Irreversible Hemichorea-Hemiballism in a Case of Nonketotic Hyperglycemia Presenting as the Initial Manifestation of Diabetes Mellitus

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.

Diabetic Striatopathy: Parenchymal Transcranial Sonography as a Supplement to Diagnosis at the Emergency Department

Background: Diabetic striatopathy (DS) is a rare condition with a debated pathophysiology; a local metabolic dysfunction is the most likely hypothesis. We present a case of DS mimicking an acute stroke, outline a few uncommon/atypical features, and report for the first time the parenchymal transcranial sonography (pTCS) findings. Case Report: An 86-year-old man, treated for insulin-dependent diabetes, presented at an emergency department because of the occurrence of isolated choreo-athetotic movements in his left limbs with fluctuations in the location, frequency, and duration. The blood glucose level was 569 mg/dL. Both urgent and follow-up brain computed tomography (CT) were negative for recent lesions whereas pTCS revealed hyperechogenicity in the right lenticular nucleus. Subsequent magnetic resonance imaging (MRI) showed T1-weighted hyperintensity in the right putamen with negative diffusion-weighted imaging. The symptoms were responsive to glucose control and haloperidol administration, although they persisted during sleep. Conclusions: Unlike previously described cases characterized by hemichorea and/or hemiballism, our patient presented with a stroke-like onset of unilateral irregular choreo-athetotic movements. Notably, based on CT alone, it would not have been possible to distinguish DS from a stroke. In this scenario, the pTCS hyperechogenicity of the right lenticular nucleus helped to hypothesize a metabolic disorder, which was subsequently confirmed by MRI.

Non-Ketotic Hyperglycemic Hemichorea-Hemiballismus in the Setting of Antipsychotics and Methamphetamine

The management of common chronic conditions presenting in uncommon ways is an important facet of medical education and patient care. We report a 54-year-old patient who developed left arm dystonia precipitated by several potential factors. These include laboratory findings notable for significant hyperglycemia, methamphetamine positive on urine drug testing and patient history consistent with bipolar II managed with Lurasidone, a second-generation antipsychotic medication. The potential etiology of this uncommon presentation is discussed below.

A Rare Case of Hemichorea-Hemiballismus Due to Chronic Uncontrolled Hyperglycemia

Chronic uncontrolled hyperglycemia is a rare yet important cause of hemichorea-hemiballismus and very common among postmenopausal women. This case report illustrates the importance of recognizing hyperglycemia as a potential cause of hemiballismus. There is a need to differentiate hyperglycaemic intracranial changes from other intracranial pathologies, as prompt glycemic control can help improve hemiballistic symptoms and prevent a more aggressive or invasive workup.

"Dancing belly" in an old diabetic lady

Movement disorder, although rare, is increasingly being recognized as the initial presenting sign of the hyperglycemic state. Although chorea-ballism has frequently been reported among diabetics, monoballism is a very rare phenomenon. While myoclonus is common, diaphragmatic myoclonus is extremely rare. Moreover, diaphragmatic myoclonus as the initial presenting manifestation has never been reported before. Herein, we report an index case of a 62-year-old previously undiagnosed diabetic lady presented with acute onset constellation of multiple abnormal movements viz. monoballism, focal myoclonus, action myoclonus, and diaphragmatic myoclonus. All of them disappeared with achieving normoglycemia. This case underscores the importance of rapid capillary blood glucose testing in any patient presenting with acute onset abnormal movements. This approach can especially be rewarding as it helps in the rapid diagnosis of a reversible catastrophe and avoiding unnecessary costly investigations.

Hemichorea Associated With Non-ketotic Hyperglycemia: A Case Report and Literature Review

Objective: To explore the clinical manifestation, diagnosis, therapy, and mechanism of hemichorea associated with non-ketotic hyperglycemia (HC-NH) so as to enhance awareness and avoid misdiagnosis or missed diagnosis of the disease.

Methods: A case of HC-NH was reported and reviewed in terms of the clinical features, diagnosis and treatment.

Results: Hemichorea associated with non-ketotic hyperglycemia is a rare complication of diabetes mellitus, which is commonly seen in elderly women with poorly-controlled diabetes. The condition is characterized by non-ketotic hyperglycemia, unilateral involuntary choreiform movements, and contralateral basal ganglia hyper-intensity by T1-weighted MR imaging or high density on CT scans. Blood glucose control is the basal treatment, in combination with dopamine receptor antagonists and benzodiazepine sedative, in controlling hemichorea.

Conclusion: In clinical practice, the possibility of unilateral chorea should be considered for diabetic patients with poor blood glucose control.

Hemichorea-Hemiballismus as an Unusual Presentation of Hyperosmolar Hyperglycemic Syndrome

Diabetes mellitus can lead to a diverse array of systemic complications. Poorly managed hyperglycemia can result in serious neurological consequences ranging from peripheral neuropathy to seizures and coma. A rare neurologic disorder seen in acute decompensated type 2 diabetes mellitus (T2DM) is hemichorea-hemiballismus (HCHB). HCHB is a movement disorder primarily associated with cerebrovascular accidents of infarct or hemorrhagic origin. It is a condition that can occur in a diabetic patient, especially when no other signs or symptoms of hyperglycemia are present. It is urgent to recognize HCHB movement disorder quickly as it may be the only presenting sign of hyperglycemia and can alert medical personnel to a possible hyperosmolar hyperglycemic state (HHS). We report an unusual case of HCHB in a patient with HHS, whose only presenting sign was unilateral hyperkinesis, which completely resolved after adequate blood glucose control. Prompt treatment and management of hyperglycemia yields an excellent prognosis in HCHB.

Glycemic Choreoballism

In Response To: Roy U, Das SK, Mukherjee A, et al. Irreversible hemichorea-hemiballism in a case of nonketotic hyperglycemia presenting as the initial manifestation of diabetes mellitus. Tremor Other Hyperkinet Mov. 2016; 6. doi: 10.7916/D8QZ2B3F Cosentino C, Torres L, Nuñez Y, et al. Hemichorea/hemiballism associated with hyperglycemia: report of twenty cases. Tremor Other Hyperkinet Mov. 2016; 6. doi: 10.7916/D8DN454P.

Reply #2 to: Glycemic Choreoballism

In Response To: Lee D, Ahn, TB. Glycemic choreoballism. Tremor Other Hyperkinet Mov. 2016; 6. doi: 10.7916/D8QJ7HNF Original Article: Roy U, Das SK, Mukherjee A, et al. Irreversible hemichoreahemiballism in a case of nonketotic hyperglycemia presenting as the initial manifestation of diabetes mellitus. Tremor Other Hyperkinet Mov. 2016; 6. doi: 10.7916/D8QZ2B3F.