Tremor as a Neuropsychiatric Manifestation of Systemic Lupus Erythematosus: A Case Report and Review of Related Literature

Abstract

Movement disorders in neuropsychiatric systemic lupus erythematosus (NPSLE) are rare. Chorea remains the predominant phenomenology whereas tremors are reported as a treatment-related side effect or as a component of another syndrome. However, an isolated tremor is rarely reported as a movement-related NPSLE manifestation. We report a 27-year-old female initially admitted because of a 2-month history of undocumented fever, malaise, anorexia, weight loss, and progressive dyspnea. She was eventually referred to the Neurology service because of tremors. Evaluation revealed postural and intention tremors involving bilateral arms with no signs of parkinsonism, ataxia, or other movement abnormalities. Propranolol 20 mg/day was started and afforded tremor reduction whereas neuroimaging revealed findings suggestive of central nervous system (CNS) vasculitis. She was eventually diagnosed with SLE given the over-all findings of positive anti-nuclear antibody, low complement 3, pericarditis, pleuritis, leukopenia, and hemolytic anemia. Her tremors and CNS vasculitis were also deemed active neuropsychiatric manifestations of her lupus. Plan was to administer methylprednisolone pulse but prior to her first dose, she succumbed to pulmonary embolism. A systematic search of literature yielded four studies reporting 12 NPSLE cases with isolated tremor syndromes. Tremors in lupus likely result from the autoantibody attack of the extrapyramidal system on top of previously described tremor generation mechanisms. NPSLE may rarely present with an isolated tremor syndrome. Although much had been discovered regarding tremor generation pathways, those occurring as a result of systemic conditions may reflect additional mechanisms that have yet to be explored further.