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Phan T, Klouda E, Jackson CD. Chorea - Is Diabetes Mellitus the Cause? J Gen Intern Med 2024:10.1007/s11606-024-08666-1. [PMID: 38886324 DOI: 10.1007/s11606-024-08666-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 01/25/2024] [Indexed: 06/20/2024]
Abstract
Diabetic striatopathy (DS) is an uncommon complication of diabetes characterized by hemiballismus-hemichorea, often accompanied by reversible striatal hyperintensity on neuroimaging. Diabetes is the most common metabolic cause of hemiballismus and hemichorea. However, it is underreported as clinicians do not always consider it in the diagnosis of new movement abnormalities. The prognosis is generally excellent, and management involves glycemic control and anti-chorea medications. We present a case of a patient with bilateral chorea and ballismus and classic MRI findings of DS, though his history of diabetes and substance use confounds the clinical picture of DS.
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Affiliation(s)
- Tina Phan
- Lt. Col. Luke Weathers, Jr. VA Medical Center, Memphis, TN, USA.
- Department of Internal Medicine, University of Tennessee Health Science Center, 920 Madison Ave, Room 551, Memphis, TN, 38163, USA.
| | - Elisabeth Klouda
- Lt. Col. Luke Weathers, Jr. VA Medical Center, Memphis, TN, USA
- Department of Internal Medicine, University of Tennessee Health Science Center, 920 Madison Ave, Room 551, Memphis, TN, 38163, USA
| | - Christopher D Jackson
- Lt. Col. Luke Weathers, Jr. VA Medical Center, Memphis, TN, USA
- Department of Internal Medicine, University of Tennessee Health Science Center, 920 Madison Ave, Room 551, Memphis, TN, 38163, USA
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2
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Oksenhendler R, Pellerin D, Almutlaq A. A Case of Non-ketotic Hyperglycemic Hemichorea and Fahr Syndrome. Cureus 2024; 16:e60265. [PMID: 38872643 PMCID: PMC11175089 DOI: 10.7759/cureus.60265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/13/2024] [Indexed: 06/15/2024] Open
Abstract
Non-ketotic hyperglycemic hemichorea (NHH) denotes acute hemichorea or hemiballism in patients with poorly controlled diabetes with striatal abnormalities seen on brain MRI. Here, we describe a case with diabetes mellitus and primary hypoparathyroidism who developed NHH with bilateral chorea due to the abrupt stopping of her diabetic regimen. She presented with subacute and progressive bilateral asymmetric chorea. Over the prior six months, she stopped following her diabetic regimen. Brain imaging showed features of diffuse brain calcifications suggestive of Fahr syndrome. Extensive blood investigations including genetic testing for causes of basal ganglia calcifications were unremarkable. Treatment with tetrabenazine and resumption of her diabetes medications slowly improved her chorea. This case highlights the importance of interpreting imaging findings in the context of the nature and time course of the chorea presentation. In addition, it emphasizes a systematic approach to interpreting diffuse brain calcifications with the appropriate investigations.
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Affiliation(s)
| | | | - Ahmad Almutlaq
- Neurology, King Fahad Medical City, Riyadh, SAU
- Neurology, McGill University, Montreal, CAN
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3
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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] [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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Costa Hoffmeister M, Bonavides PSG, Maurer Wiercinski V, Alessio Baggio V, de Pádua Borges R, Francisco Xavier Junior G, Maraschin CK, Schaan BD. Hyperglycemia-induced hemichorea-hemiballismus syndrome - a systematic review. ARCHIVES OF ENDOCRINOLOGY AND METABOLISM 2024; 68:e220413. [PMID: 38530964 PMCID: PMC11081041 DOI: 10.20945/2359-4292-2022-0413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 07/21/2023] [Indexed: 03/28/2024]
Abstract
Nonketotic hyperglycemia may occur as a cause of chorea in patients with chronic decompensated diabetes. Because it is rare and consequently poorly studied, diagnosis and treatment can be delayed. Therefore, our objective was to summarize clinical and radiological features, as well as treatments performed, from previously reported cases to facilitate adequate management in clinical practice. We searched MEDLINE/PubMed, EMBASE, Cochrane, CINAHL, Web of Science, Scopus, and LILACS databases for studies published before April 23, 2021. We included case reports and case series of adults (aged ≥ 18 years) that described hyperglycemic chorea with measurement ofglycated hemoglobin (HbA1c) and cranial magnetic resonance imaging (MRI). Studies were excluded if participants were pregnant women, aged < 18 years, and had no description of chorea and/or physical examination. We found 121 studies that met the inclusion criteria, for a total of 214 cases. The majority of the included studies were published in Asia (67.3%). Most patients were women(65.3%) aged > 65 years (67.3%). Almost all patients had decompensated diabetes upon arrival at the emergency department (97.2%). The most common MRI finding was abnormalities of the basal ganglia (89.2%). There was no difference in patient recovery between treatment with insulin alone and in combination with other medications. Although rare, hyperglycemic chorea is a reversible cause of this syndrome; therefore, hyperglycemia should always be considered in these cases.
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Affiliation(s)
| | - Paola S G Bonavides
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | | | - Viviane Alessio Baggio
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
| | | | | | - Clara K Maraschin
- Universidade Federal do Rio Grande do Sul,Faculdade de Medicina,Departamento de Medicina Interna, Porto Alegre, RS, Brasil
| | - Beatriz D Schaan
- Serviço de Endocrinologia, Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil,
- Universidade Federal do Rio Grande do Sul,Faculdade de Medicina, Departamento de Clínica Médica,Programa de Pós-graduação em Ciências Médicas: Endocrinologia, Porto Alegre, RS, Brasil
- Instituto de Avaliação de Tecnologia em Saúde (IATS), Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq), Hospital de Clínicas de Porto Alegre, Porto Alegre, RS, Brasil
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5
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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] [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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Chaudhari P, Sawant R, Karwa V, Raut SS, Acharya S, Kumar S. Revealing Non-ketotic Hyperglycemia as a Trigger for Hemichorea-Hemiballismus in Uncontrolled Diabetic Asthmatics: A Case Report. Cureus 2024; 16:e55678. [PMID: 38586764 PMCID: PMC10998648 DOI: 10.7759/cureus.55678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/04/2024] [Indexed: 04/09/2024] Open
Abstract
Uncontrolled diabetes can trigger a movement disorder called hemichorea-hemiballismus, characterized by non-ketotic hyperglycemia-related chorea/ballism and usually reversible basal ganglia abnormalities on CT and/or MRI. The condition is diagnosed clinically and is mostly based on radiological imaging. Here, we report a case of a 68-year-old female presenting with right-sided and facial involuntary movements owing to uncontrolled hyperglycemia who was treated with antidiabetic and anticholinergic medications. The patient responded well to the treatment and showed a favorable outcome with no complications.
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Affiliation(s)
| | - Rucha Sawant
- Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Vineet Karwa
- Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | - Sarang S Raut
- Medicine, Jawaharlal Nehru Medical College, Wardha, IND
| | | | - Sunil Kumar
- Medicine, Jawaharlal Nehru Medical College, Wardha, IND
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Obara K. Acute Hemichorea in an Elderly Patient With Positive Anti-centromere Antibodies and Lung Tumor. Cureus 2024; 16:e56448. [PMID: 38638733 PMCID: PMC11025876 DOI: 10.7759/cureus.56448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/20/2024] Open
Abstract
Though rare, autoimmune paraneoplastic and non-paraneoplastic chorea can be leading causes of adult-onset acute/subacute chorea. Here, we report a case of acute-onset chorea with suspected autoimmune-mediated mechanisms in a 79-year-old female who exhibited acute-onset choreiform movements on the right side of her body. She tested positive for anti-centromere antibodies (ACAs) without displaying symptoms of scleroderma. Blood sugar levels, genetic testing for Huntington's disease, and an antibody panel related to paraneoplastic neurological syndrome were unremarkable. Brain magnetic resonance imaging revealed no significant abnormalities. Computed tomography (CT) identified an irregularly shaped nodule in the middle lobe of the right lung. An 18F-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET)-CT scan showed an accumulation of radioactivity in the nodule and slight hypermetabolism in the striatum of both hemispheres. Her choreiform movements almost disappeared with a low dose of tiapride alone, without the need for anti-tumor therapy or immunotherapy. In cases of adult-onset acute/subacute chorea, investigating neoplasms and autoimmune diseases as underlying conditions is recommended. Tiapride, due to its good tolerability, is a valuable symptomatic therapy for elderly patients presenting with chorea, even in cases driven by autoimmune mechanisms.
