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Lin L, Cai M, Su F, Wu T, Yuan K, Li Y, Luo Y, Chen D, Pei Z. Real-world experience with Deutetrabenazine management in patients with Huntington's disease using video-based telemedicine. Neurol Sci 2024; 45:2047-2055. [PMID: 37973627 DOI: 10.1007/s10072-023-07179-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 10/31/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Huntington's disease (HD) is a rare progressive neurological disorder, and telemedicine has the potential to improve the quality of care for patients with HD. Deutetrabenazine (DTBZ) can reduce chorea symptoms in HD; however, there is limited experience with this medication in Asian countries. METHODS Retrospective and prospective studies were employed to explore the feasibility and reliability of a video-based telemedicine system for HD patient care. Reliability was demonstrated through consistency between selected-item scores (SIS) and total motor scores (TMS) and the agreement of scores obtained from hospital and home videos. Finally, a single-centre real-world DTBZ management study was conducted based on the telemedicine system to explore the efficacy of DTBZ in patients with HD. RESULTS There were 77 patients included in the retrospective study, and a strong correlation was found between SIS and TMS (r = 0.911, P < 0.0001), indicating good representativeness. There were 32 patients enrolled in the prospective study. The reliability was further confirmed, indicated by correlations between SIS and TMS (r = 0.964, P < 0.0001) and consistency of SIS derived from the in-person and virtual visits (r = 0.969, P < 0.0001). There were 17 patients included in the DTBZ study with a mean 1.41 (95% confidence interval, 0.37-2.46) improvement in chorea score and reported treatment success. CONCLUSIONS A video-based telemedicine system is a feasible and reliable option for HD patient care. It may also be used for drug management as a supplementary tool for clinical visits.
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Affiliation(s)
- Lishan Lin
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China
| | - Mansi Cai
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China
| | - Fengjuan Su
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China
| | - Tengteng Wu
- Department of Neurology, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Kang Yuan
- Zhongshan School of Medicine, Sun Yat-Sen University, Guangzhou, China
| | - Yucheng Li
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China
| | - Yue Luo
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China
| | - Dingbang Chen
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China.
| | - Zhong Pei
- Department of Neurology, Guangdong Provincial Key Laboratory of Diagnosis and Treatment of Major Neurological Diseases, Department and Key Discipline of Neurology, The First Affiliated Hospital, National Key Clinical, Sun Yat-Sen University, Guangzhou, China
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Garcia JJB, Tecson-Delos Santos CMA. Dancing Out of Step: A Case of Tuberculous Meningitis Presenting as Childhood Chorea. Tremor Other Hyperkinet Mov (N Y) 2024; 14:17. [PMID: 38617830 PMCID: PMC11011945 DOI: 10.5334/tohm.871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/24/2024] [Indexed: 04/16/2024] Open
Abstract
Background Acute to subacute pediatric movement disorders require prompt diagnosis to identify potentially treatable diseases. Case Report We present a 6-year-old male with a three-week history of generalized chorea transitioning to predominantly right-sided hemichorea and then to left hemiplegia. Discussion We review the mechanisms in tuberculous meningitis underlying his movement abnormalities.
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Affiliation(s)
- Jao Jarro B. Garcia
- Division of Adult Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
| | - Cherie Marie A. Tecson-Delos Santos
- Division of Pediatric Neurology, Department of Neurosciences, College of Medicine and Philippine General Hospital, University of the Philippines Manila, Manila, Philippines
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Wang X, Zhang Y, Yang F, Bao S, Duan L, Jiang X. Further learning of clinical characteristics and imaging manifestations of nonketotic hyperglycemic hemichorea. J Diabetes 2024; 16:e13543. [PMID: 38584150 PMCID: PMC10999500 DOI: 10.1111/1753-0407.13543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 01/18/2024] [Accepted: 01/31/2024] [Indexed: 04/09/2024] Open
Abstract
OBJECTIVE To summarize the clinical characteristics and imaging manifestations of patients with nonketotic hyperglycemic hemichorea (NH-HC) and to explore the possible pathogenesis, diagnosis. and treatment of the disease in order to improve the understanding of this disease and avoid misdiagnosis. METHODS Retrospective analysis was performed on the case data of five patients with NH-HC admitted to our hospital in recent years. The patients were treated in the department of endocrinology, department of neurology, and department of neurosurgery in our hospital, respectively. Meanwhile, relevant literatures were consulted for further learning. RESULTS NH-HC is usually presented as a triad of nonketotic hyperglycemia, lateral chorea, and typical imaging manifestations of head magnetic resonance imaging or computed tomography, but the clinical manifestations are not the same, and imaging features may also be different, presenting a diversified trend in clinical practice. All five patients were given glucose-lowering drugs and improved with or without combination of drugs to control symptoms of chorea. CONCLUSION NH-HC is a rare complication of diabetes, characterized by hyperglycemia and hemichorea. How to identify the extreme situation and make fast judgment is a top priority. Timely and correct control of blood glucose is the key to the treatment, and when necessary, application of dopamine receptor antagonists in patients with combination therapy can accelerate improvement of the clinical symptoms. The prognosis of NH-HC is good, the clinician should strengthen comprehensive understanding of this disease to avoid missed diagnosis or misdiagnosis and enable patients to get more timely and effective treatment.
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Affiliation(s)
- Xiaoyu Wang
- Department of Endocrinology and MetabolismTianjin First Central HospitalTianjinChina
| | - Yuting Zhang
- Department of NeurologyTianjin First Central HospitalTianjinChina
| | - Fan Yang
- Department of NeurosurgeryTianjin First Central HospitalTianjinChina
| | - Suqing Bao
- Department of Endocrinology and MetabolismTianjin First Central HospitalTianjinChina
| | - Lijun Duan
- Department of Endocrinology and MetabolismTianjin First Central HospitalTianjinChina
| | - Xia Jiang
- Department of Endocrinology and MetabolismTianjin First Central HospitalTianjinChina
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Eyre M, Thomas T, Ferrarin E, Khamis S, Zuberi SM, Sie A, Newlove-Delgado T, Morton M, Molteni E, Dale RC, Lim M, Nosadini M. Treatments and Outcomes Among Patients with Sydenham Chorea: A Meta-Analysis. JAMA Netw Open 2024; 7:e246792. [PMID: 38625703 PMCID: PMC11022117 DOI: 10.1001/jamanetworkopen.2024.6792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 02/17/2024] [Indexed: 04/17/2024] Open
Abstract
Importance Sydenham chorea is the most common acquired chorea of childhood worldwide; however, treatment is limited by a lack of high-quality evidence. Objectives To evaluate historical changes in the clinical characteristics of Sydenham chorea and identify clinical and treatment factors at disease onset associated with chorea duration, relapsing disease course, and functional outcome. Data Sources The systematic search for this meta-analysis was conducted in PubMed, Embase, CINAHL, Cochrane Library, and LILACS databases and registers of clinical trials from inception to November 1, 2022 (search terms: [Sydenham OR Sydenham's OR rheumatic OR minor] AND chorea). Study Selection Published articles that included patients with a final diagnosis of Sydenham chorea (in selected languages). Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. Individual patient data on clinical characteristics, treatments, chorea duration, relapse, and final outcome were extracted. Data from patients in the modern era (1945 through 2022) were entered into multivariable models and stratified by corticosteroid duration for survival analysis of chorea duration. Main Outcomes and Measures The planned study outcomes were chorea duration at onset, monophasic course (absence of relapse after ≥24 months), and functional outcome (poor: modified Rankin Scale score 2-6 or persisting chorea, psychiatric, or behavioral symptoms at final follow-up after ≥6 months; good: modified Rankin Scale score 0-1 and no chorea, psychiatric, or behavioral symptoms at final follow-up). Results In total, 1479 patients were included (from 307 articles), 1325 since 1945 (median [IQR] age at onset, 10 [8-13] years; 875 of 1272 female [68.8%]). Immunotherapy was associated with shorter chorea duration (hazard ratio for chorea resolution, 1.51 [95% CI, 1.05-2.19]; P = .03). The median chorea duration in patients receiving 1 or more months of corticosteroids was 1.2 months (95% CI, 1.2-2.0) vs 2.8 months (95% CI, 2.0-3.0) for patients receiving none (P = .004). Treatment factors associated with monophasic disease course were antibiotics (odds ratio [OR] for relapse, 0.28 [95% CI, 0.09-0.85]; P = .02), corticosteroids (OR, 0.32 [95% CI, 0.15-0.67]; P = .003), and sodium valproate (OR, 0.33 [95% CI, 0.15-0.71]; P = .004). Patients receiving at least 1 month of corticosteroids had significantly lower odds of relapsing course (OR, 0.10 [95% CI, 0.04-0.25]; P < .001). No treatment factor was associated with good functional outcome. Conclusions and Relevance In this meta-analysis of treatments and outcomes in patients with Sydenham chorea, immunotherapy, in particular corticosteroid treatment, was associated with faster resolution of chorea. Antibiotics, corticosteroids and sodium valproate were associated with a monophasic disease course. This synthesis of retrospective data should support the development of evidence-based treatment guidelines for patients with Sydenham chorea.
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Affiliation(s)
- Michael Eyre
- School of Biomedical Engineering and Imaging Sciences, King’s College London, London, United Kingdom
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Terrence Thomas
- Department of Paediatrics, Neurology Service, KK Women’s and Children’s Hospital, Singapore
| | | | - Sonia Khamis
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Sameer M. Zuberi
- Paediatric Neurosciences Research Group, Royal Hospital for Children, Glasgow, United Kingdom
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Adrian Sie
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- NHS Lanarkshire, Bothwell, United Kingdom
| | - Tamsin Newlove-Delgado
- Children and Young People’s Mental Health (ChYMe) Research Collaboration, University of Exeter Medical School, Exeter, United Kingdom
| | - Michael Morton
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Erika Molteni
- School of Biomedical Engineering and Imaging Sciences, King’s College London, United Kingdom
| | - Russell C. Dale
- Kids Neuroscience Centre, The Children’s Hospital at Westmead, Faculty of Medicine and Health, University of Sydney, Westmead, Australia
| | - Ming Lim
- Faculty of Life Sciences and Medicine, King’s College London, United Kingdom
- Children’s Neurosciences, Evelina London Children’s Hospital at Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Margherita Nosadini
- Paediatric Neurology and Neurophysiology Unit, Department of Women’s and Children’s Health, University Hospital of Padova, Padova, Italy
- Neuroimmunology Group, Paediatric Research Institute “Città della Speranza,” Padova, Italy
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Dixit A. Nonketotic hyperglycemia hemichorea and hemiballismus: a case report. J Med Case Rep 2024; 18:154. [PMID: 38468351 DOI: 10.1186/s13256-023-04332-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 12/20/2023] [Indexed: 03/13/2024] Open
Abstract
BACKGROUND Diabetic striatopathy, also known as hyperglycemic hemichorea-hemiballismus, is a rare movement disorder associated with nonketotic hyperglycemia in patients with poorly controlled diabetes mellitus. The pathophysiology is not fully elucidated but may involve hyperviscosity, ischemia, and alterations in basal ganglia neurotransmitters. CASE PRESENTATION We present a case of a 64-year-old Asian female patient with longstanding poorly controlled type 2 diabetes mellitus who developed abrupt-onset right-sided hemichorea-hemiballismus. Laboratory results showed hyperglycemia without ketoacidosis. Neuroimaging revealed left putaminal hyperdensity on computed tomography and T1 hyperintensity on magnetic resonance imaging. With insulin therapy and tetrabenazine, her movements improved but persisted at 1-month follow-up. DISCUSSION This case illustrates the typical features of diabetic striatopathy, including acute choreiform movements contralateral to neuroimaging abnormalities in the setting of nonketotic hyperglycemia. While neuroleptics may provide symptomatic relief, prompt glycemic control is critical given the risk of recurrence despite imaging normalization. CONCLUSION Diabetic striatopathy should be recognized as a rare disorder that can occur with poorly controlled diabetes. Further study of its pathophysiological mechanisms is needed to better guide management. Maintaining tight glycemic control is essential to prevent recurrence of this debilitating movement disorder.
