Abstract
Tremors have been well-described in association with monoclonal gammopathy. We report a case of a patient with asymmetric hands tremor who responded well to levodopa-carbidopa treatment. Further workup showed an underlying gammopathy. To our knowledge, this is one of the rarest case reports of successful treatment of gammopathy-related tremors with levodopa-carbidopa. The patient was a 75-year-old male who presented to the neurology clinic for a one-year history of worsening tremors in bilateral upper extremities. A review of systems was only remarkable for mild numbness and tingling in his feet. His neurological examination was remarkable for asymmetric right more than left (R > L) resting and kinetic tremor in both upper extremities associated with mild rigidity and bradykinesia in right upper extremity and decreased bilateral ankle jerks. With the primary diagnosis of Parkinson’s disease, he was started on levodopa-carbidopa and a neuropathy workup was requested. His follow-up visit after three months was remarkable for significant improvement of his tremors with carbidopa-levodopa. However, his blood work was consistent with a significant increase in lambda light chain levels and the presence of an M spike in serum protein electrophoresis. Based on the presentation and clinical workup, he was finally found to have both multiple myeloma and Waldenstrom’s macroglobulinemia. Underlying malignancy was treated with chemotherapy and immunotherapy. Levodopa-carbidopa was discontinued after three months of chemotherapy and his tremor did not recur in one year of follow-up. Gammopathy is one of the well-known causes of tremors in the adult population. It can cause both resting and kinetic tremors in the upper extremities. It is supposed that peripheral neuropathy associated with gammopathy is the main underlying cause of tremors in these groups of patients. However, central causes are also suggested. In this case, we are led to conclude that our patient’s tremor was centrally mediated since it responded well to dopamine replacement therapy. However, further study is needed to elucidate the role of dopamine depletion in the pathogenesis of tremors associated with gammopathies.
Highlights
Monoclonal gammopathy can present with systemic symptoms such as fatigue, generalized weakness, weight loss as well as anemia, bleeding, and increased bruising
His neurological examination was remarkable for asymmetric right more than left (R > L) resting and kinetic tremor in both upper extremities associated with mild rigidity and bradykinesia in right upper extremity and decreased bilateral ankle jerks
We reported on a 75-year-old Caucasian male who presented with a one-year history of asymmetric, slowly progressive, and distally predominant resting and kinetic tremor in bilateral upper extremities with mild rigidity and bradykinesia, who responded very well to C/L 25/100 mg times a day (TID)
Summary
Monoclonal gammopathy can present with systemic symptoms such as fatigue, generalized weakness, weight loss as well as anemia, bleeding, and increased bruising. Positive findings in his neurological examination were pill-rolling resting tremor (more pronounced in the right hand), with a frequency of 6-8 Hz, which was enhanced with mental distraction and contralateral voluntary movements, mild to moderate postural and action tremor of bilateral arms, with mild rigidity and bradykinesia noted in right hand, decreased ankle jerks bilaterally, and mildly decreased light touch and pinprick sensation in both feet up to distal legs He walked with a cane and his gait was stable but slow with limping due to remote history of right hip surgery, and he had severe genu varum in both knees.
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