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Affiliation(s)
- Koji Obara
- Neurology, Yasumi Hospital, Morioka, JPN
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Chatterjee S, Ghosh R, Biswas P, Das S, Sengupta S, Dubey S, Ray BK, Pandit A, Benito-León J, Bhattacharjee R. Diabetic striatopathy and other acute onset de novo movement disorders in hyperglycemia. Diabetes Metab Syndr 2024; 18:102997. [PMID: 38582065 DOI: 10.1016/j.dsx.2024.102997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 03/21/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND AND AIMS Acute onset de novo movement disorder is an increasingly recognized, yet undereported complication of diabetes. Hyperglycemia can give rise to a range of different movement disorders, hemichorea-hemiballism being the commonest. This article delves into the current knowledge about this condition, its diverse presentations, ongoing debates regarding its underlying mechanisms, disparities between clinical and radiological findings, and challenges related to its management. METHODS PubMed and Google Scholar were searched with the following key terms- "diabetes", "striatopathy", "hyperglycemia", "striatum", "basal ganglia", "movement disorder", "involuntary movement". Case reports, systematic reviews, meta-analysis, and narrative reviews published in English literature related to the topic of interest from January 1, 1950, to October 20, 2023, were retrieved. The references cited in the chosen articles were also examined, and those considered relevant were included in the review. RESULTS Diabetic striatopathy is the prototype of movement disorders associated with hyperglycemia with its characteristic neuroimaging feature (contralateral striatal hyperdensitity on computed tomography or hyperintensity on T1-weighted magnetic resonance imaging). Risk factors for diabetic striatopathy includes Asian ethnicity, female gender, prolonged poor glycemic control, and concurrent retinopathy. Several hypotheses have been proposed to explain the pathophysiology of movement disorders induced by hyperglycemia. These hypotheses are not mutually exclusive; instead, they represent interconnected pathways contributing to the development of this unique condition. While the most prominent clinical feature of diabetic striatopathy is a movement disorder, its phenotypic expression has been found to extend to other manifestations, including stroke, seizures, and cognitive and behavioral symptoms. Fortunately, the prognosis for diabetic striatopathy is generally excellent, with complete resolution achievable through the use of anti-hyperglycemic therapy alone or in combination with neuroleptic medications. CONCLUSION Hyperglycemia is the commonest cause of acute onset de novo movement disorders presenting to a range of medical specialists. So, it is of utmost importance that the physicians irrespective of their speciality remain aware of this clinical entity and check blood glucose at presentation before ordering any other investigations. Prompt clinical diagnosis of this condition and implementation of intensive glycemic control can yield significant benefits for patients.
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Affiliation(s)
- Subhankar Chatterjee
- Department of Endocrinology & Metabolism, Medical College & Hospital, Kolkata, India.
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College & Hospital, Burdwan, India.
| | - Payel Biswas
- Department of Radiodiagnosis, GNRC Hospitals, Barasat, Kolkata, India.
| | - Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER & SSKM Hospital, Kolkata, India.
| | - Samya Sengupta
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER & SSKM Hospital, Kolkata, India.
| | - Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER & SSKM Hospital, Kolkata, India.
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER & SSKM Hospital, Kolkata, India.
| | - Alak Pandit
- Department of Neuromedicine, Bangur Institute of Neurosciences, IPGMER & SSKM Hospital, Kolkata, India.
| | - Julián Benito-León
- Department of Neurology, University Hospital "12 de Octubre", Madrid, Spain; Instituto de Investigación Sanitaria Hospital 12 de Octubre (imas12), Madrid, Spain; Centro de Investigación Biomédica en Red Sobre Enfermedades Neurodegenerativas (CIBERNED), Madrid, Spain; Department of Medicine, Faculty of Medicine, Complutense University, Madrid, Spain.
| | - Rana Bhattacharjee
- Department of Endocrinology & Metabolism, Medical College & Hospital, Kolkata, India.
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Wettasinghe I, Elanko A, Ratnayake A, Rajendiran VT, Mendis S. A rare neurological manifestation of diabetes mellitus-Hemichorea-hemiballismus in a patient with diabetic striatopathy: A case report. SAGE Open Med Case Rep 2024; 12:2050313X231222203. [PMID: 38187814 PMCID: PMC10768625 DOI: 10.1177/2050313x231222203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024] Open
Abstract
Diabetic striatopathy is a rare neurological complication of diabetes mellitus that presents with sudden onset hemichorea or hemiballismus and is associated with hyperglycemia and striatal abnormality, either by hyperdensity on non-contrast computer tomography or hyperintensity on T1-weighted magnetic resonance imaging. Here we report a 55-year-old female, from Sri Lanka, who presented with involuntary movements of the left upper and lower limbs. Her past medical history included diabetes mellitus and she was on warfarin 5 mg daily for a mechanical mitral and tricuspid valve replacement. The random blood sugar on admission was 462 mg/dL and the last INR was 3.03. While hemiballismus has multiple etiologies, intracranial hemorrhage would be the main differential in a patient on anticoagulation. Other differentials include drug-induced dyskinesia, metabolic abnormalities, and autoimmune etiologies. Hemiballismus in the presence of high blood glucose should always raise the suspicion of diabetic striatopathy. The non-contrast computed tomography of the brain showed hyperdensity in the right-side caudate nucleus, lentiform nucleus, and globus pallidus which is a characteristic of diabetic striatopathy but could have been mistaken for an intracranial hemorrhage. The involuntary movements improved with glucose control and treatment with clonazepam and tetrabenazine. This case highlights the potential for misdiagnosis of diabetic striatopathy as an intracranial hemorrhage in a patient on warfarin, which can lead to delays in appropriate management and erroneous omission of warfarin. Early recognition and treatment of diabetic striatopathy can lead to significant improvement in the quality of life.
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Affiliation(s)
| | | | | | | | - Suresh Mendis
- Colombo South Teaching Hospital, Kalubowila, Sri Lanka
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10
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Lu XP, Chen AC, Wu MC, Tseng HC, Kao PF. FDG PET/CT Demonstrated Unilateral Striatum Hypometabolism in a Case of Advanced Nasopharyngeal Cancer. Clin Nucl Med 2024; 49:104-105. [PMID: 37976532 DOI: 10.1097/rlu.0000000000004940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
ABSTRACT A 79-year-old man with nasopharyngeal cancer (NPC) presented with diplopia symptom and a history of diabetes mellitus was referred for an FDG PET/CT scan to determine the pretreatment staging. The FDG PET/CT scan revealed NPC with skull base invasion and decreased FDG uptake at the left striatum. A review of his clinical history and a brain MRI conducted 5 months ago confirmed a previous diagnosis of left hyperglycemic hemichorea. In this NPC patient with inadequate blood sugar control, unilateral striatum hypometabolism may persist for up to 5 months after the initial clinical symptoms.
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Arecco A, Ottaviani S, Boschetti M, Renzetti P, Marinelli L. Diabetic striatopathy: an updated overview of current knowledge and future perspectives. J Endocrinol Invest 2024; 47:1-15. [PMID: 37578646 PMCID: PMC10776723 DOI: 10.1007/s40618-023-02166-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/24/2023] [Indexed: 08/15/2023]
Abstract
PURPOSE Diabetic striatopathy (DS) is a rare complication of poorly controlled diabetes mellitus (DM), characterized by hyperglycemia associated with chorea/ballism and characteristic reversible basal ganglia abnormalities on computed tomography (CT) and/or magnetic resonance imaging (MRI). We propose a narrative review of the literature on this topic, currently unknown to most, and about which physicians should be aware. We intend to summarize, critically review, and take to mean the evidence on this disorder, describing its typical features. METHODS We searched Pubmed for English-language sources using the following keywords in the title and the abstract: diabetic striatopathy, hyperglycemic non-ketotic hemichorea/hemiballism, chorea/hemichorea associated with non-ketotic hyperglycemia, diabetic hemiballism/hemichorea, chorea, hyperglycemia, and basal ganglia syndrome. We collected scientific articles, including case reports, reviews, systematic reviews, and meta-analyses from the years 1975 to 2023. We eliminated duplicate, non-English language or non-related articles. RESULTS Older Asian women are more frequently affected. Suddenly or insidiously hemichorea/hemiballism, mainly in the limbs, and high blood glucose with elevated HbA1c in the absence of ketone bodies have been observed. Furthermore, CT striatal hyperdensity and T1-weighted MRI hyperintensity have been observed. DS is often a treatable disease following proper hydration and insulin administration. Histopathological findings are variable, and no comprehensive hypothesis explains the atypical cases reported. CONCLUSION DS is a rare neurological manifestation of DM. If adequately treated, although treatment guidelines are lacking, the prognosis is good and life-threatening complications may occur occasionally. During chorea/hemiballism, we recommend blood glucose and HbA1c evaluation. Further studies are needed to understand the pathogenesis.
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Affiliation(s)
- A Arecco
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, 16132, Genoa, Italy
| | - S Ottaviani
- Section of Geriatrics, Department of Internal Medicine and Medical Specialties, University of Genova, 16132, Genoa, Italy
| | - M Boschetti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, School of Medical and Pharmaceutical Sciences, University of Genova, 16132, Genoa, Italy.