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Affiliation(s)
- Abhishek Dixit
- Department of Neurology, Institute of Medical Science, Banaras Hindu University, Varanasi, India.
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Curtis K, Sung V. Real-World Experience With Deutetrabenazine for Huntington Disease Chorea. J Clin Pharmacol 2024; 64:178-181. [PMID: 37565322 DOI: 10.1002/jcph.2336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 08/09/2023] [Indexed: 08/12/2023]
Abstract
Huntington disease (HD) is a hereditary neurodegenerative disorder with a hallmark feature of chorea. While no disease-modifying therapies currently exist for HD, symptomatic treatment of HD-associated chorea includes US Food and Drug Administration-approved vesicular monoamine transporter type 2 inhibitors-tetrabenazine and deutetrabenazine. Deutetrabenazine was more recently approved (2017), and while structurally similar to tetrabenazine, deutetrabenazine has a unique pharmacokinetic profile that allows for a longer half-life, reduced plasma fluctuations, and less frequent dosing. In pivotal trials, deutetrabenazine seemed to have an improved safety and tolerability profile over tetrabenazine but real-world data to confirm this are lacking. Here, we evaluate our real-world clinical experience with deutetrabenazine for HD-associated chorea. We performed a retrospective chart review of all patients with HD who initiated treatment with deutetrabenazine from January 2017 to May 2019 at the University of Alabama at Birmingham. Total maximal chorea scores, patient-reported subjective efficacy, dosing information, and subjective reports of adverse events (AEs) were abstracted for each patient. Our review included 58 patients with a mean length of treatment of 476.4 days. In the reviewed time period, the mean treatment difference in total maximal chorea scores was 4.4. The combined total rate of occurrence of any AEs was relatively low, at 32.8%, and the most commonly reported AEs were sedation (15.5%), insomnia (6.9%), and diarrhea (3.4%). Our real-world data support current literature indicating that deutetrabenazine is an effective and well-tolerated treatment for HD-associated chorea. Further studies repeating this on a larger scale, across a greater geography and practice pattern, are needed.
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Affiliation(s)
- Kendall Curtis
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurology, Division of Movement Disorders, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Victor Sung
- Department of Neurology, Division of Movement Disorders, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Javed F, Piranavan P. Chorea as an initial and solitary manifestation of systemic lupus erythematosus with antiphospholipid syndrome in an elderly man. BMJ Case Rep 2024; 17:e257086. [PMID: 38290987 PMCID: PMC10828870 DOI: 10.1136/bcr-2023-257086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024] Open
Abstract
Chorea can be an initial manifestation of systemic lupus erythematosus (SLE) or antiphospholipid syndrome (APS). It has been mostly described in younger female adults in association with other manifestations of SLE. When chorea appears as an initial and only manifestation in SLE/APS patients, the establishment of the correct diagnosis is difficult, and it may be initially attributed to a more common aetiology. Here we report an elderly man who presented with a new onset of right-sided chorea without other clinical manifestations of SLE/APS. He started on steroids a year later, however, there was no improvement. His chorea was symptomatically managed along with aspirin, and hydroxychloroquine as he refused to be on additional immunosuppression. Anticoagulation was relatively contraindicated, and also not favoured by this patient; therefore, aspirin was initiated. Even in elderly patients, once the common etiologies of chorea have been worked up, we suggest doing a rheumatological evaluation. Early diagnosis and prompt treatment can prevent persistent neurological abnormality.
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Affiliation(s)
- Faiza Javed
- Hospital Medicine, University of Kentucky, Lexington, Kentucky, USA
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Yu YW, Chung CY, Chiou YH, Fang NW. Recurrent hemichorea in an adolescent with systemic lupus erythematosus and previous ipsilateral cerebral infarction. Int J Rheum Dis 2024; 27:e14886. [PMID: 37606173 DOI: 10.1111/1756-185x.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Systemic lupus erythematosus (SLE) can present with movement disorders, among which chorea is closely associated with antiphospholipid (aPL) antibodies. Brain imaging results obtained in patients with chorea are generally inconsistent with the clinical manifestation of chorea; moreover, medical tests for hemichorea, which are expected to reveal distinct localization, may show negative findings. Herein, we present a case of a 15-year-old girl with SLE who had a history of left cerebral infarction; tests revealed elevated aPL levels, and she developed recurrent left hemichorea 2 years later. Brain magnetic resonance imaging (MRI) results revealed no acute lesions during each episode of involuntary movements, and an MRI perfusion scan failed to provide an explanation for the asymmetric presentation. Although various hypotheses have been proposed regarding the mechanism underlying the occurrence of chorea, some scenarios still remain unexplained. Further investigation on the pathophysiology of chorea in SLE may be warranted to clarify its prognosis.
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Affiliation(s)
- Ya-Wen Yu
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Yu Chung
- Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yee-Hsuan Chiou
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Fooyin University, Kaohsiung, Taiwan
| | - Nai-Wen Fang
- Division of Pediatric Nephrology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Pingtung Veterans General Hospital, Pingtung, Taiwan
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Mahler S, Braun M, Thapa K. Resolving the Dance: A Case Study on Non-Ketotic Hyperglycemic Hemichorea-Hemiballismus in a Patient with Long-Standing Type 2 Diabetes. Am J Case Rep 2023; 24:e941443. [PMID: 38064410 PMCID: PMC10721340 DOI: 10.12659/ajcr.941443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/01/2023] [Accepted: 09/26/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Non-ketotic hyperglycemic hemichorea-hemiballism (HCHB) is a rare complication of diabetes, which is mainly described in case reports. This condition occurs more commonly in older women and is known to be associated with T1 hyperintensity basal ganglia lesions on magnetic resonance imaging (MRI). The pathophysiology of non-ketotic hyperglycemic HCHB is not well defined, although a combination of regional metabolic failure and ischemia due to hyperglycemia is suspected to occur. Treatment entails tight blood glucose control, although antipsychotic medications such as risperidone may be helpful in refractory cases. CASE REPORT We describe a case of a middle-aged man with long-standing type 2 diabetes who experienced 3 weeks of progressive unilateral arm, leg, and face choreiform movements. Laboratory testing performed just prior to symptom onset was notable for a hemoglobin A1C of >15% and a serum blood glucose of 566 mg/dl. MRI revealed diffuse T1 hyperintensity in the left lentiform nucleus. Our patient's insulin regimen was adjusted, resulting in improvement in average serum glucose (A1C of 9.4%). However, his symptoms did not improve significantly. A trial of benzodiazepine was attempted, without success. When risperidone was started, the patient experienced resolution of symptoms. Recurrence of non-ketotic hyperglycemic HCHB while off risperidone has not occurred to date. CONCLUSIONS Non-ketotic hyperglycemic HCHB is a rare but important diagnosis to consider in patients with hyperglycemia and new-onset choreiform movements. Patients with long-standing type 2 diabetes may be affected, especially when glycemic control worsens. When tight blood glucose control does not resolve symptoms, a short course of antipsychotic agents may provide relief.
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Affiliation(s)
- Stewart Mahler
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Melanie Braun
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kriti Thapa
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Hospital Medicine, Department of Medicine, NYU Langone Health, New York City, NY, USA
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Nou-Fontanet L, Martín-Gómez C, Isabel-Gómez R, Bachoud-Lévi AC, Zorzi G, Capuano A, Blasco-Amaro JA, Ortigoza-Escobar JD. Systematic review of drug therapy for chorea in NXK2-1-related disorders: Efficacy and safety evidence from case studies and series. Eur J Neurol 2023; 30:3928-3948. [PMID: 37694681 DOI: 10.1111/ene.16038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/25/2023] [Accepted: 08/08/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND The NKX2-1-related disorders (NKX2-1-RD) is a rare disorder characterized by choreiform movements along with respiratory and endocrine abnormalities. The European Reference Network of Rare Neurological Disorders funded by the European Commission conducted a systematic review to assess drug treatment of chorea in NKX2-1-RD, aiming to provide clinical recommendations for its management. METHODS A systematic pairwise review using various databases, including MEDLINE, Embase, Cochrane, CINAHL, and PsycInfo, was conducted. The review included patients diagnosed with chorea and NKX2-1-RD genetic diagnosis, drug therapy as intervention, no comparator, and outcomes of chorea improvement and adverse events. The methodological quality of the studies was assessed, and the study protocol was registered in PROSPERO. RESULTS Of the 1417 studies examined, 28 studies met the selection criteria, consisting of 68 patients. The studies reported 22 different treatments for chorea, including carbidopa/levodopa, tetrabenazine, clonazepam, methylphenidate, carbamazepine, topiramate, trihexyphenidyl, haloperidol, propranolol, risperidone, and valproate. No clinical improvements were observed with carbidopa/levodopa, tetrabenazine, or clonazepam, and various adverse effects were reported. However, most patients treated with methylphenidate experienced improvements in chorea and reported only a few negative effects. The quality of evidence was determined to be low. CONCLUSIONS The management of chorea in individuals with NKX2-1-RD presents significant heterogeneity and lack of clarity. While the available evidence suggests that methylphenidate may be effective in improving chorea symptoms, the findings should be interpreted with caution due to the limitations of the studies reviewed. Nonetheless, more rigorous and comprehensive studies are necessary to provide sufficient evidence for clinical recommendations.
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Affiliation(s)
- Laia Nou-Fontanet
- Department of Paediatric Neurology, Hospital Sant Joan de Déu, Barcelona, Spain
| | - Carmen Martín-Gómez
- Health Technology Assessment Area-AETSA, Andalusian Public Foundation for Progress and Health ("Fundación Progreso y Salud"-"FPS"), Seville, Spain
- Research Group HUM604: Lifestyle Development in the Life Cycle and Health Promotion, University of Huelva, Huelva, Spain
| | - Rebeca Isabel-Gómez
- Health Technology Assessment Area-AETSA, Andalusian Public Foundation for Progress and Health ("Fundación Progreso y Salud"-"FPS"), Seville, Spain
| | - Anne-Catherine Bachoud-Lévi
- Assistance Publique-Hôpitaux de Paris, Henri Mondor Hospital, National Center of Reference for Huntington's Disease, Créteil, France
- Département d'Etudes Cognitives, École Normale Supérieure, PSL University, Paris, France
- European Reference Network for Rare Neurological Diseases (ERN-RND), Tübingen, Germany
| | - Giovanna Zorzi
- Department of Pediatric Neuroscience, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Alessandro Capuano
- Movement Disorders Clinic, Department of Neurosciences, Bambino Gesù Children's Hospital, Rome, Italy
| | - Juan Antonio Blasco-Amaro
- Health Technology Assessment Area-AETSA, Andalusian Public Foundation for Progress and Health ("Fundación Progreso y Salud"-"FPS"), Seville, Spain
| | - Juan Darío Ortigoza-Escobar
- Department of Paediatric Neurology, Hospital Sant Joan de Déu, Barcelona, Spain
- European Reference Network for Rare Neurological Diseases (ERN-RND), Tübingen, Germany
- U-703 Centre for Biomedical Research on Rare Diseases (CIBER-ER), Instituto de Salud Carlos III, Barcelona, Spain
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Soller T, Roberts KV, Middleton BF, Ralph AP. Sydenham chorea in the top end of Australia's Northern Territory: A 20-year retrospective case series. J Paediatr Child Health 2023; 59:1210-1216. [PMID: 37589435 DOI: 10.1111/jpc.16481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/15/2023] [Accepted: 07/28/2023] [Indexed: 08/18/2023]
Abstract
AIM Sydenham chorea is an immune-mediated neuropsychiatric condition, and a major criterion for diagnosis of acute rheumatic fever (ARF). Children in remote Northern Australia experience disproportionately high rates of ARF, yet studies looking at the epidemiology, clinical presentation and management of Sydenham chorea are limited in this population. METHODS We conducted a retrospective case series from January 2002 to April 2022 of all paediatric patients aged ≤18 years admitted to Royal Darwin Hospital with Sydenham chorea. Cases were identified using the hospital's clinical coding system (ICD10). Medical records were reviewed and data on demographics, clinical presentation, investigation results, treatment and outcome were extracted, deidentified and analysed. RESULTS One hundred ten presentations of Sydenham chorea occurred between 2002 and 2022, 109 (99%) of these were in First Nations children, with 85% residing in very remote locations. Most commonly, chorea presented as a generalised movement disorder affecting all four limbs (49%). Neuropsychiatric symptoms were reported in 33 (30%), and there was evidence of rheumatic heart disease on echocardiogram in 86 (78%) at presentation. All patients received benzathine penicillin, but there was significant variation in management of chorea, ranging from supportive management, to symptomatic management with anticonvulsants, to immunomodulatory medications including corticosteroids. CONCLUSION This case series highlights the significant burden of Sydenham chorea among First Nations children living in Northern Australia and demonstrates wide variation in treatment approaches. High-quality clinical trials are required to determine the best treatment for this disabling condition.
