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Wring Tremor as a Manifestaon of Vitamin B12 Deciency
Guijarro-Castro C* and Estallo-Guijarro L
Hospital Virgen de la Luz (Cuenca), Caracas and San Bernardo Medical Center (Madrid), Spain
*Corresponding author: Guijarro-Castro C, Hospital Virgen de la Luz (Cuenca), Caracas and San Bernardo Medical Center (Madrid), Spain, Tel:
34969179900; E-mail: crisna.guijarro@sen.es
Received date: January 12, 2017; Accepted date: January 24, 2017; Published date: January 31, 2017
Citaon: Guijarro-Castro C and Estallo-Guijarro L. Wring Tremor as a Manifestaon of Vitamin B12 Deciency. Arch Med. 2017, 9:1
Copyright: © 2017 Guijarro-Castro C, et al. This is an open-access arcle distributed under the terms of the Creave Commons Aribuon License,
which permits unrestricted use, distribuon, and reproducon in any medium, provided the original author and source are credited.
Leer to Editor
Postural and kinec tremor due to vitamin B12 decit is rare
in adults, but secondary wring tremor due this decit is more
unusual. We report the case of a wring tremor paent that was
resolved aer cyanocobalamin treatment. An 80-year-old man
presented with a three-month history of trembling on his right
hand, only becoming apparent when wring. He suered from
hypertension and diabetes, had no familial history recorded, and
did not take dopaminergic-block drugs. Neurologic examinaon
showed a ne, rapid tremor of the hands that began
immediately aer the paent began to write. Results of the rest
of the examinaon were normal. Results of laboratory tests
were normal, except for a serum vitamin B12 level of 132 ng per
liter (normal range, 222 ng/l to 753 ng/l). A Schilling test
demonstrated malabsorpon of vitamin B12. A magnec
resonance image of the brain was normal. Surface
electromyogram showed a 7 Hz synchronous tremor of the
exor and extensor muscles of the forearm that began when the
paent was wring and was absent in other acons.
Electrophysiological studies also showed mild sensory axonal
polyneuropathy. Clonazepam (1 mg per day) and
cyanocobalamin (injecons of 1000 µg given daily for two
weeks, then weekly for two months, and once a month
thereaer) provided complete relief of the tremor. Follow-up
aer one year showed no abnormalies. Then, treatment with
clonazepam was disconnued, without recurrence of the
tremor. Task-specic tremor is a form of acon tremor that
occurs when a person is performing a specic task [1]. The most
frequent form of task-specic tremor is wring tremor (WT). The
pathophysiology of WT is not clear and could be a variant of
essenal tremor or a type of focal dystonia or an independent
enty [2]. However, the results in corcal inhibion during task-
specic contracons indicate that WT is not a variant of focal
task-specic dystonia, but rather an independent enty [3]. WT
typically occurs at a frequency of 5 Hz to 7 Hz. The wring
tremor may progress to another task specic tremor of specic
acon, or rest tremor, but not to postural tremor. Tremor
temporary suppression by alcohol is observed in about one-third
of the cases, and benecial responses to propranolol,
primidone, ancholinergics, botulinum toxin treatment, and
stereotacc surgery has been reported [2].
Although the associaon of tremor in adults with vitamin B12
deciency is very rare [4,5], the paent’s tremor disappeared
aer vitamin B12 supplements, which supports this associaon.
Hyperacvity in the cerebellar hemispheres have been
demonstrated with positron emission tomography in PWT, and it
is known that these structures may be aected by vitamin B12
deciency [6]. There is only one case of postural and kinec
tremor due to vitamin B12 decit reported in the last 13 years
[4] and, like in our paent, it was quickly resolved aer
correcon of this decit. The tremor is a characterisc symptom
of vitamin B12 deciency in children, but not known in adults
[7,8]. The vitamin B12 deciency should be added to the list of
diseases that can cause wring tremor. The deciency correcon
completely solves the tremor.
References
1. Bain PG, Findley LJ, Brion TC, Rothwell JC, Gresty MA, et al.
(1995) Primary wring tremor. Brain 118: 1461-72.
2. Pita Lobo P, Quarocchi G, Jutras MF, Sangla S, Apars E, et al.
(2013) Primary wring tremor and writer's cramp: two faces of a
same coin? Mov Disord 28: 1306-1307.
3. Ljubisavljevic M, Kacar A, Milanovic S, Svetel M, Kosc VS (2006)
Changes in corcal inhibion during task-specic contracons in
primary wring tremor paents. Mov Disord 21: 855-859.
4. Koussa S, Taher A, Sayegh R (2003) Postural and kinec tremor
associated with vitamin B12 deciency. Rev Neurol 159:
1173-1174.
5. Benito-León J, Porta-Etessam J (2000) Shaky-leg syndrome and
vitamin B12 deciency. N Engl J Med 342: 981.
6. Katsaros VK, Glocker FX, Hemmer B, Schumacher M (1998) MRI of
spinal cord and brain lesions in subacute combined degeneraon.
Neuroradiology 40: 716-719.
7. Demir N, Koc A, Üstyol L, Peker E, Abuhandan M (2013) Clinical
and neurological ndings of severe vitamin B12 deciency in
infancy and importance of early diagnosis and treatment. J
Paediatr Child Health 49: 820-824.
8. Uddin MK, Rodnitzky RL (2003) Tremor in children. Semin Pediatr
Neurol 10: 26-34.
Letter to Editor
iMedPub Journals
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DOI: 10.21767/1989-5216.1000188
ARCHIVES OF MEDICINE
ISSN 1989-5216 Vol.9 No.1:5
2017
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Primary writing tremor (PWT) is considered to be a type of task-specific tremor in which tremor predominantly occurs and interferes with handwriting. We describe the clinical and neurophysiological features of 21 patients (20 male and one female) with PWT. Mean age at tremor onset was 50.1 years. A family history of PWT was obtained from seven patients. Ten patients obtained benefit from drug treatment (mainly propranalol or primidone) and seven responded to alcohol. The writing speeds of the patients (mean +/- SEM: 73.1 +/- 6.6 letters per minute) when using their preferred hand were significantly reduced (Student's t test: P < 0.001) compared with those of healthy control subjects (mean +/- SEM: 127.7 +/- 6.4). Surface polymyography performed during writing showed 4.1-7.3 Hz rhythmic activity predominantly in the intrinsic hand and forearm muscles. Alternating, extensor activation alone, skipping from alternating to extensor activation, and co-contracting EMG patterns were recorded from the flexor and extensor muscles of the forearm. There was no evidence for excessive 'overflow' of this rhythmic EMG activity, as similar activity was detected in comparable muscle groups of healthy control subjects. Accelerometry confirmed that the frequency of PWT ranged from 4.1-7.3 Hz (median 5.5 Hz) and that normal subjects wrote with a 4.0-7.7 Hz oscillation (median 4.6 Hz). Forearm reciprocal inhibition was normal in PWT (n = 13), and thus patients with PWT can be distinguished from those with writer's cramp in whom decreased presynaptic inhibition has been found. Patients were sub-classified as having either type A (n = 11) or B (n = 10) PWT depending on whether tremor appeared during writing (type A: task induced tremor) or whilst writing and adopting the hand position used in writing (type B: positionally sensitive tremor). However, the only differences between these two groups were that a co-contracting EMG pattern and tremor induced by tendon taps to the volar aspect of the wrist were present in type B but not type A cases.
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