- IRCCS Ospedale Policlinico San Martino, 16132, Genoa, Italy.
| | - P Renzetti
- IRCCS Ospedale Policlinico San Martino, 16132, Genoa, Italy
| | - L Marinelli
- IRCCS Ospedale Policlinico San Martino, 16132, Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, 16132, Genoa, Italy
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Karthik V, Jabbar PK, Nair A, Basheer S. Diabetic striatopathy in type 1 diabetes mellitus: a rare conundrum. BMJ Case Rep 2023; 16:e257448. [PMID: 38160036 PMCID: PMC10759014 DOI: 10.1136/bcr-2023-257448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Abstract
Diabetic striatopathy is a clinicoradiological syndrome characterised by acute hyperkinetic movement disorder in the form of hemichorea-hemiballism with basal ganglia abnormalities in neuroimaging. The hallmark basal ganglia abnormalities appear as hyperdensities in CT brain and hyperintensities in MRI brain, which could mislead the clinician towards an erroneous diagnosis of cerebral haemorrhage. It is classically described in elderly patients with type 2 diabetes mellitus, and its occurrence in type 1 diabetes is extremely rare. This case report entails the clinical details of a young man in his 20s with type 1 diabetes mellitus who had uncontrolled blood glucose levels and presented with a recent onset of abnormal movements in his left upper and lower limbs. The semiology, biochemistry and radiological investigation findings and treatment are detailed. A clear understanding of the condition could lead to an early diagnosis, spare the patient unnecessary investigations and improve treatment outcomes.
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Affiliation(s)
- Vijayakumar Karthik
- Endocrinology, Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | | | - Abilash Nair
- Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
| | - Shameer Basheer
- Government Medical College Thiruvananthapuram, Thiruvananthapuram, Kerala, India
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Liang ZY, Lu ZH, Qu JF, Chen YK. Clinical and imaging associations for non-ketotic hyperglycemic chorea: a case-control study. Front Endocrinol (Lausanne) 2023; 14:1323942. [PMID: 38189042 PMCID: PMC10769489 DOI: 10.3389/fendo.2023.1323942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/01/2023] [Indexed: 01/09/2024] Open
Abstract
Background The non-ketotic hyperglycemic chorea (NKHC) was a rare complication for patients with diabetes mellitus, but not been well studied. In the present research, we aimed to investigate the clinical and imaging characteristics of NKHC and explore the potential association. Methods We performed a case-control study with patients diagnosed as NKHC. The patients with group of NKHC were retrospectively recruited, while the matched group were set to screened patients with diabetes mellitus but no NKHC at a 1:3 ratio. The clinical and imaging data were collected for all the participants of the two groups. Firstly, Correlation analysis was conducted to test the difference of all the variables between the NKHC group and matched group. Then, the putative associated factors for NKHC were further identified. Results Eleven men and 9 women with NKHC and 60 matched participants were analyzed. The mean age of the NKHC group was 68.5 ± 14.9 years. Participants with NKHC were more likely to have a higher glycosylated hemoglobin (HbA1c) level (13 ± 2.82 vs. 10.57 ± 2.71, P<0.001), and a higher frequency of renal dysfunction (estimated glomerular filtration rates <60 ml/min/1.73m2) (55% vs. 20%, P=0.005). Logistic regression analyses showed that both higher HbA1c and renal dysfunction were significantly correlated with NKHC. Conclusion A higher value of HbA1c and renal dysfunction may be associated with the occurrence of NKHC.
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Affiliation(s)
- Zhuo-Yuan Liang
- Department of Neurology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People’s Hospital), Dongguan, Guangdong, China
- Intelligent Brain Imaging and Brain Function Laboratory (Dongguan Key Laboratory), Dongguan People’s Hospital, Dongguan, Guangdong, China
| | - Zhi-Hao Lu
- Department of Neurology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People’s Hospital), Dongguan, Guangdong, China
- Intelligent Brain Imaging and Brain Function Laboratory (Dongguan Key Laboratory), Dongguan People’s Hospital, Dongguan, Guangdong, China
| | - Jian-Feng Qu
- Department of Neurology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People’s Hospital), Dongguan, Guangdong, China
- Intelligent Brain Imaging and Brain Function Laboratory (Dongguan Key Laboratory), Dongguan People’s Hospital, Dongguan, Guangdong, China
| | - Yang-Kun Chen
- Department of Neurology, The Tenth Affiliated Hospital of Southern Medical University (Dongguan People’s Hospital), Dongguan, Guangdong, China
- Intelligent Brain Imaging and Brain Function Laboratory (Dongguan Key Laboratory), Dongguan People’s Hospital, Dongguan, Guangdong, China
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14
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Zhu SH, Peng JJ, Li KF, Peng JC, Li J. Non-ketotic hyperglycaemic hemichorea-hemiballismus with Fahr's disease in a Chinese family: a case report. Int J Neurosci 2023; 133:1242-1246. [PMID: 35510430 DOI: 10.1080/00207454.2022.2074846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 04/18/2022] [Accepted: 04/27/2022] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Non-ketotic hyperglycaemic hemichorea-hemiballismus (NHHH) is often secondary to middle-aged and elderly diabetic people with poor-controlled diabetes; Fahr's disease (FD) is another rare neurological disorder characterized by abnormal calcified deposits in the brain that control movement. We described a rare case of NHHH combined with a heterozygous mutation (SLC20A2) resulting in one family with FD. CASE PRESENTATION The patient has a 30-day history of involuntary choreic movements of the left limbs and left face. In addition, he had a bit of speech slurred and walked unsteadily. He was diagnosed with type 2 diabetes mellitus two months ago. Over the past two months, he had noticed that urination, appetite, and water volume increased obviously and weight loss drastically. Other problems such as dizziness, headache, difficulty swallowing, nausea, and vomiting did not occur. T1- weighted MRI indicts characteristic contralateral basal ganglia hyper-intensity. During hospitalization, he was injected insulin and oral haloperidol. And the clinical symptoms improved, but parkinsonism symptoms emerge soon after discharge. The parkinsonism symptoms were gradually improved after adjusting medications. Combined with the subsequent genetic test results, we attribute it to NHHH with FD. CONCLUSION It is relatively rare that NHHH or FD is both presents. We should use antipsychotics with caution in these patients to avoid parkinsonism symptoms.
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Affiliation(s)
- Si-Huan Zhu
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
- Graduate School, Anhui University of Traditional Chinese Medicine
| | - Jin-Jin Peng
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
- Graduate School, Anhui University of Traditional Chinese Medicine
| | - Ke-Fan Li
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
- Graduate School, Anhui University of Traditional Chinese Medicine
| | - Jian-Cheng Peng
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
- Graduate School, Anhui University of Traditional Chinese Medicine
| | - Jun Li
- Department of Neurology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, China
- Graduate School, Anhui University of Traditional Chinese Medicine
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15
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Sperotto R, Ceccarelli L, Tereshko Y, Merlino G, Gigli GL, Valente M. The Possible Precipitating Role of SARS-CoV-2 in a Case of Late-Onset Hemichorea Due to a Hyperosmolar Hyperglycemic State: Case Report and Brief Literature Review. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1949. [PMID: 38003998 PMCID: PMC10673596 DOI: 10.3390/medicina59111949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/18/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023]
Abstract
Case report: An 83-year-old Italian female developed postural instability and gait disturbance associated with a concomitant hyperosmolar hyperglycemic state. Brain CT and MRI scans detected a lesion in the right putamen due to metabolic derangement. A month later, the patient started suffering from choreic movements along the left side of the body with brachio-crural distribution, approximately three weeks after SARS-CoV-2 infection. She was treated with tetrabenazine with complete resolution of the aberrant movements. Any attempt to reduce tetrabenazine caused a relapse of the symptoms. Discussion: In diabetic patients, choreic syndrome should be considered a rare event with a benign prognosis and favorable response to treatment. It is the result of a condition known as "diabetic striatopathy". The association of new-onset choreic movements, an episode of hyperglycemia, and a basal ganglia lesion is suggestive of this condition. Its pathophysiology remains unclear, and a lot of hypotheses are still debated. SARS-CoV-2 might have played a role in triggering the patient's motor symptoms. Conclusions: Our case report agrees with the general features of those reported in the literature about movement disorders in diabetic patients. The late onset of symptoms and the poor response to treatment seem to be atypical characteristics of the syndrome. Although speculative, we cannot exclude the role of SARS-CoV-2. This case can be added to the literature for further studies and reviews.
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Affiliation(s)
- Roberto Sperotto
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Laura Ceccarelli
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Yan Tereshko
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
| | - Gian Luigi Gigli
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology Unit, Udine University Hospital, Piazzale Santa Maria della Misericordia 15, 33100 Udine, Italy
- Department of Medicine (DAME), University of Udine, 33100 Udine, Italy
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16
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Inoue H, Kusano E, Shinkai Y, Ito H. A Case of Diabetic Chorea Secondary to Appetite Loss Due to COVID-19 Vaccination. Cureus 2023; 15:e49138. [PMID: 38130532 PMCID: PMC10733162 DOI: 10.7759/cureus.49138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/20/2023] [Indexed: 12/23/2023] Open
Abstract
A 76-year-old woman with type 2 diabetes mellitus was admitted to our hospital with a complaint of involuntary movements of the limbs and face. Brain MRI demonstrated a bilateral high signal of putamen on the T1 weighted image, and she was diagnosed with diabetic chorea. She took a second dose of the COVID-19 vaccine 28 days before admission and lost her appetite. Consequently, her HbA1c level on admission decreased from 13.5% to 10.0% in 28 days. This case suggests that diabetic chorea could be induced by the rapid amelioration of a hyperglycemic state due to appetite loss after COVID-19 mRNA vaccination.
