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 Table of Contents 
CASE REPORT
Year : 2013  |  Volume : 2  |  Issue : 3  |  Page : 296-297  

Hemichorea-hemiballism in a nonketotic diabetic patient


Department of Medicine, Thengamara Mohila Sabuj Sangha Medical College and Rafatullah Community Hospital, Bogra, Bangladesh

Date of Web Publication29-Oct-2013

Correspondence Address:
Ahmed Al Montasir
Resident Physician, Department of Medicine, TMSS Medical College & Rafatullah Community Hospital, Bogra - 5800
Bangladesh
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2249-4863.120772

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  Abstract 

Hemichorea-hemiballism can be the solely presentation of a wide range of non-neurological clinical pictures, such as metabolic or hydro-electrolyte derange­ments. Hemichorea-hemiballism as the first presentation of type 2 diabetes mellitus has been described. The case depicted herein reinforces this association highlighting that especially in elder patients with new­ly diagnosed hemichorea-hemiballism, non-ketotic hyperglycemia should promptly be recognized.

Keywords: Diabetes mellitus, hemichorea-hemiballism, putamen


How to cite this article:
Al Montasir A, Sadik MH. Hemichorea-hemiballism in a nonketotic diabetic patient. J Family Med Prim Care 2013;2:296-7

How to cite this URL:
Al Montasir A, Sadik MH. Hemichorea-hemiballism in a nonketotic diabetic patient. J Family Med Prim Care [serial online] 2013 [cited 2019 May 22];2:296-7. Available from: http://www.jfmpc.com/text.asp?2013/2/3/296/120772


  Introduction Top


Diabetes is common all over the world. It leads to complications related to every system of the body. Movement disorders namely chorea, hemiballismus-hemichorea, and choreoathetosis can be induced by hyperglycemia. Early recognition of hyperglycemia induced movement disorders is important, as hyperglycemia is an easily treatable disorder and these carries a good prognosis. [1] It should also be noted that movement disorders can be one of the presenting feature of diabetes mellitus. Hence, screening all patients who present with involuntary movements for hyperglycemia, even in patients without a previous history of diabetes is important. [1] We hereby report an interesting case of hemichorea-hemiballism due to hyperglycemia with complete remission of symptoms after control of blood sugar level.


  Case Report Top


A 67-year-old male normotensive, nonsmoker, and diabetic patient presented with involuntary movements of left side of the body. He was known diabetic for 10 years and on good control with oral gliclazide preparation. Recently, he discontinued the medication for 5 days without any reason. His family members mentioned that the patient was reasonably well till the evening he presented. There was no history of fever or intake of any other drugs. Patient was oriented, conscious, and vital signs were normal. Patient was violently moving his left sided limbs [Video 1]. Routine investigations were in normal limit except blood glucose was 35 mmol/l. There were no ketone bodies in urine. Computed tomography (CT) brain showed nonenhancing hyperdensities in the right sided basal ganglia region. Controlling of blood glucose reduced the intensity of movements. Oral tetrabenazine added prior to discharge from hospital. A follow-up visit after 4 weeks showed no residual movements.




  Discussion Top


Movement disorders have been documented with diabetes mellitus. [1],[2],[3],[4],[5],[6],[7],[8] These involuntary movements can be due to hereditary reasons, drugs, metabolic causes-hyperglycemia, thyroid/parathyroid disorders, infections, immunological, and perinatal hypoxia. [1] Metabolic cause is one of the easily treatable and completely reversible cause of involuntary movements. Among the metabolic disorders, diabetes mellitus has a high prevalence. [1] Diabetes and impaired glucose tolerance showed increasing trend with age. [11] Stroke and diabetes mellitus remain as the major causes of movement disorders. [12] Majority of the patients who reported with movement disorders caused by nonketotic hyperglycemia were Asians, due to possible genetic predisposition. [7],[9],[12] It can also be a presenting symptom of diabetes. [2],[3],[4],[10] Proposed hypothesis for hyperglycemia as a cause of these movement disorders in diabetes are a) hyperglycemia induces mild ischemia in the putamen via hypoperfusion and b) it induces anaerobic metabolism which leads on to gamma-aminobutyric acid (GABA) depletion. [8] It mostly occurs in females of 50-80 years of age. [1] Brain CT shows hyperdensity of putamen/caudate nucleus, resolves eventually with resolution of symptoms. The cause of hyperdensity is due to protein hydration inside the cytoplasm of swollen gemistocytes. [5],[7] Elder female diabetic patients from East Asian origin are more prone to develop hemichorea-hemiballism, but whether this is related to a particular genetic predisposition is still a matter of debate. Recently, it was suggested that the presence of acanthocytes in circulating peripheral blood might render diabetic patients prone to develop hemichorea-hemiballism. [6] In our case, we did not search for acanthocytes on the peripheral blood since a good relief of symptoms was obtained with glycemia control and the use of neuroleptics. The prognosis of nonketotic hyperglycemia-induced hemichorea-hemiballism is favorable and depends on the prompt identification of undiagnosed diabetes or the compensation of previously diagnosed patients. Additionally, typical neuroleptics and sometimes benzodiazepines are useful in the management of the choreic movements. Topiramate, levetiracetan, and tetrabenazine have also been tried in selected cases with favorable outcomes. [8]

