Chorea associated with non-ketotic hyperglycemia and hyperintensity basal ganglia lesion on T1-weighted brain MRI study: a meta-analysis of 53 cases including four present cases

Nonketotic hyperglycemic chorea

This is a unique case of nonketotic hyperglycemic (NKH) chorea in a 34-year-old white male. The patient had a poorly controlled type 2 diabetes mellitus (DM) due to medication incompliance. He complained of polyuria, polydipsia, and weight loss of 20 pounds within a month before presentation. T2-weighted (T2W) MRI showed hyperintensity in the left basal ganglion. Glycated hemoglobin (HBA1c) was 13.6%. The patient was started on insulin and clonazepam and the chorea resolved after proper control of the glucose level. To our knowledge, this is the first reported case of NKH chorea in a young white male with high T2-weighted (T2W) magnetic resonance signal in the basal ganglia.

Chorea, Hyperglycemia, Basal Ganglia Syndrome (C-H-BG) in an uncontrolled diabetic patient with normal glucose levels on presentation

Patient: Female, 66

Final Diagnosis: Chorea • hyperglycemia • Basal Ganglia Syndrome (C-H-BG)

Symptoms: Hemibalism • hemichorea

Medication: —

Clinical Procedure: —

Specialty: Endocrinology and Metabolic

Hemichorea associated with nonketotic hyperglycemia: clinical and neuroimaging features in 12 patients

BACKGROUND

Nonketotic hyperglycemia is a rare cause of hemichorea. Patients with hemichorea associated with nonketotic hyperglycemia (HCNH) always have a favorable prognosis when given prompt treatment.

METHODS

We reviewed the medical records of 12 patients with HCNH in our hospital between January 2005 and January 2013. The clinical data, laboratory findings, and imaging features of the patients were collected.

RESULTS

All 12 patients were admitted to the hospital with a complaint of involuntary movements. Ten patients had a history of diabetes, while the other 2 patients had not been diagnosed. The mean level of blood glucose on admission was 330.7 ± 107.8 mg/dl, and the ketones were negative. A cranial computed tomography scan showed hyperdensity in the striatum, which quickly resolved. Magnetic resonance imaging showed hyperintensity on T1-weighted images without change over several months. Nearly all of the patients experienced relief from the hemichorea symptoms after correcting hyperglycemia with a combination of dopamine receptor inhibitors and the sedative lorazepam, if necessary.

CONCLUSION

HCNH is a benign disorder, the pathogenesis of which remains unclear. Radiologic changes can provide guidance for early treatment and generally give an estimation of the degree of injury.

Case 204: Nonketotic hyperglycemia-induced hemiballism-hemichorea

HISTORY

An 87-year-old white woman presented to our emergency department with a 2-day history of involuntary movements of the right upper and lower extremities. The movements increased with action, decreased with relaxation, and disappeared during sleep. The patient's medical history included diabetes mellitus type 2, congestive heart failure, and hypertension. No history of parkinsonism or other neurologic disorders was reported. Furthermore, the patient had no prior history of dopamine antagonist or estrogen medication use. At admission, she was fully alert and oriented. A physical examination revealed her muscle tone and strength were normal on both sides; however, she reported transient weakness in the right limbs. There was no evidence of sensory impairment, and cranial nerves were normal. The deep tendon reflexes were symmetrically hypoactive. Her skin was pink, warm, and dry. Laboratory tests revealed poorly controlled diabetes mellitus, with a fasting blood glucose level of 410 mg/dL (22.8 mmol/L) and a hemoglobin A1C level of 18.0%. The urine examination was negative for ketones. Shortly after admission, the patient's blood sugar was controlled with insulin; this led to a steady correction of glycemia in the subsequent days. At admission, the patient underwent unenhanced brain computed tomography (CT) (Fig 1). Magnetic resonance (MR) imaging of the brain was performed 2 days later (Fig 2). After she was discharged from the hospital, the involuntary movements progressively decreased over the next few weeks until they disappeared. Two months later, follow-up unenhanced brain CT (not shown) showed the absence of abnormal findings.