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Affiliation(s)
- Tasmyn Soller
- Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Kathryn V Roberts
- Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Bianca F Middleton
- Paediatric Department, Royal Darwin Hospital, Darwin, Northern Territory, Australia
- Global Health Division, Menzies School of Health Research, John Mathews Building Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
| | - Anna P Ralph
- Global Health Division, Menzies School of Health Research, John Mathews Building Royal Darwin Hospital Campus, Darwin, Northern Territory, Australia
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Saigoh K, Hirano M, Mitsui Y, Oda I, Ikegawa A, Samukawa M, Yoshikawa K, Yamagishi Y, Kusunoki S, Nagai Y. Memantine administration prevented chorea movement in Huntington's disease: a case report. J Med Case Rep 2023; 17:431. [PMID: 37840138 PMCID: PMC10578007 DOI: 10.1186/s13256-023-04161-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 09/01/2023] [Indexed: 10/17/2023] Open
Abstract
BACKGROUND Huntington's disease is an autosomal dominant inherited disorder characterized by personality changes (such as irritability and restlessness) and psychotic symptoms (such as hallucinations and delusions). When the personality changes become noticeable, involuntary movements (chorea) also develop. The disease is caused by the CAG repeat expansion in the coding region of the HTT gene, and the diagnosis is based on the presence of this expansion. However, there is currently no effective treatment for the progression of Huntington's disease and its involuntary motor symptoms. Herein, we present a case in which memantine was effective in treating the chorea movements of Huntington's disease. CASE PRESENTATION A 75-year-old Japanese woman presented to the hospital with involuntary movements of Huntington's disease that began when she was 73 years old. In a cerebral blood flow test (N-isopropyl-p-iodoamphetamine-single-photon emission computed tomography), decreased blood flow was observed in the precuneus (anterior wedge) and posterior cingulate gyrus. Usually, such areas of decreased blood flow are observed in patients with Alzheimer's-type dementia. So, we administered memantine for Alzheimer's-type dementia, and this treatment suppressed the involuntary movements of Huntington's disease, and the symptoms progressed slowly for 7 years after the onset of senility. In contrast, her brother died of complications of pneumonia during the course of Huntington's disease. CONCLUSIONS We recorded changes in parameters such as the results of the N-isopropyl-p-iodoamphetamine-single-photon emission computed tomography and gait videos over 7 years. Treatment with memantine prevented the chorea movement and the progression of Huntington's disease. We believe this record will provide clinicians with valuable information in diagnosing and treating Huntington's disease.
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Affiliation(s)
- Kazumasa Saigoh
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan.
- Department of Life Science, Faculty of Science, and Engineering, Kindai University, 377-2, Ohno-Higashi, Osakasayama, Osaka, 589-8511, Japan.
- Department of Clinical Genetics, Kindai University Hospital, Osakasayama, Japan.
| | - Makito Hirano
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Yoshiyuki Mitsui
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Itsuki Oda
- Department of Clinical Genetics, Kindai University Hospital, Osakasayama, Japan
| | - Atsuko Ikegawa
- Department of Clinical Genetics, Kindai University Hospital, Osakasayama, Japan
| | - Makoto Samukawa
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Keisuke Yoshikawa
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Yuko Yamagishi
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Susumu Kusunoki
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
| | - Yoshitaka Nagai
- Department of Neurology, Faculty of Medicine, Kindai University, Osakasayama, Japan
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Wood H. A new drug to treat chorea in Huntington disease. Nat Rev Neurol 2023; 19:387. [PMID: 37280292 DOI: 10.1038/s41582-023-00832-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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Tariq S, Niaz F, Waseem S, Shaikh TG, Ahmed SH, Irfan M, Nashwan AJ, Ullah I. Managing and treating Sydenham chorea: A systematic review. Brain Behav 2023; 13:e3035. [PMID: 37150977 PMCID: PMC10275551 DOI: 10.1002/brb3.3035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/09/2023] Open
Abstract
INTRODUCTION Sydenham's chorea (SC), prevalent in developing countries and occasionally affecting developed ones, poses a clinical challenge due to the lack of systematic guidelines for diagnosis and treatment. Resulting from Group A Beta-Hemolytic Streptococcus infection, SC presents various symptoms. This review aims to collect and evaluate available data on SC management to propose a cohesive treatment plan. METHODS We searched PubMed, the Cochrane Library, Google Scholar, and ClinicalTrials.gov for literature on SC management from inception until 24th July 2022. Studies were screened by titles and abstracts. Cochrane Collaboration's Risk of Bias tool (RoB-1) assessed Randomized Controlled Trials, while the Risk of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool evaluated nonrandomized studies. RESULTS The review includes 11 articles assessing 579 patients. Excluding one study with 229 patients, of the remaining 550 patients, 338 (61.5%) were females. Treatments used were dopamine antagonists in 118 patients, antiepileptics in 198, corticosteroids in 134, IVIG in 7, and PE in 8 patients. Dopamine antagonists, particularly haloperidol, were the primary treatment choice, while valproic acid (VPA) was favored among antiepileptics. Prednisolone, a corticosteroid, showed promising results with weight gain as the only side-effect. Our review emphasizes the importance of immunomodulators in SC, contrasting previous literature. CONCLUSION Despite limitations, dopamine antagonists can serve as first-line agents in SC management, followed by antiepileptics. The role of immunomodulators warrants further investigation for conclusive recommendations.
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Affiliation(s)
- Samiuddin Tariq
- Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Faizan Niaz
- Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Summaiyya Waseem
- Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | - Taha Gul Shaikh
- Dow Medical CollegeDow University of Health SciencesKarachiPakistan
| | | | - Muhammad Irfan
- Department of Internal MedicineWellstar Health System Spalding Hospital GriffinGeorgiaUSA
| | | | - Irfan Ullah
- Kabir Medical CollegeGandhara UniversityPeshawar Khyber PakhtunkhkwaPakistan
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Furr Stimming E, Claassen DO, Kayson E, Goldstein J, Mehanna R, Zhang H, Liang GS, Haubenberger D. Safety and efficacy of valbenazine for the treatment of chorea associated with Huntington's disease (KINECT-HD): a phase 3, randomised, double-blind, placebo-controlled trial. Lancet Neurol 2023; 22:494-504. [PMID: 37210099 DOI: 10.1016/s1474-4422(23)00127-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 03/03/2023] [Accepted: 03/27/2023] [Indexed: 05/22/2023]
Abstract
BACKGROUND Valbenazine is a highly selective vesicular monoamine transporter 2 (VMAT2) inhibitor approved for treatment of tardive dyskinesia. To address the ongoing need for improved symptomatic treatments for individuals with Huntington's disease, valbenazine was evaluated for the treatment of chorea associated with Huntington's disease. METHODS KINECT-HD (NCT04102579) was a phase 3, randomised, double-blind, placebo-controlled trial, performed in 46 Huntington Study Group sites in the USA and Canada. The study included adults with genetically confirmed Huntington's disease and chorea (Unified Huntington's Disease Rating Scale [UHDRS] Total Maximal Chorea [TMC] score of 8 or higher) who were randomly assigned (1:1) via an interactive web response system (with no stratification or minimisation) to oral placebo or valbenazine (≤80 mg, as tolerated) for 12 weeks of double-blinded treatment. The primary endpoint was a least-squares mean change in UHDRS TMC score from the screening and baseline period (based on the average of screening and baseline values for each participant) to the maintenance period (based on the average of week 10 and 12 values for each participant) in the full-analysis set using a mixed-effects model for repeated measures. Safety assessments included treatment-emergent adverse events, vital signs, electrocardiograms, laboratory tests, clinical tests for parkinsonism, and psychiatric assessments. The double-blind placebo-controlled period of KINECT-HD has been completed, and an open-label extension period is ongoing. FINDINGS KINECT-HD was performed from Nov 13, 2019, to Oct 26, 2021. Of 128 randomly assigned participants, 125 were included in the full-analysis set (64 assigned to valbenazine, 61 assigned to placebo) and 127 were included in the safety-analysis set (64 assigned to valbenazine, 63 assigned to placebo). The full-analysis set included 68 women and 57 men. Least-squares mean changes from the screening and baseline period to the maintenance period in the UHDRS TMC score were -4·6 for valbenazine and -1·4 for placebo (least-squares mean difference -3·2, 95% CI -4·4 to -2·0; p<0·0001). The most commonly reported treatment-emergent adverse event was somnolence (ten [16%] with valbenazine, two [3%] with placebo). Serious treatment-emergent adverse events were reported in two participants in the placebo group (colon cancer and psychosis) and one participant in the valbenazine group (angioedema because of allergic reaction to shellfish). No clinically important ch anges in vital signs, electrocardiograms, or laboratory tests were found. No suicidal behaviour or worsening of suicidal ideation was reported in participants treated with valbenazine. INTERPRETATION In individuals with Huntington's disease, valbenazine resulted in improvement in chorea compared with placebo and was well tolerated. Continued research is needed to confirm the long-term safety and effectiveness of this medication throughout the disease course in individuals with Huntington's disease-related chorea. FUNDING Neurocrine Biosciences.
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Affiliation(s)
- Erin Furr Stimming
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Daniel O Claassen
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - Raja Mehanna
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Hui Zhang
- Neurocrine Biosciences, San Diego, CA, USA
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Bovenzi R, Conti M, Schirinzi T. Pharmacotherapy for Sydenham's chorea: where are we and where do we need to be? Expert Opin Pharmacother 2023; 24:1317-1329. [PMID: 37204415 DOI: 10.1080/14656566.2023.2216380] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/17/2023] [Indexed: 05/20/2023]
Abstract
INTRODUCTION Sydenham's chorea (SC) is the most common cause of acquired chorea in children. The existing literature describes it as a benign, self-remitting condition. However, recent evidence discloses the persistence of long-course neuropsychiatric and cognitive complications in adulthood, which imposes to redefine the concept of 'benignity' of such condition. In addition, therapies are mostly empirical and non-evidence based. AREAS COVERED Here, we conducted an electronic exploration of the PubMed database and selected 165 relevant studies directly correlated to SC treatment. Critical data from selected articles were synthesized to provide an update on pharmacotherapy in SC, which basically consists of three pillars: antibiotic, symptomatic and immunomodulant treatments. Moreover, since SC mostly affects females with recurrences occurring in pregnancy (chorea gravidarum), we focused on the management in pregnancy. EXPERT OPINION SC is still a major burden in developing countries. The first therapeutic strategy should be the primary prevention of group A beta-hemolytic streptococcal (GABHS) infection. Secondary antibiotic prophylaxis should be performed in every SC patient as the World Health Organization (WHO) guidelines recommend. Symptomatic or immunomodulant treatments are administered according to clinical judgment. However, a greater effort to understand SC physiopathology is needed, together with larger trials, to outline appropriate therapeutic indications.
