Chorea associated with nonketotic hyperglycemia: A case report with atypical imaging changes

Revealing Non-ketotic Hyperglycemia as a Trigger for Hemichorea-Hemiballismus in Uncontrolled Diabetic Asthmatics: A Case Report

Uncontrolled diabetes can trigger a movement disorder called hemichorea-hemiballismus, characterized by non-ketotic hyperglycemia-related chorea/ballism and usually reversible basal ganglia abnormalities on CT and/or MRI. The condition is diagnosed clinically and is mostly based on radiological imaging. Here, we report a case of a 68-year-old female presenting with right-sided and facial involuntary movements owing to uncontrolled hyperglycemia who was treated with antidiabetic and anticholinergic medications. The patient responded well to the treatment and showed a favorable outcome with no complications.

Nonketotic Hyperglycemic Hemichorea in an Elderly Male: A Case Report

BACKGROUND

Nonketotic hyperglycemic hemichorea is a rare complication of diabetes mellitus seen in the emergency department. It is most commonly reported in elderly women, predominantly of Asian race, with poorly controlled diabetes mellitus. Patients present with a triad of nonketotic hyperglycemia, hemichorea, and contralateral basal ganglia abnormality on imaging. Its exact pathophysiology is still not known. However, it has a very good prognosis with early diagnosis and treatment.

CASE REPORT

We report a case of hemichorea involving the right upper and lower limbs due to nonketotic hyperglycemia. The patient's symptoms resolved after normalization of blood glucose. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Nonketotic hyperglycemic hemichorea should be included in the differential of a patient presenting with chorea and high blood glucose levels. It has an excellent prognosis with both symptoms and imaging abnormalities typically resolving completely with restoration of normoglycemia.

Study of Involuntary Limb Movements as a Presenting Feature in Nonketotic Hyperglycemia

Background Hyperglycaemia can rarely manifest as hemichorea/hemiballismus, which subsides with adequate control of blood sugar. Our study accounted for patients with abnormal, involuntary limb movements with high blood sugar, excluding other conditions leading to or mimicking such a clinical appearance. It is very important to identify such patients as chorea secondary to an underlying etiology like hyperglycemia, which can be cured. Material & methods This study was done in IMS & SUM Hospital for a duration of one year, from March 2019 to February 2020, with a total of 11 cases with abnormal limb movements with a blood sugar of 250 mg% and above. Results In this study, 36.36%( n=4) of patients were female, and 63.63% (n=7) were males. The mean age of the patients at presentation was 66.5 years. Eighteen point one percent (18.1%; n=2) of the patients showed hemiballismus, 36.3% (n=4) showed hemichorea, 18.1% (n=2) showed hemiathetosis, 9.1% (n=1) showed myoclonus, and 18.1% (n=2) showed hemiballismus with hemichorea. The mean duration to correct hyperglycemia was found to be 34 hours and the mean duration to correct abnormal limb movements was 90.54 hours. Eighty-one point eight percent (81.8%; n=9) of patients showed basal ganglia changes on brain imaging.

A rare case of hemichorea in the setting of non-ketotic hyperglycaemia with subtle radiological changes: a case report

Movement disorders have been associated with hyperglycaemia including chorea, hemiballismus and choreoathetosis. In almost all documented cases, there is an association between clinical and radiological findings. We report a case of an 82-year-old man with hemichorea in the setting of hyperglycaemia and poorly controlled type 2 diabetes. He had subtle striatal changes on his radiology, and with intravenous fluids and insulin, his involuntary movements resolved on day 4, which correlated with improvement in glycaemic control. He was followed up through our local insulin stabilization programme after discharge.

Atypical Imaging Findings of Nonketotic Hyperglycemic Hemichorea: A Case Report and Review of the Literature

Nonketotic hyperglycemic hemichorea (NH-HC) is a rare condition presenting in the clinical setting. Brain imaging plays an important role in diagnosing NH-HC, which typically shows basal ganglia changes contralateral to the side of the hemiballismus/hemichorea. Only a few articles in the literature have reported normal pertinent magnetic resonance/CT findings in patients presenting with NH-HC. To the authors' knowledge, no cases in the literature have reported basal ganglia changes solely observed on CT but not on MRI in patients presenting with NH-HC. Herein, we describe a unique case in which a CT of a patient presenting with NH-HC demonstrated basal ganglia abnormalities with negative MRI findings.

Chorea: An unusual manifestation of endocrine diseases

Chorea is a movement disorder involving involuntary movements of muscles of the face, neck, and limbs, usually caused by basal ganglia lesions. As an important part of the presentation of many neurological diseases, chorea is also an unusual manifestation of endocrine diseases and can be challenging to diagnose. Although the most common etiology of chorea is genetic, it is vital to identify acquired or symptomatic chorea, as these are potentially treatable conditions. This review summarizes the latest developments in various endocrine disease-related chorea, which will help clinicians to correctly identify and accurately treat it.

Clinical and imaging features of diabetic striatopathy: report of 6 cases and literature review

Objective

To explore the clinical manifestations, diagnosis, treatment, and pathogenesis of diabetic striatopathy (DS) to improve the understanding of the disease and avoid misdiagnosis or underdiagnosis.

Methods

The clinical, laboratory, and imaging data of 6 patients (5 Asian females and 1 Asian male) with diabetic striatum were analyzed retrospectively, and the related literature was reviewed.

Results

All 6 patients showed hyperglycemia, 5 patients presented with involuntary movement of unilateral limbs, and 1 with unilateral limb numbness. Besides, 5 patients (except case 3) underwent MRI examinations that showed hyperintensity in unilateral caudate and lentiform nucleus on T1-weighted images. And all 6 patients who underwent brain CT examinations showed hyperdensity or isodensity in unilateral caudate and lentiform nucleus. None had a family history of similar abnormal movements. After blood glucose control and symptomatic support treatment, the symptoms of all patients improved to various degrees, and reexaminations showed that the lesions gradually disappeared.