Classic neuroimaging findings of nonketotic hyperglycemia on computed tomography and magnetic resonance imaging with absence of typical movement disorder symptoms (hemichorea-hemiballism)

While there are broad differential diagnoses for either the clinical finding of hemichorea-hemiballism or the imaging finding of lateralizing/asymmetric basal ganglia lesions (hyperdense on computed tomography, hyperintense on T1 magnetic resonance imaging), the presence of both findings is highly suggestive of nonketotic hyperglycemia. We present an unusual case of a patient with vague stroke-like complaints and imaging findings notable for lateralizing basal ganglia lesions. Laboratory analysis revealed nonketotic hyperglycemia and neurologic exam failed to elicit any findings of movement disorder. As far as we know, this is the first published case of a patient with typical neuroimaging manifestations of nonketotic hyperglycemia without associated hemichorea-hemiballism (a disorder of abnormal movements comprised of more proximal, higher amplitude movements-ballismus and lower amplitude, more distal movements-chorea). This finding suggests that radiologists should be alert to the possibility of nonketotic hyperglycemia in patients with asymmetric/lateralizing basal ganglia lesions even in the absence of a movement disorder.

Chorea-Ballismus Associated with Hyperglycemia

Chorea-ballismus which is a rare complication of nonketotic hyperglycemia may be the first symptom of type 2 diabetes mellitus. In this paper, we present two patients, who had involuntary movements and were diagnosed as having ballismus-chorea associated with nonketotic hyperglycemia. While one of the patients was not diagnosed with diabetes mellitus, the other one did not administer insulin therapy for a long time which was prescribed. The patients were investigated by cranial imaging and biochemical tests. The symptoms improved in one of them within hours, however, it took days to improve for the other one. This clinical situation, which is thought to be caused by hyperglycemia, cerebral ischemia and failure of gamma-aminobutyric acid (GABA) and which probably improves with regulation of blood glucose levels, should be kept in mind by emergency physicians, because it can be the first presentation of type 2 diabetes mellitus.

Acute chorea-dystonia heralding diabetes mellitus

Hemichorea-hemiballism associated with non-ketotic hyperglycaemia is a rare dyskinetic syndrome during uncontrolled or undiagnosed diabetes. We reported a 41-year-old man suffering from sudden choreodystonic movements and undiagnosed hyperglycaemia. We described a combination of several rare aspects, emphasising the importance of screening for diabetes as a cause of acute onset of hyperkinetic movement disorders.

Non-ketotic hyperglycaemia hemichorea-hemiballismus and acute ischaemic stroke

Here we describe a patient with a rare movement disorder, hemichorea-hemiballismus, which is described as a complication of non-ketotic hyperglycaemia. This complication may be seen in individuals with poorly controlled long-standing diabetes mellitus. Proper diagnosis is established with CT and MRI of the brain, which typically show classic findings in the basal ganglia. Treatment focuses on improvement of glycaemic control and usually results in rapid resolution of the movement disorder. Nevertheless, recurrent episodes of hemichorea-hemiballismus, and even more ominous complications such as ischaemic stroke may occur.

Dyskinesia associated with hyperglycemia and basal ganglia hyperintensity: report of a rare diabetic complication

The syndrome of dyskinesia associated with hyperglycemia and basal ganglia hyperintensity on T1 - weighted MR images is rare and most often affects elderly patients with type 2 diabetes. We report a case of a 79 year-old female patient who presented to the ED with a 12 h history of a left sided hemichoreoathetosis. Laboratory results revealed pronounced nonketotic hyperglycemia [27 mmol/L (486 mg/dL); HbA1c 140 mmol/mol (15 %)] and brain MRI showed bilateral T1 hyperintensity in the basal ganglia, more noticeable on the right side. One week before she had been admitted with a diagnosis of transient ischemic attack consisting in left hemiparesthesia, also with nonketotic hyperglycemia [38.9 mmol/L (700 mg/dL)] and was discharged home with partial correction of her metabolic disturbance. The movement disorder did not improve with adequate glycemic control so haloperidol was started. Six weeks later she was seen on an outpatient basis. She still had minimal residual involuntary movements of the left arm and leg. Laboratory exams revealed a well controlled diabetes mellitus [glycemia 6.0 mmol/L (109 mg/dL), HbA1c 57 mmol/mol (7.4 %)]. In conclusion, the syndrome of dyskinesia associated to hyperglycemia and hyperintensity in the basal ganglia on T1 - weighted MR images is a rare, intriguing and yet incompletely understood complication of diabetes mellitus. The increasing number of reported cases may help to better understand its peculiarities such as the existence of a clear clinical radiological dissociation and to unveil pathophysiological aspects. We suggest the possibility that the metabolic disturbances unmask a previous established asymptomatic striatum vasculopathy.

