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An unusual cause of tremor in an elderly man
  1. S A W Fadilaha,
  2. A A Raymondb,
  3. S K Cheonga
  1. aDepartment of Haematology and Transplantation, MAKNA-HUKM Cancer Institute, Kuala Lumpur, Malaysia, bDepartment of Medicine (Division of Neurology), Hospital Universiti Kebangsaan Malaysia (HUKM), Kuala Lumpur, Malaysia
  1. Dr S Fadilah, Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia (UKM), Jalan Yaacob Latif, Bandar Tun Razak, 56000 Kuala Lumpur, Malaysia sfadilah{at}mail.hukm.ukm.my

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Answers on p 277.

A 70 year old man presented with a two day history of coarse tremors of the head and upper limbs. The tremor was evident at rest and it became more obvious on movement. There were no symptoms of hyperthyroidism or history of a similar problem in the past. Apart from slight low back pain, he had been in good health. His urinary and bowel habits were normal. He denied taking any drugs. He was a non-smoker and a teetotaller.

On examination, the patient appeared pale. Coarse tremors of the head and upper limbs were evident at rest. The tremor of the head consisted of vertical head nodding. The upper limb tremor was markedly accentuated during the finger-nose test and mildly accentuated by holding the arms outstretched parallel to the floor. Neurological examination otherwise showed no abnormality. There was mild prostatic enlargement noted on digital rectal examination. Chest and abdomen examination was unremarkable.

The haemoglobin concentration was 86 g/l with normal red cell indices, white cell count 2.3 × 109/l, and platelet count 88 × 109/l. Microscopic examination of the peripheral blood did not reveal leucoerythroblastosis. The erythrocyte sedimentation rate was 102 mm in the first hour. Bone profile was recorded as calcium 2.9 mmol/l (normal range 2.2–2.6), phosphorus 1.2 mmol/l (0.8–1.4), and alkaline phosphatase 678 IU/l (40–120). The thyroid, renal, and liver profiles were within normal limits. The radiograph of the lumbar spine is shown in fig 1. Chest radiography and contrasted computed tomogra-phy of the brain did not reveal any abnormality. An aspirate of the bone marrow is shown in fig2.

Figure 1

Radiograph of the lumbar spine showing sclerotic lesions of the lower lumbar vertebrae.

Figure 2

Aspirate of the bone marrow showing a clump of neoplastic cells infiltrating the marrow (May-Grunwald-Giemsa × 400).

Questions

(1)
What is the probable diagnosis?
(2)
What other investigations should be done to confirm the diagnosis?
(3)
What are the possible causes of the tremor in this patient?

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