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Affiliation(s)
- Roberta Bovenzi
- Neurology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Matteo Conti
- Neurology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Tommaso Schirinzi
- Neurology Unit, Department of Systems Medicine, University of Rome "Tor Vergata", Rome, Italy
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Hwang YS, Shin BS, Ryu HU, Kang HG. Monochorea after acute contralateral pontine infarction: A case report. Medicine (Baltimore) 2023; 102:e32660. [PMID: 36701735 PMCID: PMC9857559 DOI: 10.1097/md.0000000000032660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
RATIONALE Chorea is a hyperkinetic movement characterized by random, brief, and involuntary muscle contractions. In stroke, a common cause of chorea, basal ganglia are anatomical locations that can cause chorea when a stroke occurs, and chorea is less frequently triggered by a stroke in other anatomical brain regions. Herein, we report a rare case of monochorea after acute contralateral pontine infarction. PATIENT CONCERNS A 32-year-old man visited the emergency room due to dysarthria and right hemiparesis that occurred approximately 6 hours and 30 minutes before the visit. A brain magnetic resonance image confirmed a diffusion restriction lesion in the left pons. The patient was initially diagnosed with acute infarction at the left pons and began to receive medical treatment with an antiplatelet agent and statin with admission. DIAGNOSIS Approximately 14 hours after the onset of the initial stroke symptoms, the patient complained of involuntary movement in the right arm for the first time. Intermittent, irregular involuntary movements were observed in the distal part of the right arm. This symptom was unpredictable and random, and a similar symptom was not observed in other parts of the patient's body. Clinically, post-stroke monochorea was suspected. INTERVENTIONS AND OUTCOMES The symptom improved from day 5 without specific medical treatment for chorea. LESSONS The monochorea caused by the pontine lesion in this case was triggered by the direct lesions of the corticospinal tract, and its underlying pathophysiology remains unclear. However, abnormal movements can occur due to inadequate downstream activation or inhibition of the corticospinal tract, which is induced by functional abnormalities of the motor cortex. This case suggests that further investigation is needed on the mechanisms of direct corticospinal tract lesions for chorea.
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Affiliation(s)
- Yun Su Hwang
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Byoung-Soo Shin
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Han Uk Ryu
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
| | - Hyun Goo Kang
- Department of Neurology, Jeonbuk National University Medical School and Hospital, Jeonju, South Korea
- Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, South Korea
- * Correspondence: Hyun Goo Kang, Department of Neurology & Research Institute of Clinical Medicine of Jeonbuk National University – Biomedical Research Institute of Jeonbuk National University Hospital, 20 Geonji-ro, Deokjin-gu, Jeonju-si, Jeonbuk-do 54907, South Korea (e-mail: )
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Ermolenko NA, Krasnorutskaya ON, Bykova VA, Golosnaya GS, Shiryaev OY. [A case of a pathological variant of the PRRT2 gene in twins with paroxysmal kinesiogenic dyskinesia]. Zh Nevrol Psikhiatr Im S S Korsakova 2023; 123:83-86. [PMID: 37942977 DOI: 10.17116/jnevro202312309283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2023]
Abstract
Paroxysmal dyskinesia is a clinically and etiologically polymorphic group of diseases, the main clinical manifestation of which is transient attacks of extrapyramidal movements, with different conditions of occurrence. Paroxysmal kinesigenic dyskinesia belongs to the group of primary dyskinesias, which also includes paroxysmal non-kinesigenic dyskinesia and exercise-induced paroxysmal dyskinesia. The most common cause of paroxysmal kinesiogenic dyskinesia is mutations in the PRRT2 gene; in cases of non-kinesiogenic dyskinesia, a mutation in the MR1 gene is detected. The diagnosis of primary dyskinesias causes significant difficulty for clinicians due to the rarity of occurrence, as well as the large spectrum of conditions occurring with paroxysmal motor disorders in childhood. The article describes the clinical observation of 16-year-old twin brothers with transient attacks of dystonic, choreic and ballistic hyperkinesis that suddenly arose during movement. Patients were treated for tics and epilepsy for 12 years. Taking into account the clinical picture - transient attacks of hyperkinesis, their connection with movement, as well as data from video-electroencephalographic monitoring, a diagnosis of paroxysmal kinesiogenic dyskinesia was established, which in a further diagnostic search was confirmed by targeted sequencing of the pathological variant of the PRRT2 gene previously described in patients with kinesiogenic dyskinesia. The administration of carbamazepine, which is the drug of choice in the treatment of this category of patients, has achieved significant control over hyperkinesis in twins. Thus, molecular genetic diagnosis helps confirm the diagnosis of paroxysmal dyskinesias, but careful analysis of the clinical picture, considering the provoking factor, remains the basis of diagnosis.
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Affiliation(s)
- N A Ermolenko
- Burdenko Voronezh State Medical University, Voronezh, Russia
| | | | - V A Bykova
- Burdenko Voronezh State Medical University, Voronezh, Russia
| | - G S Golosnaya
- Burdenko Voronezh State Medical University, Voronezh, Russia
| | - O Yu Shiryaev
- Burdenko Voronezh State Medical University, Voronezh, Russia
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Currò CT, Nicocia G, Ziccone V, Ciacciarelli A, Russo G, Toscano A, Terranova C, Girlanda P. Pimozide and pancreatic cancer in diabetic chorea: a case report. Int J Neurosci 2022; 132:1217-1220. [PMID: 33491547 DOI: 10.1080/00207454.2021.1879063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 10/19/2020] [Accepted: 12/27/2020] [Indexed: 10/22/2022]
Abstract
PURPOSE/AIM Diabetic chorea is a rare movement disorder associated with diabetes mellitus. We report the case of a patient that benefited from pimozide and died of pancreatic cancer. CASE REPORT A 70-year-old woman presented with pollakiuria and involuntary movements of left limbs since three months. Laboratory tests revealed high serum levels of glycemia and glycated haemoglobin. She was admitted to internal medicine department and discharged one week later: insulin was administered with normalization of blood glucose levels and the involuntary movements gradually disappeared. Three weeks later she was admitted to neurological department due to the recurrence of the involuntary movements. Glycemia and other routine laboratory tests were normal. Neurological examination showed choreic movements involving left limbs. MRI showed a hyperintensity on T1- and T2-weighted sequences of right putamen and caudate nucleus head. Haloperidol was administered without improvement, it was successively substituted with tetrabenazine and the patient was discharged with an unvaried clinical picture. Two months later tetrabenazine was discontinued because of inefficacy and pimozide was started. The choreic movements considerably diminished after few days. Four months later, a pancreatic cancer was diagnosed and the patient died in the same month. CONCLUSION Clinical and radiological features were suggestive of diabetic chorea. Our patient benefited exclusively from pimozide, it could be reasonable to use pimozide in resistant form and also propose it as first choice treatment. Another important element is the diagnosis of pancreatic cancer some months after chorea onset: a causal link could exist.
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Affiliation(s)
- Carmelo Tiberio Currò
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giulia Nicocia
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Vanessa Ziccone
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Ciacciarelli
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Giuseppina Russo
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Toscano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Carmen Terranova
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paolo Girlanda
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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James M, Garosi L, Bessant C, Lowrie M. Phenotypic characterisation of paroxysmal dyskinesia in Sphynx cats. J Feline Med Surg 2022; 24:500-505. [PMID: 34313487 DOI: 10.1177/1098612x211032123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVES The aim of this study was to identify the phenotypic features of a paroxysmal dyskinesia observed in Sphynx cats. METHODS The owners of affected Sphynx cats were invited to provide video footage of abnormal episodes for review. Those that demonstrated episodes consistent with paroxysmal dyskinesia were then invited to complete an online questionnaire designed to allow further characterisation. RESULTS Ten Sphynx cats were included in the study. All affected cats were <4 years of age at the onset of the episodes (range 0.5-4.0). The episodes had a duration of <5 mins in 9/10 cats (range 0.5-10), while episode frequency was variable between and within individual cats. The episodes were characterised by impaired ambulation due to muscle hypertonicity, most commonly affecting the hips and pelvic limbs (9/10) and shoulders and thoracic limbs (8/10). The head and neck (6/10), tail (5/10), and back and abdomen (3/10) were also involved in some cats. Sudden movement, excitement and stress were identified as possible triggers for the episodes in three cats. Therapeutic intervention was not attempted in 7/10 cases, although two cats were reported to become free of the episodes while receiving acetazolamide. The two cats that were followed beyond 2 years from onset entered spontaneous remission. None of the owners believed that the abnormal episodes had affected the quality of life of their cat. CONCLUSIONS AND RELEVANCE The phenotype of paroxysmal dyskinesia in Sphynx cats presented in this study appears to share similarities with paroxysmal kinesigenic dyskinesia described in human classification systems. Some cats appear to achieve episode freedom spontaneously. Subsequent research should focus on evaluating response to treatment and determining an underlying genetic cause.
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Noguchi K, Arain N, Galloway C. Acute Rheumatic Fever: Case Report and Literature Review. S D Med 2022; 75:212-215. [PMID: 35724350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
A previously healthy 8-year-old Native American female presented with right-sided weakness and joint pain for two weeks. Following an initially unremarkable workup including negative brain and spine MRI she was noticed to have chorea and subsequently diagnosed with acute rheumatic fever (ARF). ARF is a group A streptococcus-related disease that most commonly is a sequelae of pharyngitis. The diagnosis of ARF utilizes the Jones criteria which includes heart disease, arthritis, chorea, the characteristic rash of erythema marginatum, and subcutaneous nodules. The most serious consequences of ARF include rheumatic heart disease and chorea. ARF can be treated with a combination of antibiotics and anti-inflammatories like aspirin.
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Affiliation(s)
- Ken Noguchi
- Department of Family Medicine, University of South Dakota Sanford School of Medicine
- Family Medicine Residency Program, Center for Family Medicine, Sioux Falls, South Dakota
| | - Nofil Arain
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
- Sanford Children's Hospital, Sioux Falls, South Dakota
| | - Carl Galloway
- Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota
- Sanford Children's Hospital, Sioux Falls, South Dakota
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Abstract
Diabetic Striatopathy (DS) is a rare complication of diabetes mellitus (DM) with poor glycemic control and typical neuroimaging findings. DS predominantly leads to a unilateral reversible injury of the basal ganglia resulting in various movement disorders such as hemichorea and hemibalismus. We present a rare case of DS with left-sided hemichorea as a first presentation for a newly diagnosed Diabetes Mellitus (DM) type II and to make a thorough review of this disorder and to provide a practical approach to its management. A 63-year-old female was admitted to the neurology ward with symptoms of involuntary hyperkinetic movements for the left limbs and the left half of the face. The blood samples revealed random serum glucose of 30.8 mmol/l and an HbA1c of 15.13%. The computed tomography of the brain showed asymmetric, unilateral hyperdensity in the right basal ganglia (BG) - the putamen and nucleus caudatus. The patient was managed with Insulin and Haloperidol as the symptoms entirely resolved on the tenth day. In conclusion (DS) is a condition with a good prognosis and reversible clinical and neuroimaging findings after a prompt diagnosis and management. DS should be considered a possible differential diagnosis in patients with abrupt onset of hyperkinetic movement disorders.