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Affiliation(s)
- Hideyuki Inoue
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, JPN
| | - Eiji Kusano
- Department of Internal Medicine, Wasshoi Clinic, Tokyo, JPN
| | | | - Hiroyuki Ito
- Department of Diabetes, Metabolism and Kidney Disease, Edogawa Hospital, Tokyo, JPN
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17
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LeDoux MS. Persistent hemichoreoathetosis-hemidystonia after nonketotic hyperosmolar hyperglycemia. Clin Park Relat Disord 2023; 9:100221. [PMID: 37927362 PMCID: PMC10623360 DOI: 10.1016/j.prdoa.2023.100221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 09/16/2023] [Accepted: 10/05/2023] [Indexed: 11/07/2023] Open
Abstract
Most commonly, hemichorea associated with nonketotic and ketotic hyperglycemia resolves with normalization of blood glucose. Herein, we present a case of hyperosmolar hyperglycemic left hemichoreoathetosis-hemidystonia that has persisted for over 1 year. The subject presented to the emergency room with dysarthria and manifested left hemichoreoathetosis-hemidystonia within 36 h of admission. Initial computed tomography (CT) showed hyperdensity in the right putamen and left caudate. Magnetic resonance imaging (MRI) showed T1 hyperintensity within the right putamen. Failure to detect these classic imaging abnormalities during hospitalization resulted in a delayed etiologic diagnosis. Modest symptomatic improvement in the severity of hemichoreoathetosis-hemidystonia has been noted with low dose tetrabenazine.
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Affiliation(s)
- Mark S. LeDoux
- Veracity Neuroscience, 5050 Poplar Avenue, Suit 511, Memphis, TN 38157, United States
- University of Memphis, Memphis, TN, United States
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18
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Kim YS, Park DG, Shin IJ, An YS, Yoon JH. Striatal Hyperperfusion Observed in Dual-Phase 18F-FP-CIT PET Imaging of Hyperglycemic Chorea. Clin Nucl Med 2023; 48:881-882. [PMID: 37682604 DOI: 10.1097/rlu.0000000000004808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Abstract
ABSTRACT A 76-year-old woman with a history of diabetes mellitus presented with right-side dominant generalized chorea. At presentation, her blood glucose level was 500 mg/dL with an HbA1C of 11%. Because the patient had been on levodopa treatment from her primary physician, a dual-phase 18F-FP-CIT PET scan was performed. The early-phase images showed increased perfusion in the bilateral striatum, and the delayed-phase images revealed decreased uptake in the left caudate. Hyperperfusion in the striatum may indicate the acute phase of hyperglycemic chorea. This image illustrates the advantage of adding early-phase scans in 18F-FP-CIT PET in differentiating various hyperkinetic and hypokinetic disorders.
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Affiliation(s)
| | | | | | - Young Sil An
- Nuclear Medicine, Ajou University School of Medicine, Suwon, South Korea
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19
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Ganessane E, Nathan B, Balaraman N, Uthayakumar A, Karn S. Nonketotic Hyperglycemic Hemichorea in an Elderly Male: A Case Report. J Emerg Med 2023; 65:e234-e236. [PMID: 37500419 DOI: 10.1016/j.jemermed.2023.04.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/10/2023] [Accepted: 04/10/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Nonketotic hyperglycemic hemichorea is a rare complication of diabetes mellitus seen in the emergency department. It is most commonly reported in elderly women, predominantly of Asian race, with poorly controlled diabetes mellitus. Patients present with a triad of nonketotic hyperglycemia, hemichorea, and contralateral basal ganglia abnormality on imaging. Its exact pathophysiology is still not known. However, it has a very good prognosis with early diagnosis and treatment. CASE REPORT We report a case of hemichorea involving the right upper and lower limbs due to nonketotic hyperglycemia. The patient's symptoms resolved after normalization of blood glucose. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Nonketotic hyperglycemic hemichorea should be included in the differential of a patient presenting with chorea and high blood glucose levels. It has an excellent prognosis with both symptoms and imaging abnormalities typically resolving completely with restoration of normoglycemia.
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Affiliation(s)
- Ezhilkugan Ganessane
- Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India.
| | - Balamurugan Nathan
- Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Nithya Balaraman
- Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Amaravathi Uthayakumar
- Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
| | - Shivani Karn
- Department of Emergency Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry, India
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20
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Chithrapathra KE, Hewanayake WS, Egodage S, Silva S. Diabetic Striatopathy: A Case Report of a Patient With Poor Glycaemic Control and Abnormal Movements. Cureus 2023; 15:e45581. [PMID: 37868561 PMCID: PMC10587642 DOI: 10.7759/cureus.45581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Abstract
Diabetic striatopathy (DS) is a condition occurring in individuals with type II diabetes mellitus (T2DM) where there are abnormal (usually single-sided) bodily movements (hemiballismus-hemichorea (HBHC)). DS involves the interaction between diabetes leading to damage to areas such as the striatum with the development of a noticeable hyperkinetic movement disorder. Here, we present a case of a 72-year-old man with T2DM, ischaemic heart disease, and dyslipidaemia, who presented with involuntary movements of the bilateral upper limbs (the left side more affected than the right) for three weeks along with progressively worsening subtle involuntary movements of the mouth and tongue, with intact speech, swallowing, and gait. The neurological examination revealed high-amplitude intermittent, sudden onset involuntary movements of the bilateral upper limbs, primarily affecting the left side. Based on clinical findings, which were supported by imaging studies, a diagnosis of diabetic striatopathy was made. His presentation was beyond the classical presentation of unilateral involvement seen in HBHC, but with early identification and strict glycemic control, satisfactory improvement of his clinical status was achieved.
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Affiliation(s)
| | | | | | - Shehan Silva
- Medicine, University of Sri Jayawardenapura, Gangodawila, LKA
- Internal Medicine, Colombo South Teaching Hospital, Kalubowila, LKA
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21
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Dhar SK, Jafri AD, Fatima K, Samant S, Samal S, Maiti S. Study of Involuntary Limb Movements as a Presenting Feature in Nonketotic Hyperglycemia. Cureus 2023; 15:e43579. [PMID: 37719546 PMCID: PMC10503595 DOI: 10.7759/cureus.43579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/16/2023] [Indexed: 09/19/2023] Open
Abstract
Background Hyperglycaemia can rarely manifest as hemichorea/hemiballismus, which subsides with adequate control of blood sugar. Our study accounted for patients with abnormal, involuntary limb movements with high blood sugar, excluding other conditions leading to or mimicking such a clinical appearance. It is very important to identify such patients as chorea secondary to an underlying etiology like hyperglycemia, which can be cured. Material & methods This study was done in IMS & SUM Hospital for a duration of one year, from March 2019 to February 2020, with a total of 11 cases with abnormal limb movements with a blood sugar of 250 mg% and above. Results In this study, 36.36%( n=4) of patients were female, and 63.63% (n=7) were males. The mean age of the patients at presentation was 66.5 years. Eighteen point one percent (18.1%; n=2) of the patients showed hemiballismus, 36.3% (n=4) showed hemichorea, 18.1% (n=2) showed hemiathetosis, 9.1% (n=1) showed myoclonus, and 18.1% (n=2) showed hemiballismus with hemichorea. The mean duration to correct hyperglycemia was found to be 34 hours and the mean duration to correct abnormal limb movements was 90.54 hours. Eighty-one point eight percent (81.8%; n=9) of patients showed basal ganglia changes on brain imaging.
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Affiliation(s)
- Srikant K Dhar
- Department of Medicine, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneshwar, IND
| | - Asif D Jafri
- Department of Medicine, SUM Ultimate Hospital, Bhubaneshwar, IND
| | - Kaneez Fatima
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Bhubaneswar, Bhubaneswar, IND
| | - Swati Samant
- Department of Ophthalmology, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, IND
| | - Sonam Samal
- Department of Medicine, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, IND
| | - Sourav Maiti
- Department of Medicine, Institute of Medical Sciences (IMS) and SUM Hospital, Bhubaneswar, IND
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22
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Nahid E, Gupta S, Prasad K, Saha AK, Meher MP, Meena LP. Diabetic striatopathy in an adult with ketotic hyperglycaemia. THE NATIONAL MEDICAL JOURNAL OF INDIA 2023; 36:229-230. [PMID: 38692636 DOI: 10.25259/nmji_283_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Diabetic striatopathy (DS) is a rare and life-threatening mani- festation of diabetes. The disease commonly affects individuals of Asian descent, women and the elderly. DS is characterized by dyskinesias with basal ganglia hyperintensities on imaging. Despite being rare, prompt recognition of a hyperglycaemia- induced hemichorea-hemiballismus is essential because the symptoms are reversible with correction of hyperglycaemia. Diagnosis is based on blood analysis and neuroimaging findings. Laboratory tests reveal raised glycosylated haemoglobin (HbA1c) levels, which indicate poorly controlled diabetes. Neuroimaging provides suggestive findings of DS. It is usually associated with non-ketotic hyperglycaemia. We report a 50-year-old woman who presented with ketotic hyperglycaemia and left-sided hemichorea and partial seizures with secondary generalization.
