Progressive tremors, paresis and a sudden locked-in state.

DESCRIPTION A 37-year-old man developed low grade fever during January 2007 for which he received symptomatic treatment following which he gradually noticed a tremor of his left hand thatmade it difficult for him towrite and even to put his signature. The tremors gradually progressed to his arms and trunk and he also developed a nodding movement in his head. There was progressive slowness in walking with a tendency to fall on either side. On examination in April 2007, he was noted to have a low frequency tremor at rest varying with posture and goal-directed activity suggestive of rubral tremor. His limb power at this timewas normal. A cerebrospinal fluid examinationwas also normal and aMRI revealed signal hyperintensities in the mid brain tegmentum (figure 1) and hypodensities on the thalami on a subsequent CT head (figure 2). He was put on propranolol, tetrabenazine and clonazepam for his tremors but his symptoms kept progressing with gradual development of quadriparesis. Hewas brought to us inNovember 2008with a history of sudden loss of consciousness. We initially thought he was comatosewith a blank stare but his relative alerted us to the fact that he was moving his eyelids and seemed to be conscious. We found that he had quadriplegia with near complete cranial nerve paralysis and preserved upper eyelid movement (video 1). Video 1 Quadriplegia with near complete cranial nerve paralysis andpreserveduppereyelidmovement10.1136/bcr.02.2009.1621v1 Rubral tremor (the term rubral is derived from its prior described associationwith lesions around the red nucleus in the midbrain tegmentum) is characterised by a slow coarse tremor at rest that is exacerbated by postural adjustments