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Affiliation(s)
- Mihael Emilov Tsalta-Mladenov
- Department of Neurology and Neuroscience, Faculty of Medicine, Medical University "Prof. Paraskev Stoyanov", Varna, Bulgaria
- Second Clinic of Neurology with ICU and Stroke Unit, University Hospital "St. Marina", Varna, Bulgaria
| | - Darina Kirilova Georgieva
- Department of Neurology and Neuroscience, Faculty of Medicine, Medical University "Prof. Paraskev Stoyanov", Varna, Bulgaria
- Second Clinic of Neurology with ICU and Stroke Unit, University Hospital "St. Marina", Varna, Bulgaria
| | - Silva Peteva Andonova
- Department of Neurology and Neuroscience, Faculty of Medicine, Medical University "Prof. Paraskev Stoyanov", Varna, Bulgaria
- Second Clinic of Neurology with ICU and Stroke Unit, University Hospital "St. Marina", Varna, Bulgaria
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Gibson JS, Claassen DO. State-of-the-art pharmacological approaches to reduce chorea in Huntington's disease. Expert Opin Pharmacother 2021; 22:1015-1024. [PMID: 33550875 PMCID: PMC8222076 DOI: 10.1080/14656566.2021.1876666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/12/2021] [Indexed: 02/07/2023]
Abstract
Introduction Chorea is a common motor manifestation of Huntington's disease (HD). Two vesicular monoamine transporter type 2 (VMAT-2) inhibitors have been approved by the FDA for treatment of HD chorea, and a third is currently being assessed in a phase 3 trial. Antipsychotic therapies are used off-label for treatment of chorea and can treat comorbid psychiatric symptoms. There is considerable clinical equipoise regarding the safe and effective treatment of chorea and comorbid symptoms in HD.Areas covered: The authors review existing medications used to treat HD chorea in the United States of America (USA). Implications for common comorbid symptoms (e.g. psychiatric, metabolic) are also discussed. Available therapies vary widely in cost, dosing frequency, and off -target effects, both beneficial or negative.Expert opinion: Treatment considerations for chorea should account for patient comorbidities. The authors recommend prospective, observational clinical effectiveness studies which can evaluate the long-term comparative effectiveness and safety of VMAT-2 inhibitors and antipsychotics in HD. Data regarding safety of dual therapy is another critical need. This is especially timely given the changing landscape of HD therapies which may increase cost burden and possibly extend both asymptomatic and symptomatic years for HD patients.
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Affiliation(s)
| | - Daniel O. Claassen
- Department of Neurology, Division of Behavioral and Cognitive Neurology, Vanderbilt University Medical Center
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Ghosh R, Dubey S, Chatterjee S, Ghosh M, Ray BK, Benito-León J. Hypermanganesemia Induced Chorea and Cognitive Decline in a Tea Seller. Tremor Other Hyperkinet Mov (N Y) 2020; 10:45. [PMID: 33178484 PMCID: PMC7597573 DOI: 10.5334/tohm.537] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 10/06/2020] [Indexed: 01/02/2023] Open
Abstract
Background Manganese associated neurotoxicity and neurodegeneration is quite rare yet established neurological disorder. This neurotoxic element has predilection for depositing in basal ganglia structures, manifesting mainly as parkinsonian and dystonic movement disorders with behavioral abnormalities. Case report We report a 40-year-old man who presented with a subacute onset bilateral, asymmetric hyperkinetic movement disorder (predominantly left sided chorea) with multi-domain cognitive impairment, dysarthria, and generalized rigidity. Clinical history and examination yielded multiple differential diagnoses including deposition and metabolic disorders, autoimmune and paraneoplastic encephalitis involving basal ganglia, and neurodegenerative disorders with chorea and cognitive impairment. However, magnetic resonance imaging was suggestive of paramagnetic substance deposition, which came out to be manganese after laboratory investigations. History, clinical examinations, and investigation results pointed towards a diagnosis of acquired hypermanganesemia due to over-ingestion of manganese containing substance (i.e., black tea). He was treated symptomatically and with chelation therapy (calcium disodium edetate). At the sixth month of follow-up, complete resolution of chorea, dysarthria and partial amelioration of rigidity were observed. His cognitive decline and behavioral abnormalities improved. Discussion This is probably the first reported case of acquired hypermanganesemia that presented as a combination of asymmetric chorea and cognitive dysfunction with atypical imaging characteristics. The clinical picture mimicked that of Huntington's disease. We highlight the potential deleterious effects of an apparently "benign" non-alcoholic beverage (i.e., black tea) on cerebral metabolism.
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Affiliation(s)
- Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, IN
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, IN
| | - Subhankar Chatterjee
- Department of General Medicine, Rajendra Institute of Medical Sciences, Ranchi, IN
| | - Mrinalkanti Ghosh
- Department of Radiology, Burdwan Medical College, Burdwan, West Bengal, IN
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, Kolkata, IN
| | - Julián Benito-León
- Department of Neurology, University Hospital “12 de Octubre”, Madrid, ES
- Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, ES
- Department of Medicine, Complutense University, Madrid, ES
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Dubey S, Ghosh R, Dubey MJ, Sengupta S, Benito-León J, Ray BK. Bilateral thalamic changes in anti-NMDAR encephalitis presenting with hemichorea and dystonia and acute transient psychotic disorder. J Neuroimmunol 2020; 347:577329. [PMID: 32745805 PMCID: PMC7374132 DOI: 10.1016/j.jneuroim.2020.577329] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Revised: 07/16/2020] [Accepted: 07/16/2020] [Indexed: 11/24/2022]
Abstract
Anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis is one of the most common causes of autoimmune encephalitis. Both movement disorders and neuropsychiatric manifestations are considered core features of anti-NMDAR encephalitis. Strong clinical suspicion, along with NMDAR antibody positivity in paired sample of serum and cerebrospinal fluid, with supportive MRI changes clinch diagnosis in majority. We herein report a case of a middle-aged woman with subacute behavioral abnormalities, which were so severe that forced her to attempt suicide. Hemichorea and dystonia, which appeared later in course, are not previously reported movement disorders in combination in anti-NMDAR encephalitis. Further, magnetic resonance imaging showed bilateral thalamic hyperintensities with diffusion restriction, which are in turn not described in this entity. After amalgamation of history, especially the presence of neuropsychiatric symptoms, clinical features, physical examination, and investigations, the diagnosis of anti-NMDAR encephalitis could be established. Our case not only highlights that the combination of hemichorea and dystonia can be features of anti-NMDAR encephalitis, but adds novelty by bilateral symmetric thalamic changes.
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Affiliation(s)
- Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College, Burdwan, West Bengal, India
| | - Mahua Jana Dubey
- Department of Psychiatry, Berhampore Mental Hospital, Berhampore, West Bengal, India
| | - Samya Sengupta
- Department of General Medicine, Apollo Gleneagles Hospitals, Kolkata, West Bengal, India
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Centro de Investigación Biomédica en Red sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Universidad Complutense, Madrid, Spain.
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences (BIN), Kolkata, West Bengal, India
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Mikulenka P, Stetkarova I. Hemichorea in ketotic hyperglycemia with hyperdense striatum mimicking hemorrhagic transformation in a patient using apixaban. Neuro Endocrinol Lett 2020; 41:162-165. [PMID: 33307650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 09/23/2020] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Diabetic striatopathy is a rare condition characterized by unilateral hemichorea and/or hemiballismus in the settings of uncontrolled nonketotic diabetes mellitus. Imaging studies usually reveal striatal abnormality - subtle hyperdensity on CT and T1 hyperintensity on MRI. The resolution of clinical symptoms is prompt when optimal glycaemic control is achieved. CASE REPORT We present the case of a 90-year-old male who came to our attention for acute involuntary choreiform movements of his left-sided extremities lasting two-weeks. Apart from that neurological examination was unremarkable. His medical history included hypertension, atrial fibrillation, previous stroke with no residual disability and poorly controlled type 2 diabetes mellitus on metformin treatment. There was no history of movement disorders or exposure to neuroleptics. His glucose level on admission was 512.6 mg/dL, glycated hemoglobin was 14%. CT scan of the head demonstrated an abnormally increased intensity within the right striatum. Treatment consisted of symptomatic treatment of chorea and improvement of blood glucose control. Tiapride was started with a dose of 100 mg 4 times a day. The patient was initiated on intensive insulin therapy which included insulin glargine 10 units every evening and 12 units of insulin glulisine 3 times a day with meals. Abnormal movements resolved after normoglycemia was achieved approximately 7 days after admission. Though striatal hyperdensity was still present at follow-up CT scan after 10 days, it was less pronounced. CONCLUSION Diabetic striatopathy is a rare but treatable disorder and should be considered in patients with poorly controlled diabetes who present with hemichorea.
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Affiliation(s)
- Petr Mikulenka
- Department of Neurology, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
| | - Ivana Stetkarova
- Department of Neurology, Third Faculty of Medicine, Charles University and Faculty Hospital Kralovske Vinohrady, Prague, Czech Republic
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Abstract
Immune response against neuronal and glial cell surface and cytosolic antigens is an important cause of encephalitis. It may be triggered by activation of the immune system in response to an infection (para-infectious), cancer (paraneoplastic), or due to a patient's tendency toward autoimmunity. Antibodies directed toward neuronal cell surface antigens are directly pathogenic, whereas antibodies with intracellular targets may become pathogenic if the antigen is transiently exposed to the cell surface or via activation of cytotoxic T cells. Immune-mediated encephalitis is well recognized and may require intensive care due to status epilepticus, need for invasive ventilation, or dysautonomia. Patients with immune-mediated encephalitis may become critically ill and display clinically complex and challenging to treat movement disorders in over 80% of the cases (Zhang et al. in Neurocrit Care 29(2):264-272, 2018). Treatment options include immunotherapy and symptomatic agents affecting dopamine or acetylcholine neurotransmission. There has been no prior published guidance for management of these movement disorders for the intensivist. Herein, we discuss the immune-mediated encephalitis most likely to cause critical illness, clinical features and mechanisms of movement disorders and propose a management algorithm.
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Affiliation(s)
- Farwa Ali
- Department of Neurology, Mayo Clinic Rochester Minnesota, 200 1st ST SW, Rochester, MN, 55905, USA.
| | - Eelco F Wijdicks
- Department of Neurology, Mayo Clinic Rochester Minnesota, 200 1st ST SW, Rochester, MN, 55905, USA
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Abstract
PURPOSE OF REVIEW This article provides an overview of the approach to chorea in clinical practice, beginning with a discussion of the phenomenologic features of chorea and how to differentiate it from other movement disorders. The diagnostic approach, clinical features of important acquired and genetic choreas, and therapeutic principles are also discussed. Practical clinical points and caveats are included. RECENT FINDINGS C9orf72 disease is the most common Huntington disease phenocopy, according to studies in the European population. Anti-IgLON5 disease can present with chorea. The role of immunotherapies in Sydenham chorea has increased, and further clinical studies may be useful. Benign hereditary chorea is a syndrome or phenotype due to mutations in several genes, including NKX2-1, ADCY5, GNAO1, and PDE10A. New-generation presynaptic dopamine-depleting agents provide more options for symptomatic treatment of chorea with fewer adverse effects. Deep brain stimulation has been performed in several choreic disorders, but features other than chorea and the neurodegenerative nature should be taken into consideration. Studies on genetic interventions for Huntington disease are ongoing. SUMMARY Clinical features remain crucial in guiding the differential diagnosis and appropriate investigations in chorea. Given the complexity of most choreic disorders, treating only the chorea is not sufficient. A comprehensive and multidisciplinary approach is required.