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Affiliation(s)
- Eram Nahid
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
| | - Saumya Gupta
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
| | - Kshitij Prasad
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
| | - Anish Kumar Saha
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
| | - Mukti Prakash Meher
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
| | - L P Meena
- Department of General Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221005, Uttar Pradesh, India
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23
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Weinstein RM, Gowda PC, Yuan F, Khalil A, Motaghi M, Garg T, Gong AJ, Lin DD, Weiss CR. Risk factors and clinical features associated with basal ganglia manganese deposition in patients with hereditary hemorrhagic telangiectasia. Clin Imaging 2023; 101:183-189. [PMID: 37390610 DOI: 10.1016/j.clinimag.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 06/06/2023] [Accepted: 06/16/2023] [Indexed: 07/02/2023]
Abstract
BACKGROUND T1-hyperintensity of the basal ganglia (BG) due to manganese deposition is a known radiologic finding in patients with hereditary hemorrhagic telangiectasia (HHT), but risk factors and associated clinical manifestations are unclear. This study conducted a quantitative analysis of the association of T1-hyperintensity in HHT patients with specific risk factors, signs, and symptoms. METHODS Patients seen at our center between 2005 and 2020 with a definitive diagnosis of HHT who had an available non-contrast T1-weighted brain MRI were included. Hyperintensity was evaluated using oval regions of interest measurements. The BG: thalamus intensity ratio was used to quantitatively evaluate T1-hyperintensity. Patient laboratory values and clinical findings were collected from electronic medical records. Hyperintensity was analyzed for its association with laboratory values, and clinical findings. Variables were analyzed through regression analysis. RESULTS A total of 239 patients were included in this study. On 1.5 T scanners, values that were significant on multivariable regression analysis were age (p < .001), hepatic AVMs (p < .001), iron deficiency anemia (p = .0021), and cirrhosis (p = .016). On 3 T scanners, values that were significant on multivariable analysis were hepatic AVMs (p = .0024) and cirrhosis (p = .0056). On 3 T scanners, hyperintensity was significantly associated with tremor (OR = 1.17, p = .033), restless leg syndrome (OR = 1.22, p = .0086), and memory problems (OR = 1.17, p = .046). CONCLUSIONS BG hyperintensity due to manganese deposition is significantly associated with hepatic risk factors on 1.5 T and 3 T scanners and iron deficiency anemia on 1.5 T scanners. On 3 T scanners, T1-hyperintensity is associated with neuropsychiatric signs and symptoms, such as tremor, restless leg syndrome, and memory problems.
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Affiliation(s)
- Robert M Weinstein
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Prateek C Gowda
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Frank Yuan
- The Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiologic Science, Division of Interventional Radiology, United States of America
| | - Adham Khalil
- The Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiologic Science, Division of Interventional Radiology, United States of America
| | - Mina Motaghi
- Georgia Southern University, Jiann-Ping Hsu College of Public Health, Department of Biostatistics, Epidemiology and Environmental Health Sciences, United States of America
| | - Tushar Garg
- The Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiologic Science, Division of Interventional Radiology, United States of America
| | - Anna J Gong
- The Johns Hopkins University School of Medicine, Baltimore, MD, United States of America
| | - Doris D Lin
- The Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiologic Science, Division of Neuroradiology, United States of America
| | - Clifford R Weiss
- The Johns Hopkins University School of Medicine, Russell H. Morgan Department of Radiology and Radiologic Science, Division of Interventional Radiology, United States of America.
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Alkhaja OY, Alsetrawi A, AlTaei T, Taleb M. Diabetic striatopathy unusual presentation with ischemic stroke-A case report and literature review. Radiol Case Rep 2023; 18:2297-2302. [PMID: 37153487 PMCID: PMC10159814 DOI: 10.1016/j.radcr.2023.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 03/07/2023] [Accepted: 03/15/2023] [Indexed: 05/09/2023] Open
Abstract
Diabetic striatopathy (DS) is a rare condition present as a combination of hemichorea or hemiballismus with striatal computed tomography (CT) or magnetic resonance imaging (MRI) changes in the presence of a severely hyperglycemic state. Varying severity and manifestations of DS were reported throughout the literature. However, the exact pathogenesis and mechanism remain unclear. In this case report, we are presenting an unusual case of DS combined with acute ischemic stroke. A 74-year-old male presented with the main complaint of acute left arm and leg weakness, and was found to have significantly high blood sugar and evidence of DS in combination with stroke on CT and MRI. Eventually, he was labeled as a case of combined DS and ischemic stroke.
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25
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Khan F, Matta S, Malik K, Shayuk M. A Case of Bilateral Hyperglycemic Nonketotic Chorea in an 83-year-old Woman With Normal Brain Imaging. JCEM CASE REPORTS 2023; 1:luad024. [PMID: 37908463 PMCID: PMC10580400 DOI: 10.1210/jcemcr/luad024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Indexed: 11/02/2023]
Abstract
Bilateral hyperglycemic nonketotic chorea is a rare complication of hyperglycemia. In most cases, the literature illustrates patients presenting with unilateral chorea with image findings significant for hyperintense lesions in the basal ganglia on magnetic resonance imaging (MRI) or hyperdensities on computerized tomography (CT). Here, we present a case of an 83-year-old patient who was admitted to the hospital due to acute onset of orofacial and bilateral upper extremity chorea. She had no previous history of infection, genetic mutation, neoplasms, neurodegeneration, stroke, metabolic disease, drug exposure, or autoimmune disease. Surprisingly, her MRI showed only chronic microvascular changes in periventricular white matter without basal ganglia abnormalities. However, she was noted to have marked worsening of her glycemic control over the preceding 12 months based on worsening glycated hemoglobin (HbA1c) levels and elevated serum glucose on presentation. A literature review indicates that chorea caused by hyperglycemia is at times reversible with glycemic control, but as demonstrated in our patient, this is not always necessarily the case. A similar course has only been elaborated in a few other cases in the literature. We will also review the pathogenesis, the usual disease clinical course and standard treatment from the literature.
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Affiliation(s)
- Fahad Khan
- Department of Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, IL 60050, USA
| | - Siddharth Matta
- Department of Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, IL 60050, USA
| | - Komal Malik
- Department of Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, IL 60050, USA
| | - Maryna Shayuk
- Department of Internal Medicine, Northwestern Medicine McHenry Hospital, McHenry, IL 60050, USA
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26
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Chen X, Ma C, Zhi L, Wei X, Luo J, Liang C, Tan J, Zhou H, Wu J. Hemichorea associated with nonketotic hyperglycemia: A case series of 16 patients and literature review. J Clin Endocrinol Metab 2023:7044762. [PMID: 36800278 DOI: 10.1210/clinem/dgad077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/01/2023] [Accepted: 02/06/2023] [Indexed: 02/18/2023]
Abstract
INTRODUCTION Hemichorea associated with nonketotic hyperglycemia (HC-NH) is a rare diabetic complication, in which the pathogenesis remains unclear. This study reported 16 cases of HC-NH to improve the understanding of the disease and avoid misdiagnosis and missed diagnosis. METHODS Data of 16 patients with HC-NH in a single center from 2000 to 2021 were analyzed retrospectively, and the relevant literature was reviewed. RESULTS The subjects (8 males and 8 females) had a mean age of 67.6±16.4 years. Bilateral limbs were involved in 2 cases, and the others had hemichorea (6 in the left side and 8 in the right side). The average random blood glucose level was 17.51±7.67 mmol/L, and the glycated hemoglobin level was 11.9%±3.1% at admission. Eleven patients had a history of diabetes, and the other five patients were diagnosed with new-onset diabetes mellitus, but no remarkable differences were observed in the presentation or treatment of chorea. Ketonuria was detected in seven patients. The basal ganglia (putamen, globus pallidus, and caudate nucleus) of nine cases had typical hyperdensity on computed tomography and/or hyperintensity signals from magnetic resonance imaging. The chorea symptoms of 15 patients improved within 5.0 ± 1.9 days after treatment. CONCLUSION This study provides additional valuable information about the clinical and neuroimaging features of HC-NH. We hypothesize that chronic ischemia of the basal ganglia due to cerebral atherosclerosis combined with hyperglycemia is associated with HC-NH.
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Affiliation(s)
- Xiaoming Chen
- Department of Endocrinology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Choudi Ma
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Lijin Zhi
- Department of Endocrinology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Xiaodan Wei
- Department of Endocrinology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Jiaxin Luo
- First College of Clinical Medicine, Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Chanbo Liang
- Department of Endocrinology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Jieping Tan
- Department of Endocrinology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Haihong Zhou
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
| | - Jiayuan Wu
- Clinical Research Service Center, Affiliated Hospital of Guangdong Medical University, Zhanjiang, Guangdong Province, 524001, China
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The youngest patient with hemi-chorea and diabetic ketoacidosis as presenting manifestation of type 1 diabetes mellitus from India. Int J Diabetes Dev Ctries 2023. [DOI: 10.1007/s13410-023-01171-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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Muacevic A, Adler JR, Degueure A, Saad Aldine A, Arevalo O. Atypical Imaging Findings of Nonketotic Hyperglycemic Hemichorea: A Case Report and Review of the Literature. Cureus 2023; 15:e34269. [PMID: 36855488 PMCID: PMC9968442 DOI: 10.7759/cureus.34269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
Nonketotic hyperglycemic hemichorea (NH-HC) is a rare condition presenting in the clinical setting. Brain imaging plays an important role in diagnosing NH-HC, which typically shows basal ganglia changes contralateral to the side of the hemiballismus/hemichorea. Only a few articles in the literature have reported normal pertinent magnetic resonance/CT findings in patients presenting with NH-HC. To the authors' knowledge, no cases in the literature have reported basal ganglia changes solely observed on CT but not on MRI in patients presenting with NH-HC. Herein, we describe a unique case in which a CT of a patient presenting with NH-HC demonstrated basal ganglia abnormalities with negative MRI findings.