In conclusion, this case report underscores the nonketotic hyperglycemia-induced hemichorea-hemiballism syndrome as an unusual presentation of type 2 diabetes mellitus, highlighting that its recognition and stringent glycemia control associated to the use of neuroleptics hasten the patient recovery. Moreover, hemichorea-hemiballism should be regularly included in the differential diagnosis of acute movement disorders, especially in the elder population.

 
  References Top

1.Battisti C, Forte F, Rubenni E, Dotti MT, Bartali A, Gennari P, et al. Two cases of hemichorea-hemiballism with nonketotic hyperglycemia: A new point of view. Neurol Sci 2009;30:179-83.  Back to cited text no. 1
    
2.Lietz TE, Huff JS. Hemiballismus as a presenting sign of hyperglycemia. Am J Emerg Med 1995;13:647-8.  Back to cited text no. 2
    
3.Lai PH, Tien RD, Chang MH, Teng MM, Yang CF, Pan HB, et al. Chorea-ballismus with nonketotic hyperglycemia in primary diabetes mellitus. AJNR Am J Neuroradiol 1996;17:1057-64.  Back to cited text no. 3
    
4.Lin JJ, Chang MK. Hemiballism-hemichorea and non-ketotic hyperglycaemia. J Neurol Neurosurg Psychiatry1994;57:748-50.  Back to cited text no. 4
    
5.McCullen MK, Miller J, Furlong K, Shirodakar M, Ahmed I, Mandel S, et al. Expert opinion: Chorea in the setting of hyperglycemia. The precise mechanism for chorea-ballism secondary to hyperglycemia is unknown. Pract Neurol 2010:16-9.  Back to cited text no. 5
    
6.Branca D, Gervasio O, Le Piane E, Russo C, Aguglia U. Chorea induced by non-ketotic hyperglycaemia: A case report. Neurol Sci 2005;26:275-7.  Back to cited text no. 6
    
7.Lin JJ, Lin GY, Shih C, Shen WC. Presentation of striatal hyperintensity on T1-weighted MRI in patients with hemiballism-hemichorea caused by non-ketotic hyperglycemia: Report of seven new cases and a review of literature. J Neurol 2001;248:750-5.  Back to cited text no. 7
    
8.Awasthi D, Tiwari AK, Upadhyaya A, Singh B, Tomar GS. Ketotic hyperglycemia with movement disorder. J Emerg Trauma Shock 2012;5:90-1.  Back to cited text no. 8
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9.Shalini B, Salmah W, Tharakan J. Diabetic non-ketotic hyperglycemia and the hemichorea-hemiballism syndrome: A report of four cases. Neurol Asia 2010;15:89-91.  Back to cited text no. 9
    
10.Ifergane G, Masalha R, Herishanu YO. Transient hemi chorea/hemiballismus associated with new onset hyperglycemia. Can J Neurol Sci 2001;28:365-8.  Back to cited text no. 10
    
11.Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V. Diabetes epidemiology study group in India. High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44:1094-101.  Back to cited text no. 11
    
12.Lee YH, Hsieh LP. Hemichorea-hemiballism: Clinical study of thirteen patients. Cheng Ching Med J 2005;1:4.  Back to cited text no. 12
    




 

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