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Hsiao PJ, Kuo CC, Kuo TY, Kao YH, Chan JS, Lin YY, Chen MH, Chen JS, Chuu CP. Investigation of the relationship between non-ketotic hyperglycemia and hemichorea-hemiballism: A case report. Medicine (Baltimore) 2019; 98:e16255. [PMID: 31305406 PMCID: PMC6641835 DOI: 10.1097/md.0000000000016255] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Po-Jen Hsiao
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
- Department of Life Sciences, National Central University, Taoyuan City
| | - Chih-Chun Kuo
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center
| | - Tai-You Kuo
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital
- Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Yung-Hsi Kao
- Department of Life Sciences, National Central University, Taoyuan City
| | - Jenq-Shyong Chan
- Department of Internal Medicine, Taoyuan Armed Forces General Hospital
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Yen-Yue Lin
- Department of Life Sciences, National Central University, Taoyuan City
- Department of Emergency Medicine, Taoyuan Armed Forces General Hospital, Taoyuan City
| | - Ming-Hua Chen
- Division of Neurology, Department of Internal Medicine, Taoyuan Armed Forces General Hospital
| | - Jin-Shuen Chen
- Division of Nephrology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei
| | - Chih-Pin Chuu
- Institute of Cellular and System Medicine, National Health Research Institutes, Miaoli County
- Graduate Program for Aging, China Medical University, Taichung City, Taiwan
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Gavish R, Straussberg R. A Rare Presentation of Postpump Hemichorea. Isr Med Assoc J 2019; 21:286-287. [PMID: 31032575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- Rachel Gavish
- Department of Pediatrics "C", Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Rachel Straussberg
- Department of Child Neurology, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Tidehag L, Kataja Knight A, Magnusson P, Sjöholm Å. [Hemichorea/hemiballism a rare complication of hyperglycemia]. Lakartidningen 2019; 116:FIEX. [PMID: 31192395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
We present a case of hemichorea/hemiballism, a rare complication of hyperglycemia. Diagnosis is made clinically by signs of unilateral involuntary movements of the extremities combined with typical neuroradiological findings in the basal ganglia. Guidelines for treatment of the condition are lacking but in many cases correction for hyperglycemia is sufficient for full symptom relief. In other cases, symptomatic treatment with haloperidol and tetrabenazine can be used.
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Affiliation(s)
- Ludvig Tidehag
- Centrum for Forskning och Utveckling - Gavle, Sweden Centrum for Forskning och Utveckling - Gavle, Sweden
| | - Agnes Kataja Knight
- Centrum for Forskning och Utveckling - Gavle, Sweden Centrum for Forskning och Utveckling - Gavle, Sweden
| | - Peter Magnusson
- Uppsala Universitet - Centrum för forskning och utveckling, Uppsala, Sweden, Region Gävleborg, Gävle Sweden Uppsala Universitet - Centrum för forskning och utveckling, Uppsala, Sweden Region Gävleborg, Gävle Sweden
| | - Åke Sjöholm
- Västmanlands sjukhus - Internmedicinska kliniken Köping, Sweden Västmanlands sjukhus - Internmedicinska kliniken Köping, Sweden
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Philip A, Klein D, Carrillo T, Greenstein J, Hahn B. A Female with Strange Movements. J Emerg Med 2018; 55:e81-e82. [PMID: 29960654 DOI: 10.1016/j.jemermed.2018.05.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 05/17/2018] [Accepted: 05/30/2018] [Indexed: 06/08/2023]
Affiliation(s)
- Alexander Philip
- Department of Emergency Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Daniel Klein
- Department of Radiology, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | | | - Josh Greenstein
- Department of Emergency Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York
| | - Barry Hahn
- Department of Emergency Medicine, Staten Island University Hospital, Northwell Health, Staten Island, New York
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Sung VW, Iyer RG, Gandhi SK, Shah-Manek B, DiBonaventura M, Abler V, Claassen DO. Physician perceptions of pharmacologic treatment options for chorea associated with Huntington disease in the United States. Curr Med Res Opin 2018; 34:643-648. [PMID: 29383957 DOI: 10.1080/03007995.2018.1435518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To survey neurologists and obtain clinical perceptions of tetrabenazine for the treatment of chorea in patients with Huntington disease (HD). METHODS Board-certified/board-eligible neurologists, in practice for ≥5 years, who had treated treat ≥3 HD patients in the past 2 years, were recruited from an online physician panel to participate in a cross-sectional, web-based survey. Respondents provided information about themselves, their practice, approaches to HD chorea management and perceptions of available treatments. RESULTS Two hundred neurologists responded to the survey. Based on clinician responses, the most common reasons to treat chorea are impairment in activities of daily living (54%) and quality of life (41%). Although tetrabenazine was the only approved treatment for chorea in HD patients at the time of this analysis, it was only prescribed to ∼50% of patients with HD-related chorea. More than half of physicians perceive tetrabenazine as having minimal or no effectiveness in improving chorea. More than 40% of physicians consider tetrabenazine to be a non-optimal treatment, and 51% of physicians agree that they are unable to titrate to efficacious doses due to adverse side effects or tolerability concerns. Physicians report that side effects leading to dose interruptions (33%) and reductions (30%) occur in their patients "often" or "almost always". The most common side effects that led to insufficient dosing and disruptions in titration were sedation and somnolence (41%), depression (24%) and anxiety (22%). CONCLUSIONS Many physicians who treat HD-related chorea report that tolerability issues with tetrabenazine impact their ability to effectively use tetrabenazine in their clinical practice.
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Affiliation(s)
- Victor W Sung
- a University of Alabama School of Medicine , Birmingham , AL , USA
| | - Ravi G Iyer
- b Teva Pharmaceutical Industries , Frazer , PA , USA
| | | | | | | | - Victor Abler
- b Teva Pharmaceutical Industries , Frazer , PA , USA
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Abstract
Pharmacological treatment is the cornerstone in the management of movement disorders. Although most available treatment options have no impact on the underlying process of each movement disorder, symptomatic therapies can significantly improve patient's quality of life and level of disability. Here, we review the current knowledge on clinical symptomatic management of Parkinson's disease (both early and advanced stages), essential tremor, dystonia, and chorea. Ideally, treatment should be carried out by specialists with reasonable experience in movement disorders, as it needs to be tailored for each patient depending on several appraisals, including but not limited to patients' needs, compliance issues, potential side effects, caregiver support, and presence of comorbidities. When medications fail to improve patient's disability, stereotactic surgery is a well-established option for most of these disorders.
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Gontarz M, Papuć E, Rejdak K. [Paroxysmal dyskinesias - disorder categories, their causes and treatment]. Wiad Lek 2018; 71:1056-1060. [PMID: 30176640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Paroxysmal dyskinesias refer to category of abnormal involuntary movements, such as chorea, dystonia, athetosis, ballism or their various configurations. Depending on the type of seizure, sudden movement, stress, emotions, coffee or alcohol may be the trigger factors. Acute seizures are characterized by short duration and are self-limitated. Patients present correct portray of movements between seizures. Intact consciousness during seizure is the invariable characteristic of all paroxysmal dyskinesias. The intent of this work is to systematize knowledge about paroxysmal dyskinesias. This research includes synthetic information developed based on specialistic literature cencerned with paroxysmal movement disorders. The authors focused primarily on characteristics of the most important issues in this area, into which types of disorders, their causes and treament as well as psychopathology aspect having crucial influence on patients' life comfort were included. The essence of three categories of seizures were put across more extesively: paroxysmal kinesigenic dyskinesia, proxysmal non-kinesigenic dyskinesia and paroxysmal exercise-induced dyskinesia. Primary dyskinesias with genetic basis and secondary to other diseases, such as multiple sclerosis were distinguished. Modes of pharmacological treatment with antiepileptic drug and benzodiazepines were described. Special concern was put on holistic approach to problem of diagnosis and treatment of analyzed movement disorders.
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Affiliation(s)
| | - Ewa Papuć
- Klinika Neurologii Spsk4 W Lublinie, Lublin, Polska
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Gómez-Ochoa SA, Espín-Chico BB, Pinilla-Monsalve GD, Kaas BM, Téllez-Mosquera LE. Clinical and neuroimaging spectrum of hyperglycemia-associated chorea-ballism: systematic review and exploratory analysis of case reports. Funct Neurol 2018; 33:175-187. [PMID: 30663963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Hyperglycemia-associated chorea-ballism (HCB) is an infrequent neurological syndrome occurring predominantly in elderly females and in the setting of non-ketotic hyperglycemia (NKH). A systematic review was conducted in accordance with the PRISMA statement. Studies published between 1980 and 2018 that reported demographic, clinical, laboratory and imaging features from patients with HCB were screened. 136 studies describing 286 patients were included in the analysis. The patients included had a median age of 72 years; those with ketotic hyperglycemia (KH) were older (p<0.001). Women and NKH patients were the most frequently affected (63% and 92%, respectively). The median glucose level at admission was 420 mg/dL (IQR 328-535), and was significantly higher in KH (p=0.009). Moreover, the absence of a clear lesion on imaging studies and the finding of bilateral imaging evidence of lesions were each more frequent in the KH group (p=0.036 and p=0.008, respectively). 48 cases (19.4%) presented with bilateral CT/MRI lesions, having higher values of plasma osmolarity compared with the patients with unilateral lesions (p=0.011). Every patient received hypoglycemic treatment, but only 174 (60.84%) were prescribed neuroleptics. 213 patients (84.86%) showed a total recovery, after a median of 14 days (IQR 3-31). Bilateral chorea-ballism was supported by bilateral imaging evidence of involvement in only 60% of the cases (positive predictive value). Patients not prescribed neuroleptics, with negative lentiform nucleus involvement, and age within the third tertile (≥ 78 years) had an odds ratio of 6.6 (CI 95% 1.18-141.10) for a complete clinical recovery. Significant differences were identified between types of hyperglycemia and regarding the clinical and imaging laterality features. Furthermore, the predictor variables evaluated showed potential utility for assessing the prognosis of HCB patients.
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Hu Y, Zhou Y, Yi F, Yao L, Xu H, Zhou L. [Clinical characteristics of hemichorea associated with non-ketotic hyperglycemia in 3 patients: case report and literature review]. Zhong Nan Da Xue Xue Bao Yi Xue Ban 2017; 42:1341-1347. [PMID: 29187664 DOI: 10.11817/j.issn.1672-7347.2017.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
To investigate the pathophysiology, clinical manifestation and neuroimaging characteristics and therapeutic experiences for hemichore associated with non-ketotic hyperglycemia (HC-NH).
Methods: Clinical data of three patients with HC-NH from Xiangya Hospital, Central South University were analyzed retrospectively, and the related literature was reviewed.
Results: The core clinical features of HC-NH were characterized by acute/subacute onset of hemichorea with non-ketotic hyperglycemia in the elderly females. Radiologic findings associated with HC-NH were characterized by hyperattenuation on computed tomographic (CT) scans and hyperintensity on T1-weighted magnetic resonance imaging (MRI) at unilateral basal ganglion region. Blood glucose control was the foundation of treatment. Dopamine receptor antagonists and benzodiazepine sedative were helpful in controlling hemichorea.
Conclusion: Hemichorea-hemiballismus is a rare complication of nonketotic hyperglycaemia in elderly type 2 diabetes. It is associated with contralateral striatal radiological abnormality and typically T1 hyperintensity on MRI. The pathophysiology of HC-NH is not clear. The prognosis of HC-NH is favorable. Antidiabetic drugs combined with dopamine receptor antagonists can effectively relieve the hemichorea symptoms.
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Affiliation(s)
- Yacen Hu
- Department of Geriatric Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Yafang Zhou
- Department of Geriatric Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Fang Yi
- Department of Geriatric Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Lingyan Yao
- Department of Geriatric Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Hongwei Xu
- Department of Geriatric Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Lin Zhou
- Department of Geriatric Neurology, Xiangya Hospital, Central South University, Changsha 410008, China
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Abstract
INTRODUCTION This is a unique case of nonketotic hyperglycemic (NKH) chorea in 84-year-old Asian woman. The patient had a history of type 2 diabetes mellitus more than 30 years, but had a poor control of blood sugar. She complained of acute onset of bilateral limb involuntary activities, and being easy to fall within a week. Laboratory testing disclosed hyperglycemia (669 mg/dL), glycated hemoglobin (14%), and normal ketones. The brain computed tomography scan and magnetic resonance imaging did not disclose any abnormality in the basal ganglion unlike most cases. The patient was then diagnosed with NKH chorea. Her symptoms improved quickly. CONCLUSIONS NKH chorea with normal imaging may represent a new subtype.
