Infantile Tremor Syndrome

Abstract

Child was unable to cry and feed. He was exclusively breast fed. He was classified as grade 2 (IAP) malnutrition; he also had hyperpigmentation over limbs, pallor and hepatosplenomegaly. Tremors were absent during sleep, and got aggravated during activities (Web Video 1). His hemoglobin was 5.8 g/dL with dimorphic blood picture. EEG was normal and MRI showed diffuse cerebral atrophy. Mother’s serum B12 levels were low (<200 pg/mL) but child’s serum B12 levels were normal, probably because of prior treatment with injectable B12. A diagnosis of Infantile tremor syndrome (ITS) was made. Child received WHO protocol of management for moderate malnutrition. The child received blood transfusion, vitamin (A, D, B complex and C) and mineral (zinc, magnesium, calcium) supplementation. Propranolol (0.5 mg/kg/day) was started, and increased to 2 mg/kg/day till the tremor decreased in intensity and general condition of child improved. Kahn’s nutritional recovery syndrome, infections (viral encephalitis/encephalopathy), phenothiazine toxicity, degenerative diseases, and enzyme defects in tyrosine metabolism leading to substantia nigra depigmentation are the differential diagnoses of ITS.