Change in striatal metabolism in diabetic haemichorea-haemiballism

We studied metabolic changes in relation to chorea in two patients with diabetic haemichorea-haemiballism using positron emission tomography with (18)F-fluorodeoxyglucose. Metabolism of the striatum and globus pallidus did not change in the acute choreic stage, but it decreased in the later stage after the amelioration of chorea. Striatal and pallildal hypometabolism in the late stage in diabetic haemichorea-haemiballism may reflect tissue ischaemia with gliosis. Previous studies have demonstrated striatal hypometabolism in neurodegenerative choreic disorders and striatal hypermetabolism in acute inflammatory choreic disorders. Previous findings as well as our results suggest that striatal and pallidal metabolic changes may be correlated with histological changes more than with functional changes relevant to chorea.

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

CONTENT

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

OBJECTIVE

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

SETTING

The study was conducted in a tertiary care referral hospital.

RESULTS

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

CONCLUSION

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

Hypoglycemia-induced hemichorea in a patient with Fahr's syndrome

Non-ketotic hyperglycemia may be a cause of hemiballism-hemichorea. We present an elderly female type II diabetic patient with right-sided hemiballism-hemichorea of acute onset during hypoglycemia following insulin overtreatment of non-ketotic hyperglycemia. Brain computerized tomography and magnetic resonance imaging scans revealed characteristic hyperdensity and T1 hyperintensity, respectively, in the left basal ganglia, in addition to pallido-dentate calcifications, suggestive of Fahr's syndrome. Although extremely rare, hypoglycemia may be a cause of hemiballism-hemichorea especially in the presence of predisposing factors such as previous hyperglycemic episodes and Fahr's syndrome.

Metabolic encephalopathies

Kinnier Wilson coined the term metabolic encephalopathy to describe a clinical state of global cerebral dysfunction induced by systemic stress that can vary in clinical presentation from mild executive dysfunction to deep coma with decerebrate posturing; the causes are numerous. Some mechanisms by which cerebral dysfunction occurs in metabolic encephalopathies include focal or global cerebral edema, alterations in transmitter function, the accumulation of uncleared toxic metabolites, postcapillary venule vasogenic edema, and energy failure. This article focuses on common causes of metabolic encephalopathy, and reviews common causes, clinical presentations and, where relevant, management.

Hemichorea associated with non-ketotic hyperglycaemia: a case report

Hemichorea is a rare complication of non-ketotic hyperglycaemia. Patients with this syndrome have classically longstanding, poorly controlled diabetes. Here, we report a patient presenting hemichorea without diabetic history. His symptom resolved rapidly after correction of hyperglycaemia. We suggest that hemichorea may be the first manifestation of undiagnosed diabetes.

Rare presentation of unilateral weakness, involuntary movements and ataxia with subcortical t2 hypointensity in a diabetic patient: a case report

Subcortical T2 hypointensity on MRI is not a common finding. We present a case of subcortical T2 hypointensity in a diabetic patient, who was referred with weakness of left lower limb and involuntary movements and ataxia of the left upper limb. Lab reports confirmed the diagnosis of nonketotic hyperglycemia. It is rather important to identify subcortical T2 hypointensity which has only been recently found to be associated with nonketotic hyperglycemia. Early identification and prompt correction of blood sugar would help in alleviating the neurological symptoms.

Movement disorders in patients with diabetes mellitus

Movement disorders are not infrequent in patients with diabetes mellitus. These may occur on the basis of both central and peripheral nervous system dysfunction and can be secondary to severe hyperglycemia, complications of diabetes or its treatment and less often to diseases in which both diabetes and a movement disorder are primary manifestations of the same underlying disease. We present a typical case of a severe movement disorder complicating diabetes as a springboard to review the spectrum of disorders associated with this condition.

Stereotypies as a manifestation of acute hyperglycemia without ketosis

Acute hyperglycemia without ketosis is recognized to induce movement disorders characterized by hemichorea, hemiballismus, or hemidystonia. A video-case of hyperkinetic movement disorder resembling stereotypies in the context of uncompensated hyperglycemia without ketosis is presented, expanding the clinical phenotype of this disorder.

