosis is:

Though the patient has been exposed to chemicals that might specifically put her at risk for PD, she does not meet criteria. Despite her negative history, extensive drug testing of both mom and baby is undertaken and is negative. Risk factors include FH (none known in this case). Alcohol usually improves the symptoms but is not recommended as a treatment.

This video shows examples and patient’s struggles with essential tremor.
From the International Essential Tremor Foundation.

  • Propranolol
  • Primadone
  • Topiramate
  • Essential tremor.
  • Postural tremor: Present with arms outstretched.
  • Kinetic tremor: Present during writing or other movements.
  • Enhanced Physiologic tremor: Present under stress or with thyroid disease, e.g., resolves if underlying precipitant removed.
  • Intention tremor: Associated with cerebellar disease; increases with reaching for an object.
  • Others: Rubral tremor (cerebellar seen in MS, stroke, TBI); task specific tremor; orthostatic tremor (high frequency in legs with standing).
  • Medication-induced tremor.
  • Beta-adrenergic agonists (asthma inhalers).
  • Stimulants (caffeine, methylphenidate, nicotine, amphetamines).
  • Mood stabilizers (lithium, valproic acide, carbamazepine).
  • Neuroleptics (haloperidol, olanzapine, etc.)
  • Other: Amitriptyline, SSRIs (fluoxetine), cyclosporine, tacrolimus, amiodarone, levothyroxine, glucocorticoids, verapamil, atorvastatin.

Flash recall

Question

Bradykinesia + at least one other sx/sign and absence of red flags (see module); head CT to rule out vascular dz or hydrocephalus.

Question

Postural, isometric, kinetic.

Question

  • Antipsychotics: Haloperidol, chlorpromazine.
  • Risperidone, olanzapine, ziprasidone, aripiprazole.
  • Antiemetics: Metoclopramide, Prochlorperazine.
  • Dopamine depleters: Tetrabenazine, reserpine.

Question

  • Beta-adrenergic agonists (asthma inhalers).
  • Stimulants (caffeine, methylphenidate, nicotine, amphetamines).
  • Mood stabilizers (lithium, valproic acide, carbamazepine).
  • Neuroleptics (haloperidol, olanzapine, etc.)
  • Other: amitriptyline, SSRIs (fluoxetine), cyclosporine, tacrolimus, amiodarone, levothyroxine, glucocorticoids, verapamil, atorvastatin.

Sustained or intermittent involuntary muscle contractions

Classified by:

    • Age of onset.

    • Anatomic distribution.

    • Associations (e.g., drugs, PD).

 

Causes:

    • Genetic: Autosomal dominant DYT1 and DYT6); AR (Wilson dz); X-linked (Lesch-Nyan); mitochondrial (Leigh).
    • Structural: Stroke, tumor, post-encephalitis, etc.
    • Degenerative: PD, Huntington (also Autosomal dominant).
    • Perinatal: E.g., cerebral palsy.
    • Sporadic: Torticollis, writer’s cramp, blepharospasm.
    • Medications: Neuroleptics, antiemetics, antiepileptics.
    • Psychologic.

Choreiform: Huntington disease

  • Autosomal dominant and associated with gait impairment, parkinsonism, impulsiveness, psychiatric dz and dementia.
  •  Other causes: infection, hyperglycemia, thyrotoxicosis, paraneoplastic.  

 

Myoclonus: Shock-like brief jerky movement

  • Find cause or tx with clonazepam, valproic acid, levetiracetam, topiramate, etc.

 

Tourette and tic disorders

  • Stereotyped rapid movements, often start in children and sx recede as adults. Tourette starts in childhood with motor/phonic tics > 1 year.
    • Associations include ADHD, OCD and mood disorders.
    • Tx is clonidine, topiramate, levetiracetam, etc.
  • Tardive dyskinesia: Induced by antipsychotics.

  • Common cause of disturbed sleep. 

  • Screen for iron deficiency, uremia, sleep apnea, pregnancy.  

  • Medication-induced by SSRIs, stimulants and antipsychotics.

  • Treatment includes sleep hygiene, exercise, and vibration devices.

  • Meds: Pramipexole (dopa agonist) and others.

  • Idiosyncratic, acute, rare, life-threatening (10% mortality) rxn to dopamine antagonists:

    • Thorazine, chlorpromazine, metoclopramide, promethazine, paliperidone, risperidone, quetiapine, clozepine.

    • Can also be brought on by sudden cessation of PD dopa medications. 

  • Findings: Fever, rhabdomyolysis, AMS, rigidity, dystonia. Check CK.

  • Treatment: Remove offending agent.

  • Give: Dantrolene and dopamine agonists.

In honor of
the many patients, friends and family members who have struggled with Parkinson disease.
Photo © Alan Talbot.

Image credits

Unless otherwise noted, images are from Adobe Stock.