Kinesigenic Dystonia as the First Manifestation of Multiple Sclerosis with Cervical and Brainstem Lesions

Paroxysmal symptoms, particularly paroxysmal dystonia (also referred to as ‘tonic seizure’), had been clearly related to multiple sclerosis (MS) by Matthews [1] in 1958, although such symptoms had been reported since 1928 [2]. Sometimes they may be the first manifestation of the demyelinating disease [3]. When they occur without other signs or symptoms they often present diagnostic difficulties. We describe the case of a young man with laboratory-supported definite MS [4] in whom unilateral tonic spasms were the initial symptom. A 27-year old man was admitted with a history of variable numbness affecting the right side of his body, beginning 2 months earlier; 1 month later he developed carpope-dal spasms in his right hand and sometimes a dystonic involvement of his lower right limb, facial grimacing, torsion of the neck and dysarthria. The episodes lasted about 60s and were not accompanied by an alteration in consciousness, loss of sphincter control or postictal sequels. During the dystonic posturing a Babinski sign was present on the right side. Such episodes occurred 4-5 times daily only during the waking-up period. They were always evoked by voluntary movements of the neck or of the right arm and by hyperventilation (while the patient was at rest, but not if he blew into a bag). On admission physical examination disclosed brisk muscle stretch reflexes on the right, slight impairment of vibratory sensation in the right upper limb. Plantar re-