Biballism due to non-ketotic hyperglycaemia

Hyperglycemic chorea-ballism or acute exacerbation of Huntington's chorea? Huntington's disease unmasked by diabetic ketoacidosis in type 1 diabetes mellitus

CONTENT

Hyperglycemic chorea-ballism is predominantly observed in older type 2 diabetic patients, and it is rare in type 1 diabetes and diabetic ketoacidosis (DKA). Huntington's disease (HD) is one of several genetic syndromes associated with diabetes, although the reported prevalence of the association varies. There are few opportunities for most physicians to diagnose early-stage HD.

OBJECTIVE

We describe bilateral hyperglycemic chorea-ballism in a 40-yr-old female type 1 diabetes patient with DKA and HD.

SETTING

The study was conducted in a tertiary care referral hospital.

RESULTS

On admission, the patient exhibited severe involuntary movement of bilateral extremities with DKA, and hyperglycemic chorea-ballism was diagnosed. She recovered from chorea-ballism with admission of fluids and insulin, but mild choreatic movement persisted in the upper extremities. Brain magnetic resonance imaging and DNA analysis revealed HD. Although it has been considered that depletion of striatal γ-aminobutyric acid (GABA) content is rare in DKA, it is largely decreased in HD. Therefore, it is probable that hyperglycemic chorea-ballism or exacerbation of Huntington's chorea resulted from transient depletion of GABA.

CONCLUSION

The present case provides important insights on the role of GABA in hyperglycemic chorea-ballism and on the clinical issues associated with HD diagnosis.

Hyperosmolar non-ketotic hyperglycaemia: an important and reversible cause of acute bilateral ballismus

An 83-year-old lady with type 2 diabetes mellitus was admitted to hospital with pneumonia. After 3 days of oral amoxicillin she developed ballism-choreiform movements of all four limbs. Her serum glucose and osmolality were raised. She had no factors suggestive of genetic or iatrogenic causes. A CT scan of the brain revealed bilateral putamen hyperintensities. She was started on tetrabenazine and subcutaneous insulin, which led to complete resolution of her symptoms.

[Nonketotic hyperglycemia-induced hemiballism]

Nonketotic hyperglycemia-induced hemichorea or hemiballism is a well-recognized entity that is rarely encountered. Particular computed tomography and magnetic resonance imaging findings have been described. The pathophysiological mechanism of this disease remains uncertain. We report here on two female patients that presented with hemiballism secondary to nonketotic hyperglycemia and underwent brain computed tomography and magnetic resonance imaging.