The Curious Case of Three Fingers and
Four iPhones 

Michelle E. Grady

November 23, 2020

The cause of a patient's severe hand dystonia affecting three fingers had clinicians stumped, but tenacious clinical investigation eventually led them to make the call on this very unusual case.

The patient, in his mid-50s, presented to Vikram Preet Kaur, MBBS, and MD candidate working under Alan R. Hirsch, MD, Mercy Hospital and Medical Center in Chicago, Illinois, with involuntary and painful twisting of three fingers on his right hand.

"We went through his family history and ruled out a movement disorder, and we did a physical examination to rule out Parkinson's," Kaur told Medscape Medical News. "I also asked whether he was taking any antipsychotic medications, but everything came back negative." 

So Kaur delved a little deeper — and when he asked the patient how his dystonia started, the case took an interesting turn.

The patient reported neck pain with intermittent spasms and right arm muscle twitches for the past 9 months and reported he was afraid he had amyotrophic lateral sclerosis (ALS). He told Kaur that his anxiety over the possibility that he had ALS was so severe he couldn't stop himself from constantly using his iPhone to search for a diagnosis on the internet.

His compulsions got so bad that he broke four iPhones from tapping on the screens. Dr Vikram Preet Kaur

Kaur said the patient was assured that he did not have ALS. Nonetheless, the man continued scouring the Web on his iPhone in an attempt to find an answer. Kaur noted the patient's wife reported that his compulsion "got so bad that he broke four iPhones from tapping on the screens."

This was a first for Kaur. It isn't unusual, he said, for patients — often musicians, golfers, or barbers because of repetitive hand movements — to develop hand dystonia. However, he noted, this case was "entirely new."

"Because all of the neurological tests came back negative, we began to suspect his obsessive-compulsive (OC) behavior around his iPhone had sparked the dystonia," he said.

The overuse of muscles of the hand required for repetitively turning the iPhone on and off in this patient's compulsion, like musicians repetitively practicing the same stanza, may have predisposed the development of dystonia in the same muscle groups.

"We thought that this overpracticed compulsive activity may have lowered the threshold in the motor network involving the motor cortex or basal ganglia," Kaur noted.
 

Lessons Learned

The patient's dystonia eventually became so bad that he was no longer able to turn on his phone with his right hand and had to use his left. Kaur and his team used Botox injections to relieve the dystonia.

Following treatment, the symptoms quickly resolved and, after the pain and discomfort from the dystonia was gone and the patient was further reassured he didn't have ALS, his OC symptoms also began to abate.

Based on this case, said Kaur, it may be useful to screen patients with focal dystonia for an OC component. If it turns out that it is part of the clinical picture, a trial of anxiolytics and/or cognitive behavioral therapy may be worthwhile. Conversely, he added, it may also be worthwhile to check whether patients with obsessive compulsive disorder have dystonia in specific muscle groups.

With prolonged smartphone use on the rise — and with more individuals feeling compelled to check their smartphones quite frequently — Kaur suggested clinicians may want to share the findings from this unusual case with their patients.

"Patients should be made aware that continuous tapping could cause this task-specific dystonia," he said.

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Medical Mysteries is a new Medscape column featuring unusual, hard-to-crack cases solved with a combination of clinical acumen and some serious sleuthing.

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