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Epilepsia partialis continua mistaken for Parkinson's disease

A 66-year-old, right-handed man developed acute-onset right-hand tremor while he was signing his name 1 week before initial neurological evaluation. This tremor did improve to some degree while he was sleeping but never disappeared completely. This tremor interfered significantly with his ability to write and use his right hand during activities of daily living. He also reported that his hand was stiff. There were no other associated symptoms or signs. His primary care physician referred him to us for diagnosis and management of possible Parkinson’s disease because of his right hand tremor and rigidity. Our patient’s past medical history was significant for diabetes mellitus, hypertension, hypertriglyceridemia, prostate carcinoma, and 50-pack–years of cigarette smoking. He did not drink alcoholic beverages or use illicit drugs. On neurological examination, motor power was slightly impaired in the right hand but normal elsewhere. Rhythmic jerks were isolated to the distal right upper extremity (see Video, Segment 1). The thumb, index, and long fingers demonstrated low-amplitude rhythmic jerks at an average frequency of 3.8 Hz. There was no significant inclusion of the wrist flexors and extensors or digits 4 and 5. These rhythmic jerks were present at rest and did not change significantly during postural or kinetic actions. Cogwheel rigidity was present at the right wrist. Rapid alternating movements with the right upper extremity were slow and compromised by both the rhythmic jerks and tonic spasms. Fine motor control was significantly impaired in the distal right upper extremity. There was no ataxia or tremor during goaldirected movements. Gait was normal and there was no postural instability. The rhythmic jerks improved incompletely after 2 mg of intravenous lorazepam (see Video, Segment 2). EEG showed runs of sharp waves localized to the left frontal-temporal region of the brain. Magnetic resonance imaging of the brain showed mild leukoariosis and routine laboratory studies including serum glucose were unremarkable. Our patient was diagnosed with epilepsia partialis continua (EPC). He was orally loaded with phenytoin (18 mg/kg) and his rhythmic jerks resolved (see Video, Segment 3). The differential diagnosis of involuntary rhythmical movements includes tremors, asterixis, rhythmic myoclonus, clonus, EPC, diphasic dyskinesias, and stereotypies.1 EPC has been defined as “spontaneous regular or irregular clonic muscle twitching of cerebral cortical origin, sometimes aggravated by action or sensory stimuli, confined to one part of the body, and continuing for a period of hours, days, or weeks.”2 EPC should be included in the differential diagnosis of involuntary rhythmic movements and may, on occasion, superficially mimic Parkinson’s disease.