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Lau SCX, Tan SMY. Nonketotic Hyperglycemic Hemichorea. Am J Med 2023; 136:e12-e13. [PMID: 36170939 DOI: 10.1016/j.amjmed.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 09/05/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Samuel C X Lau
- Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore
| | - Sandra M Y Tan
- Division of Advanced Internal Medicine, University Medicine Cluster, National University Hospital, Singapore, Singapore.
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Zheng J, Wu X. Chorea: An unusual manifestation of endocrine diseases. Front Endocrinol (Lausanne) 2023; 14:1155638. [PMID: 36936169 PMCID: PMC10020596 DOI: 10.3389/fendo.2023.1155638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/20/2023] [Indexed: 03/06/2023] Open
Abstract
Chorea is a movement disorder involving involuntary movements of muscles of the face, neck, and limbs, usually caused by basal ganglia lesions. As an important part of the presentation of many neurological diseases, chorea is also an unusual manifestation of endocrine diseases and can be challenging to diagnose. Although the most common etiology of chorea is genetic, it is vital to identify acquired or symptomatic chorea, as these are potentially treatable conditions. This review summarizes the latest developments in various endocrine disease-related chorea, which will help clinicians to correctly identify and accurately treat it.
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Bhandari SK, Kharel H, Gajurel BP, Karn R, Rajbhandari R, Gautam N, Shrestha A, Ojha R. Chorea hyperglycemia basal ganglia syndrome: A case report from Nepal. SAGE Open Med Case Rep 2022; 10:2050313X221141533. [PMID: 36507060 PMCID: PMC9729991 DOI: 10.1177/2050313x221141533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/09/2022] [Indexed: 12/12/2022] Open
Abstract
A rare case of chorea hyperglycemic basal ganglia syndrome in a 56-year-old woman who presented with left-sided hemichorea in the setting of uncontrolled, non-ketotic, type II diabetes mellitus is reported. Early blood glucose control could lead to complete resolution of symptoms. Despite an excellent prognosis, delayed recognition and management can lead to prolong disability due to movement disorder.
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Affiliation(s)
- Samikchhya Keshary Bhandari
- Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Kathmandu, Nepal,Samikchhya Keshary Bhandari, Maharajgunj Medical Campus, Tribhuvan University Institute of Medicine, Maharajgunj, Kathmandu 44600, Nepal.
| | - Himal Kharel
- Department of Internal Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Bikram Prasad Gajurel
- Department of Neurology, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Ragesh Karn
- Department of Neurology, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Reema Rajbhandari
- Department of Neurology, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Niraj Gautam
- Department of Neurology, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Ashish Shrestha
- Department of Neurology, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
| | - Rajeev Ojha
- Department of Neurology, Tribhuvan University Institute of Medicine, Kathmandu, Nepal
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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] [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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Diabetic Striatopathy: Parenchymal Transcranial Sonography as a Supplement to Diagnosis at the Emergency Department. Diagnostics (Basel) 2022; 12:diagnostics12112838. [PMID: 36428898 PMCID: PMC9689337 DOI: 10.3390/diagnostics12112838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
Background: Diabetic striatopathy (DS) is a rare condition with a debated pathophysiology; a local metabolic dysfunction is the most likely hypothesis. We present a case of DS mimicking an acute stroke, outline a few uncommon/atypical features, and report for the first time the parenchymal transcranial sonography (pTCS) findings. Case Report: An 86-year-old man, treated for insulin-dependent diabetes, presented at an emergency department because of the occurrence of isolated choreo-athetotic movements in his left limbs with fluctuations in the location, frequency, and duration. The blood glucose level was 569 mg/dL. Both urgent and follow-up brain computed tomography (CT) were negative for recent lesions whereas pTCS revealed hyperechogenicity in the right lenticular nucleus. Subsequent magnetic resonance imaging (MRI) showed T1-weighted hyperintensity in the right putamen with negative diffusion-weighted imaging. The symptoms were responsive to glucose control and haloperidol administration, although they persisted during sleep. Conclusions: Unlike previously described cases characterized by hemichorea and/or hemiballism, our patient presented with a stroke-like onset of unilateral irregular choreo-athetotic movements. Notably, based on CT alone, it would not have been possible to distinguish DS from a stroke. In this scenario, the pTCS hyperechogenicity of the right lenticular nucleus helped to hypothesize a metabolic disorder, which was subsequently confirmed by MRI.
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Ottaviani S, Arecco A, Boschetti M, Ottaviani E, Renzetti P, Marinelli L. Prevalence of diabetic striatopathy and predictive role of glycated hemoglobin level. Neurol Sci 2022; 43:6059-6065. [PMID: 35922720 PMCID: PMC9474514 DOI: 10.1007/s10072-022-06304-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 07/25/2022] [Indexed: 11/30/2022]
Abstract
Abstract
Background
Diabetic striatopathy is defined as a state of hyperglycemia associated with chorea/ballism, striatal hyperdensity at CT, or hyperintensity at T1-weighted MRI. It is considered a rare complication of uncontrolled diabetes but prevalence data are scarce.
Objectives
Characterize diabetic striatopathy prevalence in the population afferent to the largest teaching hospital in Genova (Liguria, Italy) and investigate the role of glycated hemoglobin level in predicting the risk.
Methods
Data were retrospectively obtained from general population undergoing blood sampling for glycated hemoglobin and resulting with HbA1c values ≥ 8%, from January 2014 to June 2017. Brain neuroimaging of those who underwent at least a brain CT or MRI was examined in search of findings compatible with diabetic striatopathy and clinical information was collected. Logistic regression was used to predict the risk of diabetic striatopathy based on age and HbA1c values.
Results
Subjects with uncontrolled diabetes were 4603. Brain neuroimaging was available in 1806 subjects and three patients with diabetic striatopathy were identified, all of them reporting choreic movements. The prevalence of hemichorea due to diabetic striatopathy was therefore 3 cases out of 1806 (0.16%) in our population. Hepatic and hypoxic encephalopathies were the conditions most frequently mimicking diabetic striatopathy. Odds ratio of diabetic striatopathy and HbA1c level was significantly correlated (p = 0.0009).
Conclusions
To the best of our knowledge, this study is the first to evaluate the prevalence of diabetic striatopathy in Italy. High HbA1c values may have a role in predicting diabetic striatopathy.
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Affiliation(s)
- Silvia Ottaviani
- Section of Geriatrics, Department of Internal Medicine and Medical Specialties, University of Genova, Genoa, Italy
| | - Anna Arecco
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, University of Genova, Genoa, Italy
| | - Mara Boschetti
- Endocrinology Unit, Department of Internal Medicine and Medical Specialties, University of Genova, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Endocrinology Unit, Genoa, Italy
| | - Ennio Ottaviani
- Department of Mathematics, University of Genova, Genoa, Italy
| | - Paolo Renzetti
- Division of Neuroradiology, IRCCS Ospedale Policlinico San Martino IRCCS, Genoa, Italy
| | - Lucio Marinelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy.
- IRCCS Ospedale Policlinico San Martino, Division of Clinical Neurophysiology, Genoa, Italy.
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Miyauchi T, Yoshii M, Oshima T, Tomotsune K, Tomiyasu K. Treatment-resistant diabetic chorea manifesting with psychiatric symptoms: a case report. Neurocase 2022; 28:432-438. [PMID: 36374938 DOI: 10.1080/13554794.2022.2145906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We report a case of a 69-year-old man with treatment-resistant diabetic chorea presenting psychiatric symptoms. The right chorea lasted for 3 months and was refractory to control of diabetes mellitus or administration of haloperidol and benzodiazepines. Only administration of tiapride was efficacious. Magnetic resonance spectrometry and dopamine transporter-single photon emission computed tomography suggested that sustained ischemia at the striatum may lead to impaired expression of dopamine transporters, thereby resulting in deterioration in the indirect pathway. Tiapride inhibited dopamine D2 receptors, thereby restoring the function of the indirect pathway and resulting in improvement of diabetic chorea.
