Levodopa-Responsive Benign Tremulous Parkinsonism
A right-handed 56-year-old woman presented at our hospital with a 2-year history of right-hand tremor and complaints of fumbling with buttons. The patient had neither tremor nor family members with PD in her family history, and her past medical history was unremarkable. Physical examination showed blood pressure of 138/90 mm Hg and her cognitive function was normal. The neurological examination revealed pill rolling typical rest tremor (4–6 Hz) and slow finger tapping with decreased amplitude on her right hand; however, we did not observe posture tremor, rigidity, bradykinesia, or posture disability. Laboratory tests were all within normal limits, including thyroid function. T2-weighted magnetic resonance imaging did not show high-intensity spots in deep white matter, allowing us to rule out vascular parkinsonism (fig. ). Decreased cardiac uptake of 123I-metaiodobenzylguanidine (MIBG) during myocardial scintigraphy was observed [H/M ratio (early: 1.88, delayed: 1.78)]. Her Unified Parkinson's Disease Rating Scale III motor score was 4/108 points. She was diagnosed as having PD (Hoehn and Yahr stage 1) and received levodopa/carbidopa 200 mg/day, which effectively treated the rest tremor. When she was 61 years old, the right-hand rest tremor reoccurred and she was treated with levodopa/carbidopa (a total of 300 mg/day) and selegiline (2.5 mg/day). Slow finger tapping with decreased amplitude continued; however, her rest tremor improved. Approximately 11 years have passed since the patient's onset of symptoms and her parkinsonism is slowly progressive; however, she does not show disability apart from continuing to fumble with buttons.