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Hald SM, Krone W, Minhas ZA, Gaist D. [A stroke mimic: hemichorea associated with non-ketotic hyperglycaemia]. Ugeskr Laeger 2017; 179:V01170006. [PMID: 28504621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
An 85-year-old man with a history of diabetes was admitted with acute onset hemichorea. Laboratory findings confirmed poorly controlled diabetes. A brain computed tomography (CTC) revealed contralateral striatal hyperdensity. The findings were compatible with hyperglycaemia-induced hemichorea, and antidiabetic and symptomatic treatment was initiated. The symptoms remitted completely after six days, and a follow-up CTC showed partial resolution of the striatal changes. This case illustrates the importance of considering if hyperglycaemia is the cause of hemichorea, as early diagnosis and treatment yield an excellent prognosis.
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Bouchal S, Ouali O, Belahsen MF. Réponse spectaculaire au valproate de sodium d’une chorée de Sydenham récurrente. Pan Afr Med J 2017; 27:212. [PMID: 28979614 PMCID: PMC5622842 DOI: 10.11604/pamj.2017.27.212.11383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 12/19/2016] [Indexed: 11/29/2022] Open
Abstract
La chorée du Sydenham est la première cause de chorée acquise dans le tiers monde. Nous rapportons le cas d'une Chorée récurrente traitée avec succès par le valproate du sodium. Mlle A.C âgée de 16 ans ayant comme antécédents des angines à répétition et un épisode de mouvement choréique il y a 2 ans, pour lequel elle a été mise sous Halopéridol et sous prévention du rhumatisme articulaire aigu. La patiente a interrompue le traitement et quelques mois plus tard elle a présenté le même tableau neurologique. L'IRM cérébrale et l'échographie transthoracique étaient normales. La prévention par Extencilline a été réinstaurée ainsi que l'halopéridol sans aucune amélioration, d'où la mise en route sous valproate de sodium. La réponse était spectaculaire après 2 mois de traitement sans récidive après 3ans de recul. Le traitement de la chorée du Sydenham était les neuroleptiques. Des études récentes préconisent d'autres molécules efficaces et mieux tolérées.
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Affiliation(s)
| | - Ouarda Ouali
- Service de Neurologie, CHU Hassan II, Fès, Maroc
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Shafran I, Greenberg G, Grossman E, Leibowitz A. Diabetic striatopathy-Does it exist in non-Asian subjects? Eur J Intern Med 2016; 35:51-54. [PMID: 27296589 DOI: 10.1016/j.ejim.2016.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 05/09/2016] [Accepted: 05/25/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diabetic striatopathy (DS) is a rare complication of diabetes mellitus (DM). The syndrome appears in patients with uncontrolled DM and is characterized by abrupt onset of movement disorder, mainly hemichorea and accompanied by specific findings on brain imaging. It is believed that DS is unique to the Asian population and affects mainly elderly women with uncontrolled DM. METHODS In order to define existence and characterization of DS in Western population, we reviewed the medical records of all patients admitted to the Chaim Sheba Medical Center between 2004 and 2014 and identified those with documented elevated HbA1c (>10%). The charts and imaging studies of those with elevated HbA1c and undiagnosed neurological symptoms were reviewed to diagnose DS. RESULTS Out of 697 patients with HbA1c>10%, 328 patients had unknown neurological diagnosis. Among them, we identified 4 patients (3 women, mean age 73 and mean HbA1c of 14.8%) with hemichorea or choreoathetosis and brain imaging findings compatible with the diagnosis of DS. Only one out of the 4 patients was diagnosed during hospitalization with DS. All patients were treated with insulin with improvement of their symptoms during hospitalization. However, there was a recurrence in 2 of them and 1 died during the second episode. CONCLUSION Diabetic striatopathy exists but underdiagnosed in the Western population. It is important to increase the awareness for this clinical syndrome in order to treat those patients properly.
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Affiliation(s)
- Inbal Shafran
- Internal Medicine D, the Chaim Sheba Medical Center, Tel-Hashomer, Israel(1)
| | - Gahl Greenberg
- Radiology Department, the Chaim Sheba Medical Center, Tel-Hashomer, Israel(1)
| | - Ehud Grossman
- Internal Medicine D, the Chaim Sheba Medical Center, Tel-Hashomer, Israel(1)
| | - Avshalom Leibowitz
- Internal Medicine D, the Chaim Sheba Medical Center, Tel-Hashomer, Israel(1).
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Frank S, Testa CM, Stamler D, Kayson E, Davis C, Edmondson MC, Kinel S, Leavitt B, Oakes D, O'Neill C, Vaughan C, Goldstein J, Herzog M, Snively V, Whaley J, Wong C, Suter G, Jankovic J, Jimenez-Shahed J, Hunter C, Claassen DO, Roman OC, Sung V, Smith J, Janicki S, Clouse R, Saint-Hilaire M, Hohler A, Turpin D, James RC, Rodriguez R, Rizer K, Anderson KE, Heller H, Carlson A, Criswell S, Racette BA, Revilla FJ, Nucifora F, Margolis RL, Ong M, Mendis T, Mendis N, Singer C, Quesada M, Paulsen JS, Brashers-Krug T, Miller A, Kerr J, Dubinsky RM, Gray C, Factor SA, Sperin E, Molho E, Eglow M, Evans S, Kumar R, Reeves C, Samii A, Chouinard S, Beland M, Scott BL, Hickey PT, Esmail S, Fung WLA, Gibbons C, Qi L, Colcher A, Hackmyer C, McGarry A, Klos K, Gudesblatt M, Fafard L, Graffitti L, Schneider DP, Dhall R, Wojcieszek JM, LaFaver K, Duker A, Neefus E, Wilson-Perez H, Shprecher D, Wall P, Blindauer KA, Wheeler L, Boyd JT, Houston E, Farbman ES, Agarwal P, Eberly SW, Watts A, Tariot PN, Feigin A, Evans S, Beck C, Orme C, Edicola J, Christopher E. Effect of Deutetrabenazine on Chorea Among Patients With Huntington Disease: A Randomized Clinical Trial. JAMA 2016; 316:40-50. [PMID: 27380342 DOI: 10.1001/jama.2016.8655] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
IMPORTANCE Deutetrabenazine is a novel molecule containing deuterium, which attenuates CYP2D6 metabolism and increases active metabolite half-lives and may therefore lead to stable systemic exposure while preserving key pharmacological activity. OBJECTIVE To evaluate efficacy and safety of deutetrabenazine treatment to control chorea associated with Huntington disease. DESIGN, SETTING, AND PARTICIPANTS Ninety ambulatory adults diagnosed with manifest Huntington disease and a baseline total maximal chorea score of 8 or higher (range, 0-28; lower score indicates less chorea) were enrolled from August 2013 to August 2014 and randomized to receive deutetrabenazine (n = 45) or placebo (n = 45) in a double-blind fashion at 34 Huntington Study Group sites. INTERVENTIONS Deutetrabenazine or placebo was titrated to optimal dose level over 8 weeks and maintained for 4 weeks, followed by a 1-week washout. MAIN OUTCOMES AND MEASURES Primary end point was the total maximal chorea score change from baseline (the average of values from the screening and day-0 visits) to maintenance therapy (the average of values from the week 9 and 12 visits) obtained by in-person visits. This study was designed to detect a 2.7-unit treatment difference in scores. The secondary end points, assessed hierarchically, were the proportion of patients who achieved treatment success on the Patient Global Impression of Change (PGIC) and on the Clinical Global Impression of Change (CGIC), the change in 36-Item Short Form- physical functioning subscale score (SF-36), and the change in the Berg Balance Test. RESULTS Ninety patients with Huntington disease (mean age, 53.7 years; 40 women [44.4%]) were enrolled. In the deutetrabenazine group, the mean total maximal chorea scores improved from 12.1 (95% CI, 11.2-12.9) to 7.7 (95% CI, 6.5-8.9), whereas in the placebo group, scores improved from 13.2 (95% CI, 12.2-14.3) to 11.3 (95% CI, 10.0-12.5); the mean between-group difference was -2.5 units (95% CI, -3.7 to -1.3) (P < .001). Treatment success, as measured by the PGIC, occurred in 23 patients (51%) in the deutetrabenazine group vs 9 (20%) in the placebo group (P = .002). As measured by the CGIC, treatment success occurred in 19 patients (42%) in the deutetrabenazine group vs 6 (13%) in the placebo group (P = .002). In the deutetrabenazine group, the mean SF-36 physical functioning subscale scores decreased from 47.5 (95% CI, 44.3-50.8) to 47.4 (44.3-50.5), whereas in the placebo group, scores decreased from 43.2 (95% CI, 40.2-46.3) to 39.9 (95% CI, 36.2-43.6), for a treatment benefit of 4.3 (95% CI, 0.4 to 8.3) (P = .03). There was no difference between groups (mean difference of 1.0 unit; 95% CI, -0.3 to 2.3; P = .14), for improvement in the Berg Balance Test, which improved by 2.2 units (95% CI, 1.3-3.1) in the deutetrabenazine group and by 1.3 units (95% CI, 0.4-2.2) in the placebo group. Adverse event rates were similar for deutetrabenazine and placebo, including depression, anxiety, and akathisia. CONCLUSIONS AND RELEVANCE Among patients with chorea associated with Huntington disease, the use of deutetrabenazine compared with placebo resulted in improved motor signs at 12 weeks. Further research is needed to assess the clinical importance of the effect size and to determine longer-term efficacy and safety. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01795859.