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Affiliation(s)
- Tsubasa Miyauchi
- Department of Neurology, Saiseikai Utsunomiya Hospital, Utsunomiya-city, Tochigi, Japan.,Department of Neurosurgery, Keio University School of Medicine, Shinjuku-ku, Tokyo, Japan
| | - Masami Yoshii
- Department of Neurology, Saiseikai Utsunomiya Hospital, Utsunomiya-city, Tochigi, Japan
| | - Takeo Oshima
- Department of Neurology, Saiseikai Utsunomiya Hospital, Utsunomiya-city, Tochigi, Japan
| | - Ken Tomotsune
- Department of Endocrinology and Nephrology, Saiseikai Utsunomiya Hospital, Utsunomiya-city, Tochigi, Japan
| | - Kazuhiro Tomiyasu
- Department of Neurology, Saiseikai Utsunomiya Hospital, Utsunomiya-city, Tochigi, Japan
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36
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Xu Y, Shi Q, Yue Y, Yan C. Clinical and imaging features of diabetic striatopathy: report of 6 cases and literature review. Neurol Sci 2022; 43:6067-6077. [PMID: 35965280 PMCID: PMC9376124 DOI: 10.1007/s10072-022-06342-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022]
Abstract
Objective To explore the clinical manifestations, diagnosis, treatment, and pathogenesis of diabetic striatopathy (DS) to improve the understanding of the disease and avoid misdiagnosis or underdiagnosis. Methods The clinical, laboratory, and imaging data of 6 patients (5 Asian females and 1 Asian male) with diabetic striatum were analyzed retrospectively, and the related literature was reviewed. Results All 6 patients showed hyperglycemia, 5 patients presented with involuntary movement of unilateral limbs, and 1 with unilateral limb numbness. Besides, 5 patients (except case 3) underwent MRI examinations that showed hyperintensity in unilateral caudate and lentiform nucleus on T1-weighted images. And all 6 patients who underwent brain CT examinations showed hyperdensity or isodensity in unilateral caudate and lentiform nucleus. None had a family history of similar abnormal movements. After blood glucose control and symptomatic support treatment, the symptoms of all patients improved to various degrees, and reexaminations showed that the lesions gradually disappeared. Conclusion Diabetic striatal disease is a rare complication of diabetes mellitus, the result of a combination of different pathogenesis. It is characterized by hyperglycemia, hemichorea, and contralateral striatal T1WI hyperintensity or CT hyperdensity. Both ketosis and nonketotic hyperglycemic hemichorea have typical imaging manifestations. The prognosis is excellent when this disease is detected early, and the lesions can be gradually absorbed and dissipated with glycemic control.
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Affiliation(s)
- Yuanyuan Xu
- Department of Medical Imaging, The Second Affiliated Hospital of Shandong First Medical University, Taian, 271000, Shandong, China
| | - Qiang Shi
- Department of Medical Imaging, The Second Affiliated Hospital of Shandong First Medical University, Taian, 271000, Shandong, China
| | - Yun Yue
- Department of Hyperbaric Oxygen, The Second Affiliated Hospital of Shandong First Medical University, Taian, 271000, Shandong, China
| | - Chengxin Yan
- Department of Medical Imaging, The Second Affiliated Hospital of Shandong First Medical University, Taian, 271000, Shandong, China.
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Nassal M, San Miguel C. Level I Hyperglycemia Alert: A Case Report. Clin Pract Cases Emerg Med 2022; 6:216-219. [PMID: 36049206 PMCID: PMC9436485 DOI: 10.5811/cpcem.2022.2.55160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/04/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Nonketotic hyperglycemia-associated chorea is a rare condition that upon presentation to the emergency department can be easily misdiagnosed as a seizure or a stroke. Although uncommon, identification of this condition can aid emergency physicians in avoiding unnecessary and potentially harmful treatments for other neurological pathology. Furthermore, prompt hyperglycemic control can result in reversal of symptoms within days. Case Report We present a case of nonketotic hyperglycemia-associated chorea where the patient was transferred to our facility as a hemorrhagic stroke alert, based on a false-positive interpretation of head computed tomography (CT) imaging. Conclusion Nonketotic hyperglycemia on CT imaging and clinical presentation can mimic stroke presentations. Prompt recognition of key features can lead to appropriate treatment.
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Affiliation(s)
- Michelle Nassal
- The Ohio State University, Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Christopher San Miguel
- The Ohio State University, Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
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38
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Diabetic Chorea. J Gen Intern Med 2022; 37:2573-2574. [PMID: 35590024 PMCID: PMC9360261 DOI: 10.1007/s11606-022-07651-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
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Movement disorders and neuropathies: overlaps and mimics in clinical practice. J Neurol 2022; 269:4646-4662. [PMID: 35657406 DOI: 10.1007/s00415-022-11200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/16/2022] [Indexed: 10/18/2022]
Abstract
Movement disorders as well as peripheral neuropathies are extremely frequent in the general population; therefore, it is not uncommon to encounter patients with both these conditions. Often, the coexistence is coincidental, due to the high incidence of common causes of peripheral neuropathy, such as diabetes and other age-related disorders, as well as of Parkinson disease (PD), which has a typical late onset. Nonetheless, there is broad evidence that PD patients may commonly develop a sensory and/or autonomic polyneuropathy, triggered by intrinsic and/or extrinsic mechanisms. Similarly, some peripheral neuropathies may develop some movement disorders in the long run, such as tremor, and rarely dystonia and myoclonus, suggesting that central mechanisms may ensue in the pathogenesis of these diseases. Although rare, several acquired or hereditary causes may be responsible for the combination of movement and peripheral nerve disorders as a unique entity, some of which are potentially treatable, including paraneoplastic, autoimmune and nutritional aetiologies. Finally, genetic causes should be pursued in case of positive family history, young onset or multisystemic involvement, and examined for neuroacanthocytosis, spinocerebellar ataxias, mitochondrial disorders and less common causes of adult-onset cerebellar ataxias and spastic paraparesis. Deep phenotyping in terms of neurological and general examination, as well as laboratory tests, neuroimaging, neurophysiology, and next-generation genetic analysis, may guide the clinician toward the correct diagnosis and management.
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Oo TZ, Lim WT. Hemichorea as initial presentation of newly diagnosed diabetes and acute lacunar stroke. PROCEEDINGS OF SINGAPORE HEALTHCARE 2022. [DOI: 10.1177/20101058221147766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Hemichorea is one of the spectrums of involuntary, continuous, non-purposeful movement of one side of the body, a choreiform disorder. Hemichorea causes vary and include various inherited or acquired systemic conditions. There might be overlapping pathophysiology where the synergistic effects of uncontrolled hyperglycemia and vascular insufficiency cause an incomplete transient dysfunction of the striatum, leading to hemichorea. We herein describe a patient who presented with hemichorea triggered by hyperglycemia and was incidentally found to have an acute lacunar stroke. She was initiated on insulin with good glycemic control. Secondary stroke prevention therapy with aspirin and statin was also started. Her symptoms improved inpatient after stable glycemic control was achieved. After 3 months, her symptoms had completely resolved. Hemichorea is an unusual initial presentation for newly diagnosed diabetes mellitus or stroke. Hence, recognizing and diagnosing this uncommon disease entity is pertinent to make a timely and accurate diagnosis, which can lead to a rapid clinical response.
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Affiliation(s)
- Than Zaw Oo
- Department of General Medicine, Sengkang General Hospital, Singapore
| | - Wan Tin Lim
- Department of Internal Medicine, Singapore General Hospital, Singapore
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Yap KH, Baharudin NH, Gafor AHA, Remli R, Lim SY, Zaidi WAW, Azmin S, Mukari SAM, Khalid RA, Ibrahim NM. Movement Disorders Resulting From Bilateral Basal Ganglia Lesions in End-Stage Kidney Disease: A Systematic Review. J Mov Disord 2022; 15:258-263. [PMID: 35614016 PMCID: PMC9536908 DOI: 10.14802/jmd.21185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/19/2022] [Indexed: 12/02/2022] Open
Abstract
Objective The basal ganglia (BG) are susceptible to fluctuations in blood urea levels, sometimes resulting in movement disorders. We described patients with end-stage kidney disease (ESKD) presenting with movement disorders associated with bilateral BG lesions on imaging. Methods We report four patients and systematically reviewed all published cases of ESKD presenting with movement disorders and bilateral BG lesions (EBSCOhost and Ovid). Results Of the 72 patients identified, 55 (76.4%) were on regular dialysis. Parkinsonism was the most common movement disorder (n = 39; 54.2%), followed by chorea (n = 24; 33.3%). Diabetes mellitus (n = 51; 70.8%) and hypertension (n = 16; 22.2%) were the most common risk factors. Forty-three (59.7%) were of Asian ethnicity. Complete clinical resolution was reported in 17 (30.9%) patients, while 38 (69.1%) had incomplete clinical resolution with relapse. Complete radiological resolution occurred in 14 (34.1%) patients. Conclusion Movement disorders associated with BG lesions should be recognized as a rare and potentially reversible metabolic movement disorder in patients with ESKD.