Conclusion

Diabetic striatal disease is a rare complication of diabetes mellitus, the result of a combination of different pathogenesis. It is characterized by hyperglycemia, hemichorea, and contralateral striatal T1WI hyperintensity or CT hyperdensity. Both ketosis and nonketotic hyperglycemic hemichorea have typical imaging manifestations. The prognosis is excellent when this disease is detected early, and the lesions can be gradually absorbed and dissipated with glycemic control.

Hemichorea-Hemiballism as a Manifestation of Hyperglycemia

Hemichorea-hemiballism associated with hyperglycemia is a syndrome characterized by a sudden occurrence of hemichorea, or its more severe expression hemiballism, in patients with non-ketotic hyperglycemia. Hemichorea-hemiballism tends to occur more commonly among elderly people and women of Asian origin. The authors present two rare cases of patients who manifested choreiform and ballistic movements of the limbs and concomitant non-ketotic hyperglycemia. Radiological findings were congruent with hyperglycemia etiology. These cases show that it is important to be aware of hemichorea-hemiballism associated with hyperglycemia, as there is a possible treatment and, if detected early on, a direct impact on prognosis.

Nonketotic Hyperglycemic Chorea in a 10-Year-Old Asian Boy with Diabetes Mellitus

Nonketotic hyperglycemic chorea-ballism (NKHCB), also known as diabetic striato-pathy (DS) by some, is a rare complication of diabetes mellitus and uncommon in children. We reported a case of a 10 11/12-year-old male child of Asian descent with uncontrolled type 1 diabetes mellitus (T1DM), Hashimoto's thyroiditis, and multiple food allergies presenting with bilateral chorea-ballism. His brain magnetic resonance imaging revealed developmental venous anomaly in right parietal lobe and right cerebellum, no focal lesions or abnormal enhancements. Choreiform movements resolved with correction of hyperglycemia. Children and adolescents with a movement disorder should be evaluated for diabetes mellitus, especially with increasing prevalence and insidious nature of T2DM associated with obesity.

Hyperglycaemic hemichorea: A case series

Hemichorea has been reported in subjects with hyperglycemia and the recurrent was rarely reported. We identified clinical presentation and course of hypeglycemic hemichorea in six cases, one of whom experienced recurrence. Mean age was 77.2 years and five were women. Duration of diabetes was 1-35 years. Initial HbA1c levels were 9.3%-13% and most patients had poor compliance. Five patients undertook brain magnetic resonance imaging and high signal intensities of basal ganglia was observed in T1-weighted images. All patients were treated with insulin, and four patients were treated with dopamine-receptor blockers. Mean duration of hemichorea was 69 days. One patient’s hemichorea was recurred after 2 months from the time when the first event was resolved and then finally diagnosed with vasculitis. The prognosis of hyperglycaemic hemichoerea seemed to be good. However, we should consider other cause such as vasculitis when the symptom was recurred after adequate glycaemic control.

Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review

Non-ketotic hyperglycemia chorea-ballismus (NKH-CB) is a rare metabolical syndrome secondary to the hyperglycemic condition, which is characterized by a triad of acute or subacute hemichorea-hemiballismus, hyperglycemic state, and unique abnormalities limited to the striatum on neuroimaging. Several related case studies on this disorder have been reported previously, but NKH-CB had never been associated with intracerebral hemorrhage (ICH). Herein, we report an uncommon case of NKH-CB and ICH that occurred simultaneously in one patient, which provides a challenge for clinicians in making a correct diagnosis. An 88-year-old woman with a long-term history of poor-controlled type 2 diabetes mellitus and hypertension, who presented with a sudden-onset headache, restlessness, severe bilateral choreiform and ballistic movements, elevated levels of glucose and osmolality in the serum, an increased white blood cell count, and two-type hyperdense signs on CT imaging, was finally diagnosed with NKH-CB and ICH. Despite administrated active treatments, the patient's clinical status did not improve and ultimately passed away. This case is reported to remind clinicians to consider the possibility of NKH-CB when patients present sudden-onset choreiform and ballistic movements. It is also the first entity with two-type hyperdense signs on CT imaging simultaneously, which helps us distinguish NKH-CB from ICH more intuitively.

Investigation of the relationship between non-ketotic hyperglycemia and hemichorea-hemiballism: A case report

RATIONALE

Hemichorea-hemiballism, a rare manifestation of non-ketotic hyperglycemia, characterized by involuntary arrhythmic motions involving one side of the body, results from focal lesions in the contralateral caudate nucleus and putamen. Hyperkinetic disorders can be complications of uncontrolled diabetes mellitus and should not be ignored.

PATIENT CONCERNS

We present the case of a 39-year-old woman who presented to the emergency department with a 3-day history of left-sided hemichorea-hemiballism. She had type 2 diabetes mellitus with poor control and maintenance of regular hemodialysis.

DIAGNOSES

The patient was diagnosed as hyperglycemia, normal ketone body and hemichorea-hemiballism based on laboratory examination, computed tomography (CT) scan, and brain magnetic resonance image (MRI).

INTERVENTIONS

Intensive glycemic control via insulin injection was prescribed for correction of hyperglycemia.

OUTCOMES

The unilateral involuntary movements subsided progressively over four weeks. The patient's hemichorea had completely resolved at the three-month follow-up.

LESSONS

This unusual clinical presentation is often accompanied by severe hyperglycemia. Appropriate blood glycemic control is important. If physicians recognize and provide early treatment for this disease, it is usually treatable and has a good prognosis.