Permanent haemichorea associated with transient hyperglycemia

Hyperglycemia is associated with several common neurological syndromes. Chorea, however, is a rare association that has only been documented in the literature recently. The triad of chorea, non-ketotic hyperglycemia and a high signal basal ganglia lesion on the T1 weighted brain MRI (C-H-BG) is considered to be a unique syndrome. C-H-BG refers to the onset of chorea during or shortly after (days to weeks) an episode of non-ketotic hyperglycemia. There is usually a high signal lesion in the basal ganglia on T1 weighted brain MRI that corresponds to the location of the chorea. Most case reports of C-H-BG have been described in Asians. C-H-BG is considered to be a benign condition in which the clinical and MRI signs resolve quickly upon correction of blood glucose levels. Here, the authors describe a case of C-H-BG in a middle aged Caucasian in whom the chorea did not resolve with improved glycemic control.

Hemiballismus: current concepts and review

Hemiballism is a rare movement disorder characterized by a high amplitude movement of an entire limb or limbs on one side of the body. The acute development of hemiballismus is often caused by focal lesions in the contralateral basal ganglia and STN. Many etiologies exist for this rare disorder with vascular causes and nonketotic hyperglycemia being the most common. Clearer understanding of the pathophysiology of hemiballism has led to important insights into the function and interaction of structures within the basal ganglia. Newer models of basal ganglia function have been proposed based on the study of the pathophysiology of hemiballism. Prognosis is favorable for most patients with complete resolution with or without treatment. Medical and surgical treatments are often successful in reducing or completely ameliorating the movements in those patients with more severe movements.

Chorea-ballism associated with nonketotic hyperglycaemia or diabetic ketoacidosis: characteristics of 25 patients in Korea

Chorea-ballism is a rare form of movement disorder complicated by severe hyperglycaemia and in association with a contralateral basal ganglia lesion. We analysed the clinical characteristics of 25 Korean patients with chorea-ballism associated with nonketotic hyperglycaemia or diabetic ketoacidosis. Possible mechanisms of disease are also discussed.

A prospective series of patients with hyperglycaemia-associated movement disorders

Hyperglycaemia-associated movement disorders (MD) usually appear in older patients with diabetes and are related to acute peaks in blood glucose levels. This study aimed to describe the clinical features of a prospective series of patients with movement disorders associated with hyperglycaemia. We present a series of seven women and three men diagnosed with hyperglycaemia-associated MD who were followed for at least 1 year. Clinical evolution, treatment and neuroimaging findings are presented. Mean (± standard deviation [SD]) of the age at onset was 67.7 ± 11.7 years and mean (± SD) fasting glucose was 359.7 ± 162.5mg/dL. Putaminal hyperintensity on T1-weighted MRI was present in almost all instances. Two patients had pontine lesions compatible with osmotic myelinolysis. At follow-up, eight patients had a complete remission. We conclude that the clinical profile of patients in our series is similar to those reported in the literature. No clinical or metabolic features were found to be correlated with remission. Similarities with osmotic myelinolysis syndromes are discussed as an alternative aetiological hypothesis.

[Nonketotic hyperglycemia-induced hemiballism]

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

Hyperglycemic nonketotic states and other metabolic imbalances

Hemichorea and generalized chorea are well-recognized syndromes associated with nonketotic hyperglycemia. This condition usually occurs in older age, affects females more than men, and often heralds a new diagnosis of diabetes, usually type 2. It may resolve over days with treatment of the underlying hyperglycemia or persist for years. Magnetic resonance imaging is very characteristic, and shows T1 hyperdensity in the striatum. The underlying pathophysiology is not clear, but recent evidence suggests that the imaging may represent zinc, as opposed to calcium. Tetrabenazine has worked well when symptomatic treatment is required. Other rare causes of metabolic choreas include hypoparathyroid abnormalities, hypoglycemia, and hypernatremia.

