Holmes Tremor Following Thalamic Tuberculoma-A Case Report and Literature Review

Tremor is the most common movement disorder, defined as a rhythmical oscillatory involuntary movement that can affect almost any body part. Holmes Tremor (HT) is an irregular, slow-frequency (< 4.5 Hz) tremor that may include one or a combination of resting, postural, and action tremors. It primarily affects proximal limbs, characterized by a large and irregular amplitude tremor, and often arises due to lesions located in the upper brainstem, thalamus, and cerebellum. We present a case of Holmes tremor in a 32-year-old female patient who presented with a gradually progressive abnormal movement of the left arm for a duration of 1 month. It started one month after she completed a treatment for CNS tuberculoma. She had stable vital signs, and neurologic physical examination revealed a rest, postural, and action tremor, which was characterized by prominent, exaggerated movements occurring at a noticeably slow pace, enhanced with stretching and action, having a wing-beating feature. She had spastic muscle tone on the left upper extremity, with power 4/5 on the same limb, and deep tendon reflexes were 2/4 on both extremities bilaterally. Additionally, there were findings of dysmetria and dysdiadochokinesia on her LUE. Sensory examination was intact, and meningeal signs were negative. Pre- and post-anti-tubercular treatment brain MRI revealed a thalamic lesion that exhibited a decrement in size post treatment with no evidence of gliosis. This case highlights the challenges of management of such a rare movement disorder in a resource-limited setting. The clinical presentation, including a combination of resting, postural, and action tremors, as well as the characteristic MRI findings, led to the diagnosis of HT. Early recognition of this rare disorder, along with neuroimaging, is essential for trial of medical management, as seen in our case, which turned out to be successful at controlling the symptoms, which is cost-effective for our setting.