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Affiliation(s)
| | | | | | | | - Elise Kayson
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, New York
| | | | | | | | - Blair Leavitt
- Centre of Molecular Medicine and Therapeutics, University of British Columbia, Vancouver, Canada
| | - David Oakes
- University of Rochester, Rochester, New York
| | | | | | - Jody Goldstein
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, New York
| | - Margaret Herzog
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, New York
| | - Victoria Snively
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, New York
| | - Jacquelyn Whaley
- Center for Human Experimental Therapeutics, University of Rochester, Rochester, New York
| | | | - Greg Suter
- Hereditary Neurological Disease Centre, Wichita, Kansas
| | | | | | | | | | - Olivia C Roman
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Victor Sung
- University of Alabama School of Medicine, Birmingham, Alabama
| | - Jenna Smith
- University of Alabama School of Medicine, Birmingham, Alabama
| | | | | | | | - Anna Hohler
- Boston University Medical Campus, Boston, Massachusetts
| | - Denyse Turpin
- Boston University Medical Campus, Boston, Massachusetts
| | | | - Ramon Rodriguez
- University of Florida College of Medicine, Gainesville, Florida
| | - Kyle Rizer
- University of Florida College of Medicine, Gainesville, Florida
| | | | | | | | - Susan Criswell
- Washington University School of Medicine, St Louis, Missouri
| | - Brad A Racette
- Washington University School of Medicine, St Louis, Missouri
| | - Fredy J Revilla
- Greenville Health System, Greenville, South Carolina22University of South Carolina Medical School, Greenville, South Carolina
| | | | | | - MaryJane Ong
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tilak Mendis
- Ottowa Parkinson's and Neurodegenerative Disorders Clinic, Ottawa, Canada
| | - Neila Mendis
- Ottowa Parkinson's and Neurodegenerative Disorders Clinic, Ottawa, Canada
| | | | | | - Jane S Paulsen
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Amanda Miller
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | - Jane Kerr
- University of Iowa Carver College of Medicine, Iowa City, Iowa
| | | | - Carolyn Gray
- University of Kansas Medical Center, Kansas City
| | | | | | - Eric Molho
- Albany Medical College, Albany, New York
| | - Mary Eglow
- Albany Medical College, Albany, New York
| | | | - Rajeev Kumar
- Rocky Mountain Movement Disorders Center, Englewood, Colorado
| | | | - Ali Samii
- University of Washington, Seattle, Washington
| | - Sylvain Chouinard
- Centre hospitalier de l'Université de Montréal, Montreal, Québec, Canada
| | | | | | | | | | - Wai Lun Alan Fung
- North York General Hospital, Toronto, Canada35University of Toronto, Toronto, Ontario, Canada36Toronto General Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Clare Gibbons
- North York General Hospital, Toronto, Canada35University of Toronto, Toronto, Ontario, Canada
| | - Lina Qi
- North York General Hospital, Toronto, Canada
| | - Amy Colcher
- Cooper University Hospital, Camden, New Jersey
| | | | | | - Kevin Klos
- The Movement Disorders Clinic Oklahoma, Tulsa
| | | | - Lori Fafard
- South Shore Neurologic Associates, Islip, New York
| | | | | | - Rohit Dhall
- Parkinson's Institute and Clinical Center, Sunnyvale, California
| | | | | | | | | | | | - David Shprecher
- University of Utah Health Care, Salt Lake City, Utah46Banner Sun Health Research Institute, Sun City, Arizona
| | - Paola Wall
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Lynn Wheeler
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James T Boyd
- University of Vermont Medical Center, Burlington, Vermont
| | - Emily Houston
- University of Vermont Medical Center, Burlington, Vermont
| | | | - Pinky Agarwal
- Evergreen Neuroscience Institute, Kirkland, Washington
| | | | | | | | - Andrew Feigin
- Feinstein Institute for Medical Research, Manhasset, New York
| | | | - Chris Beck
- University of Rochester, Rochester, New York
| | | | - Jon Edicola
- University of Rochester, Rochester, New York
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Espinoza López DA, Serrano Rubio AA, Perdomo Pantoja A. Cerebral cavernous malformation in a woman presenting with hemichorea: Response to haloperidol. Neurologia 2016; 32:554-556. [PMID: 26964513 DOI: 10.1016/j.nrl.2015.12.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 07/24/2015] [Accepted: 12/21/2015] [Indexed: 11/19/2022] Open
Affiliation(s)
- D A Espinoza López
- Departamento de Neurología, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México D.F., México
| | - A A Serrano Rubio
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México D.F., México
| | - A Perdomo Pantoja
- Departamento de Neurocirugía, Instituto Nacional de Neurología y Neurocirugía Manuel Velasco Suárez, México D.F., México.
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Gregorowski C, Lochner C, Martin L, Simmons C, Kidd M, Walker K, Wilmshurst JM, Seedat S. Neuropsychological manifestations in children with Sydenham's chorea after adjunct intravenous immunoglobulin and standard treatment. Metab Brain Dis 2016; 31:205-12. [PMID: 25987537 DOI: 10.1007/s11011-015-9681-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
This was an exploratory study comparing neuropsychological manifestations of Sydenham's chorea (SC), 6 months after initiation of treatment, in children who had received intravenous immunoglobulins as an adjunct to standard treatment, with those who had received standard treatment. We included a non-SC control group for comparison. We hypothesized that compared to controls, children with SC who had received prior intravenous immunoglobulins would demonstrate less pronounced impairments compared to those who had received standard care. We conducted a cross-sectional analysis of 17 children with -SC who had received treatment 6 months previously (9 treated with standard of care and 8 augmented with intravenous immunoglobulins) and 17 non-SC, medically well controls. The standard treatment group (n = 9) exhibited significant behavioral difficulties, including significantly poorer co-operation (p = 0.009) compared with the other augmented immunoglobulins and non-SC control groups, and increased impulsivity (p = 0.016) compared with non-SC controls. The standard treatment group scored significantly lower than the other two groups on a measure of executive functioning (p = 0.03). Children with SC may be more at risk for neuropsychological difficulties than non-SC, medically well children. Intravenous immunoglobulins may mitigate some of these impairments.
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Affiliation(s)
- Claire Gregorowski
- Department of Psychiatry, University of Stellenbosch, P.O. Box 19063, Tygerberg, 7505, South Africa
| | - Christine Lochner
- US/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa
| | - Lindi Martin
- Department of Psychiatry, University of Stellenbosch, P.O. Box 19063, Tygerberg, 7505, South Africa
| | - Candice Simmons
- Department of Psychiatry, University of Stellenbosch, P.O. Box 19063, Tygerberg, 7505, South Africa.
| | - Martin Kidd
- Centre for Statistical Consultation, Department of Statistics & Actuarial science, University of Stellenbosch, Tygerberg, South Africa
| | - Kathleen Walker
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, School of Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Soraya Seedat
- Department of Psychiatry, University of Stellenbosch, P.O. Box 19063, Tygerberg, 7505, South Africa
- US/UCT MRC Unit on Anxiety & Stress Disorders, Department of Psychiatry, University of Stellenbosch, Tygerberg, South Africa
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Benrhouma H, Nasri A, Kraoua I, Klaa H, Turki I, Gouider-Khouja N. [Post-herpes simplex encephalitis chorea: Viral replication or immunological mechanism?]. Arch Pediatr 2015. [PMID: 26216066 DOI: 10.1016/j.arcped.2015.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Herpes simplex encephalitis is a severe neurological condition, whose outcome is improved if treated early with acyclovir. Post-herpes simplex encephalitis with acute chorea has rarely been reported. CASE REPORT We report on two observations of children presenting with post-herpes simplex encephalitis with acute chorea, related to two different pathophysiological mechanisms. The first one is an 11-month-old girl developing relapsing herpes simplex encephalitis with chorea due to resumption of viral replication. The second one is a 2-year-old boy with relapsing post-herpes simplex encephalitis acute chorea caused by an immunoinflammatory mechanism. We discuss the different neurological presentations of herpetic relapses, notably those presenting with movement disorders, as well as their clinical, paraclinical, physiopathological, and therapeutic aspects. CONCLUSION Post-herpes simplex encephalitis with acute chorea may involve two mechanisms: resumption of viral replication or an immunoinflammatory mechanism. Treatment of post-herpes simplex encephalitis with acute chorea depends on the underlying mechanism, while prevention is based on antiviral treatment of herpes simplex encephalitis with acyclovir at the dose of 20mg/kg/8h for 21 days.
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Affiliation(s)
- H Benrhouma
- UR 06/11, service de neurologie de l'enfant et de l'adolescent, Institut national de neurologie Mongi Ben Hmida de Tunis, 1007 Tunis, Tunisie.
| | - A Nasri
- UR 06/11, service de neurologie de l'enfant et de l'adolescent, Institut national de neurologie Mongi Ben Hmida de Tunis, 1007 Tunis, Tunisie
| | - I Kraoua
- UR 06/11, service de neurologie de l'enfant et de l'adolescent, Institut national de neurologie Mongi Ben Hmida de Tunis, 1007 Tunis, Tunisie
| | - H Klaa
- UR 06/11, service de neurologie de l'enfant et de l'adolescent, Institut national de neurologie Mongi Ben Hmida de Tunis, 1007 Tunis, Tunisie
| | - I Turki
- UR 06/11, service de neurologie de l'enfant et de l'adolescent, Institut national de neurologie Mongi Ben Hmida de Tunis, 1007 Tunis, Tunisie
| | - N Gouider-Khouja
- UR 06/11, service de neurologie de l'enfant et de l'adolescent, Institut national de neurologie Mongi Ben Hmida de Tunis, 1007 Tunis, Tunisie
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Shtemer IS, Grinberg G, Grossman E. [A rare neurologic syndrome due to a common medical condition]. Harefuah 2015; 154:81-138. [PMID: 25856857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We describe a patient with hypertension, diabetes mellitus, recurrent strokes, congestive heart failure, chronic atrial fibrillation and renal failure,who was hospitalized twice for chorea. A thorough work-up excluded all common causes for chorea in the elderly. The patient's HbA1c was > 17% and the brain computerized tomography revealed dense lesions in the basal ganglia compatible with Chorea Hyperglycemia Basal Ganglia syndrome. This syndrome includes a combination of chorea, hyperglycemia and dense lesions in the basal ganglia. The hemichorea in this syndrome is provoked by non-ketotic hyperglycemia and improves with insulin treatment. The radiographic picture also improves after there is control of glucose levels and clinical improvement.
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Sen A, Atakli D, Guresci B, Arpaci B. A rare paroxysmal movement disorder: mixed type of paroxysmal dyskinesia. Ideggyogy Sz 2014; 67:426-429. [PMID: 25720246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
Paroxysmal dyskinesias are rare, heterogeneous group of disorders characterised by recurrent attacks of involuntary movements. The four classic categories of paroxysmal dyskinesias are kinesigenic, nonkinesigenic, exercise-induced and hypnogenic. There are some patients that do not fit in these four groups of paroxysmal dyskinesia and are termed as "mixed type". We describe a 13-year-old girl who had features of both paroxysmal kinesigenic dyskinesia and paroxysmal nonkinesigenic dyskinesia that was misdiagnosed as refractory epilepsy. She improved substantially with a combination of carbamazepine and clonazepame. It is important to recognize the clinical presentation of paroxysmal dyskinesias and distinguish these movement disorders from other disorders, such as psychogenic disorders and epilepsia, for deciding the treatment and prognosis of the patients. This case highlights the importance of the recognition of a rare paroxysmal movement disorders.
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Williams KA, Swedo SE. Post-infectious autoimmune disorders: Sydenham's chorea, PANDAS and beyond. Brain Res 2014; 1617:144-54. [PMID: 25301689 DOI: 10.1016/j.brainres.2014.09.071] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Revised: 09/26/2014] [Accepted: 09/29/2014] [Indexed: 12/29/2022]
Abstract
Infections, and the resulting immune response to these infections, have recently received increased recognition as pathogenic mechanisms for neuropsychiatric disorders. Sydenham's chorea (SC), a widely recognized post-streptococcal autoimmune disorder, represents a model for this proposed pathogenesis. In SC, a dysregulated immune response to a streptococcal infection is hypothesized to result in inflammation of neuronal networks, particularly the basal ganglia nuclei. The resulting dysfunction in the basal ganglia nuclei are hypothesized to lead to a constellation of adventitious movements and psychiatric symptoms, which investigations have shown are amenable to immunomodulatory therapies. PANDAS (Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infections) has been proposed as a variant of SC, and is hypothesized to share a pathogenic mechanism, despite a unique symptom profile of predominantly psychiatric symptoms. In this review, we present the clinical aspects of both disorders, the data for potential shared etiopathogenesis between them, and the evidence for the therapeutic use of immunomodulatory therapies for the symptoms of SC and PANDAS. This article is part of a Special Issue entitled SI: Neuroimmunology in Health And Disease.
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Affiliation(s)
- Kyle A Williams
- Pediatric Neuropsychiatry and Immunology Clinic, Department of Psychiatry, Massachusetts General Hospital, MA, United States; Department of Psychiatry, Harvard Medical School, MA 02114, United States.
| | - Susan E Swedo
- Pediatrics and Developmental Neuroscience Branch, National Institute of Mental Health, National Institutes of Health, MA, United States
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Sasaki H, Ito K, Furusaki A, Amasaki Y, Abe T. [Case report; Chorea as the first manifestation of systemic lupus erythematosus associated with anti-phospholipid syndrome]. Nihon Naika Gakkai Zasshi 2014; 103:744-746. [PMID: 24796148 DOI: 10.2169/naika.103.744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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