Hemiballismus

Hemiballism is a relatively rare hyperkinetic movement disorder characterized by involuntary, violent, coarse and wide-amplitude movements involving ipsilateral arm and leg. Although classically related to lesions in the subthalamic nucleus, in clinical-radiological series of hemiballism most patients had lesions outside this nucleus, involving mainly other basal ganglia structures. It has been suggested that abnormal neuronal firing patterns in the internal segment of the globus pallidus may be related to the pathogenesis of hemiballism. Stroke is the most common cause, but in recent years an increasing number of patients with hemiballism associated with nonketotic hyperglycemia or with complications of human immunodeficiency virus (HIV) infection have been reported. Contrarily to what was stated in older literature, hemiballism has, in general, a relatively good prognosis. Depending on the underlying causes, many patients may experience spontaneous improvements or remissions. Treatment should be directed to the cause of hemiballism. Symptomatic treatment includes the use of drugs, particularly blockers of striatal D2 dopamine receptors and tetrabenazine. Surgical treatment, especially pallidotomy, is a therapeutic option for the minority of patients with severe persistent disabling hemiballism.

Hyperglycemia-induced hemiballismus hemichorea: a case report and brief review of the literature

BACKGROUND

Metabolic conditions, including hyperglycemia, can have various neurological presentations. Hemiballismus hemichorea is a rare manifestation reported to occur with severe hyperglycemia and is reversed in most cases with control of sugars.

CASE REPORT

We present a case of a patient with no known diabetes history who presented with uncontrolled jerky movements of one-half of her body, which resolved with achievement of euglycemia.

CONCLUSIONS

Important differential diagnoses that need to be evaluated are discussed.

[Hemiballism-hemichorea with non-ketotic hyperglycemia: movement disorder related to diabetes mellitus]

Diabetes mellitus, especially when not under control, can lead to several neurological complications being the development of involuntary movements one of the rarest presentations. Nonketotic hyperglycemia in aged patients who present with ballismus-chorea movements and cerebral image alterations in computerized tomography (CT) and magnetic resonance constitute a syndrome of recent characterization and few cases in literature. We present a case of a 75 year-old male patient admitted with history of hemiballismus-hemichorea movements, hyperglycemia, glycated hemoglobin of 14.4% and CT with a hyperdense area in the topography of the right basal ganglia. After glycemic control, the neurological signs resolved completely and the initial hyperdense lesion disappeared.

Hyperglycemic choreoathetosis: role of the putamen in pathogenesis

Hyperglycemic choreoathetosis (HC) is an uncommon syndrome often associated with hyperintensity of the basal ganglia on MRI. We performed a retrospective review of cases with HC to characterize the clinical, biochemical, and neuroimaging (CT, MRI, and MR spectroscopy) findings and to propose a mechanism for this syndrome. Seven HC patients with a mean age of 75.1 years, mean blood glucose of 27.4 mmol/L, and mean plasma osmolarity of 313.4 mmol/L were studied. All had MR-T1 hyperintensity of the putamen on the side contralateral to the choreoathetosis. Two patients had additional hyperintensity of the globus pallidus while one also had involvement of the caudate. On MR-T2, 2 patients showed hyperintensity, 2 isointensity, and 3 hypointensity in the putamen. MR spectroscopy showed elevated choline and reduced N-acetylaspartate; two patients also had elevated myoinositol levels. Our findings suggest that the putamen has a central role in HC, and MR spectroscopy supports neuronal dysfunction in the putamen. Biochemical and neuroimaging findings support hyperviscosity as the most plausible mechanism.

Hemichorea-hemiballismus associated with nonketotic hyperglycemia: a possible role of inflammation

Three cases of hemichorea-hemiballismus (HC-HB) associated with nonketotic hyperglycemia were reported. Of them two patients presented as HC-HB and the remaining one as generalized chorea-ballismus (CB). Brain MRI showed characteristic T1-weighted high-intensity lesions in the contralateral or bilateral striatum without edema or mass effect. They all had a prior history of respiratory or urinary infection. Cerebrospinal fluid test in two patients showed an elevation of protein concentration with normal cell and an increased IgG content and elevated IgG index or 24 h IgG intrathecal synthesis rate. These results suggested that inflammation within the central nervous system may participate in the pathogenesis of chorea and ballismus induced by NKH.

Acquired hepatocerebral degeneration

Cirrhosis and its co-morbidities may cause a variety of neurological complications, the most common being bouts of toxic metabolic encephalopathy. A proportion of patients with chronic liver disease develop acquired hepatocerebral degeneration (AHD), a chronic progressive neurological syndrome characterized by parkinsonism, ataxia and other movement disorders. This article reviews the clinical spectrum, pathophysiology, neuroimaging features and differential diagnosis of AHD along with emerging treatment options.

Diabetic striatal disease: clinical presentation, neuroimaging, and pathology

BACKGROUND

Unilateral movement disorders and contralateral neuroimaging abnormalities of the striatum have been sporadically reported as a rare syndrome associated with diabetes mellitus. Despite characteristic imaging findings and clinical manifestations, the mechanism underlying this syndrome is still unclear.

METHODS

Six patients with this syndrome were studied clinically and subjected to MRI neuroimaging; one underwent biopsy of the striatum, and another underwent additional MR spectroscopy at 3.0T and FDG-PET.

RESULTS

Neuroimaging findings were characterized by a T1-hyperintense unilateral lesion restricted to the striatum, contralateral to the symptomatic limbs. The biopsied striatum contained patchy necrotic tissue, severe thickening of all layers of arterioles, and marked narrowing of vessel lumens. Hyaline degeneration of the arteriolar walls, extravasation of erythrocytes, and prominent capillary proliferation were also notable, together with lymphocytic infiltration and macrophage invasion. In one patient, PET examination revealed decreased accumulation of FDG in the lesion. The MR spectrum for the diseased striatum revealed a decrease in the NAA/Cr ratio (1.35), normal Cho/Cr ratio (1.22), and a peak for myoinositol, while the spectrum on the contralateral site revealed a decrease in the NAA/Cr ratio (1.48), increase in Cho/Cr (1.32), but no peak for myoinositol.

CONCLUSION

The constellation of signs and symptoms and neuroimaging characteristics in previous reports and the six additional cases described here with neuropathological data and findings of MR spectroscopy appears unique enough to be termed "diabetic striatopathy." This syndrome appears in poorly controlled diabetics due to obliterative vasculopathy with prominent vascular proliferation, vulnerability to which is restricted to the striatum.

Atypical onset of diabetes in a teenage girl: a case report

Background

Chorea, hemichorea-hemiballismus and severe partial seizures may be the presenting feature of nonketotic hyperglycemia in older adults with type 2 diabetes, but cases in children with type 1 diabetes are rare, since the most easily recognized symptoms of type 1 diabetes in children are secondary to hyperglycemia, glycosuria, and ketoacidosis.

Case presentation

A previously healthy 15-year-old girl presents with sudden onset of right-sided chorea. Brain CT did not detect any abnormal density areas. A T1-weighted image of brain MRI was normal. Investigations revealed hyperglycemia with absent ketones and normal serum osmolality. Achievement of normoglycemia with insulin therapy determined the involuntary movements to regress completely within a day. The direct effect of hyperglycemia could be the pathogenesis of the chorea in our patient. Severe hyperglycemia without ketosis at the clinical onset of insulin-dependent diabetes mellitus (type 1) has been reported in children and adolescents, but nonketotic hyperglycemia is an unusual cause of chorea-ballismus in children, and chorea-ballismus is also a rare manifestation of primary diabetes mellitus.

Conclusion

The importance of clinical evaluation, laboratory testing and neuroimaging for the differential diagnostics of chorea is emphasized.

Bilateral dystonia in type 1 diabetes: a case report

INTRODUCTION

Diabetic hemichorea-hemiballismus is a rare complication of type 2 diabetes. Here, we report a case with type 1 diabetes, with hemichorea and bilateral dystonia manifested as hyperglycemia-induced involuntary movement.

CASE PRESENTATION

A 62-year-old Japanese women with body weight loss of 30 kg during the past year developed symptoms of thirst, polydipsia and polyuria. She also presented with hemichorea and bilateral dystonia for 5 days and extremely high plasma glucose (774 mg/dl), hemoglobin A1c (21.2%) and glycated albumin (100%) with ketosis. Based on the presence of glutamic acid decarboxylase antibodies (18,000 U/ml; normal <1.3 U/ml), low daily urinary excretion of C-peptide (7.8 micro), ketosis and human leucocyte antigen typing DR-4, we diagnosed type 1 diabetes mellitus. We treated the patient with a continuous intravenous regular insulin infusion and medication with haloperidol, and dystonia completely disappeared within 3 days.

CONCLUSION

Hyperglycemia-induced involuntary movement is one of the manifestations of dystonia and hemichorea-hemiballism.