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Affiliation(s)
- Kah Hui Yap
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
| | | | | | - Rabani Remli
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
| | - Shen-Yang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Shahrul Azmin
- Department of Medicine, UKM Medical Center, Kuala Lumpur, Malaysia
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Park G, Kesserwani HN. A Case Report of Diabetic Striatopathy: An Approach to Diagnosis Based on Clinical and Radiological Findings. Cureus 2022; 14:e25089. [PMID: 35733455 PMCID: PMC9205274 DOI: 10.7759/cureus.25089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2022] [Indexed: 11/21/2022] Open
Abstract
Diabetic striatopathy (DS) is an acute hyperkinetic movement disorder characterized by hemiballismus-hemichorea (HBHC) due to nonketotic hyperglycemia. DS manifests a fascinating interplay between endocrinopathy (diabetes), striatal (putamen, caudate nucleus, globus pallidus) pathology, and a dramatic neurological movement disorder, HBHC. The striking hyperintensity on imaging modalities such as computed axial tomography (CT) scan of the brain and T1-weighted magnetic resonance imaging (MRI) of the brain can mislead the clinician to an erroneous diagnosis of a cerebral hemorrhage and/or ischemic infarct, especially in an acute setting. We present an acute case of DS and outline the natural history, semiology, typical radiological findings, and therapeutic options. With careful and thoughtful analysis, an accurate diagnosis can be exacted, sparing the patient unnecessary anxiety and medical costs.
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Dubey S, Chatterjee S, Ghosh R, Louis ED, Hazra A, Sengupta S, Das S, Banerjee A, Pandit A, Ray BK, Benito-León J. Acute onset movement disorders in diabetes mellitus: A clinical series of 59 patients. Eur J Neurol 2022; 29:2241-2248. [PMID: 35403331 PMCID: PMC9542887 DOI: 10.1111/ene.15353] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/29/2022] [Accepted: 04/02/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose No previous study has assessed the frequency and clinical–radiological characteristics of patients with diabetes mellitus (DM) and acute onset nonchoreic and nonballistic movements. We conducted a prospective study to investigate the spectrum of acute onset movement disorders in DM. Methods We recruited all the patients with acute onset movement disorders and hyperglycemia who attended the wards of three hospitals in West Bengal, India from August 2014 to July 2021. Results Among the 59 patients (mean age = 55.4 ± 14.3 years, 52.5% men) who were included, 41 (69.5%) had choreic or ballistic movements, and 18 (30.5%) had nonchoreic and nonballistic movements. Ballism was the most common movement disorder (n = 18, 30.5%), followed by pure chorea (n = 15, 25.4%), choreoathetosis (n = 8, 13.6%), tremor (n = 5, 8.5%), hemifacial spasm (n = 3, 5.1%), parkinsonism (n = 3, 5.1%), myoclonus (n = 3, 5.1%), dystonia (n = 2, 3.4%), and restless leg syndrome (n = 2, 3.4%). The mean duration of DM was 9.8 ± 11.4 years (89.8% of the patients had type 2 DM). Nonketotic hyperglycemia was frequently (76.3%) detected. The majority (55.9%) had no magnetic resonance imaging (MRI) changes; the remaining showed striatal hyperintensity. Eight patients with MRI changes exhibited discordance with sidedness of movements. Most of the patients (76.3%) recovered completely. Conclusions This is the largest clinical series depicting the clinical–radiological spectrum of acute onset movement disorders in DM. Of note was that almost one third of patients had nonchoreic and nonballistic movements. Our findings highlight the importance of a capillary blood glucose measurement in patients with acute or subacute onset movement disorders, irrespective of their past glycemic status.
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Affiliation(s)
- Souvik Dubey
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research &, SSKM Hospital, Kolkata, West Bengal, India
| | - Subhankar Chatterjee
- Department of General Medicine, Patliputra Medical College & Hospital, Dhanbad, Jharkhand, India
| | - Ritwik Ghosh
- Department of General Medicine, Burdwan Medical College, and Hospital, Burdwan, West Bengal, India
| | - Elan D Louis
- Department of Neurology, University of Texas Southwestern, Dallas, TX, United States
| | - Avijit Hazra
- Department of Pharmacology, Institute of Post Graduate Medical Education and Research &, SSKM Hospital, Kolkata, West Bengal, India
| | - Samya Sengupta
- Department of General Medicine, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Shambaditya Das
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research &, SSKM Hospital, Kolkata, West Bengal, India
| | - Abhirup Banerjee
- Department of Endocrinology, N.R.S. Medical College & Hospital, Kolkata, West Bengal, India
| | - Alak Pandit
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research &, SSKM Hospital, Kolkata, West Bengal, India
| | - Biman Kanti Ray
- Department of Neuromedicine, Bangur Institute of Neurosciences, Institute of Post Graduate Medical Education and Research &, SSKM Hospital, 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, Complutense University, Madrid, Spain
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44
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Safan AS, Sharma O, Almasri M, D'Souza AI, Suliman O. Is diabetic striatopathy the culprit of seizures in a patient with ketotic hyperglycemia-induced hemichorea-hemiballismus? BMC Neurol 2022; 22:133. [PMID: 35395738 PMCID: PMC8991619 DOI: 10.1186/s12883-022-02659-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 03/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Diabetic striatopathy is a rare neurological manifestation of nonketotic hyperglycemia that presents with contralateral hemichorea-hemiballismus. Presentation with concurrent seizures is rarely reported. Clinical presentation We report a case of diabetic striatopathy presenting with focal and generalized tonic-clonic seizures (GTCS) with right hemichorea-hemiballismus induced by a ketotic hyperglycemic state. Head MRI showed high T1-weighted signal intensity in the left lentiform nucleus with no significant diffusion restriction or postcontrast enhancement. The patient’s condition gradually improved, with seizure control on AEDs. Hemichorea-hemiballismus significantly improved with adequate blood sugar control and resolved with low-dose haloperidol. Conclusions Diabetic striatopathy presenting with hemichorea-hemiballismus and concurrent GTCS has been reported previously in two cases; however, it has never been reported in ketotic hyperglycemia. To the best of our knowledge, we herein report the first case report of focal and generalized seizures in a ketotic hyperglycemic state and mesial temporal sclerosis.
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Affiliation(s)
- Abeer Sabry Safan
- Department of Neurology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar.
| | - Omna Sharma
- Weill Cornell Medicine-Qatar of Cornell University (WCM-Q), Doha, Qatar
| | - Muna Almasri
- Weill Cornell Medicine-Qatar of Cornell University (WCM-Q), Doha, Qatar
| | | | - Omer Suliman
- Department of Neurology, Neurosciences Institute, Hamad Medical Corporation, Doha, Qatar
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45
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Peddawad D. Epileptic manifestations, pathophysiology, and imaging characteristics of non-ketotic hyperglycaemia: a review of the literature and a report of two cases with irreversible cortical vision loss. J Int Med Res 2022; 50:3000605221081429. [PMID: 35301892 PMCID: PMC8943323 DOI: 10.1177/03000605221081429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The purpose of this review is to create more awareness regarding the epileptic manifestations of non-ketotic hyperglycaemia, which are not widely recognised, and to assist understanding of the pathophysiology involved. Given that type II diabetes is one of the common causes of morbidity worldwide, it is important to appreciate the various neurological manifestations of non-ketotic hyperglycaemia.Here, I present two cases and review the existing literature. Both patients developed irreversible vision loss, which is a novel finding because only transient visual defects have previously been reported. The review includes a detailed discussion of the pathophysiology and characteristic magnetic resonance imaging (MRI) findings of patients with defects in cerebral lobar regions, which were associated with a variety of clinical manifestations. These manifestations can be ascribed to epileptic phenomena involving various parts of the cerebrum.Hyperglycaemia can lead to the irreversible loss of vision. Early diagnosis and treatment on the basis of the clinical features and characteristic MRI findings are important to avoid an epilepsia partialis continua-like state and irreversible visual impairment.
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46
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Tsalta-Mladenov ME, Georgieva DK, Andonova SP. Hyperglycemic hemichorea due to diabetic striatopathy: case-based review. Curr Med Res Opin 2022; 38:365-369. [PMID: 34873977 DOI: 10.1080/03007995.2021.2015159] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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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47
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Yusuf MH, Alharthi MA, Alahmari AS, Abdulaziz GA, Alqahtani AM, Alshalfan FM, Alanazi YS, Alamri SM, Hawsawi AA, Alshaier RA, Almalki AN, Thabet AS, Alhashim AJ, Salawati AM, Al-Hawaj F. Hemichorea: A Rare Neurological Complication of Diabetes Mellitus. Cureus 2022; 14:e21131. [PMID: 35165584 PMCID: PMC8831391 DOI: 10.7759/cureus.21131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/11/2022] [Indexed: 11/05/2022] Open
Abstract
Diabetes mellitus is a prevalent metabolic disorder that has a wide range of complications. Neurological complications are common and include stroke and peripheral neuropathy. However, hemichorea is a very rare manifestation of diabetes mellitus. Chorea can be due to primary inherited conditions or secondary to other disorders. Careful evaluation of patients with chorea is crucial since secondary chorea can be managed with the treatment of the underlying cause. We report the case of a 51-year-old man who presented to the emergency department with a two-week history of sudden involuntary and random-appearing movements of the right upper and lower extremities. These movements were non-suppressible and disappeared during sleep. Further, the movements were not associated with any neurological symptoms, including headache, dizziness, weakness, sensory deficits, or loss of consciousness. The patient had a longstanding history of hypertension and diabetes mellitus. He reported that he was not compliant with his medications. Laboratory investigation revealed a very high level of blood glucose (580 mg/dL) with associated pseudohyponatreamia (127 mEq/L). Head computed tomography scan showed increased density in right caudate nuclei and putamen with no surrounding edema or mass effect. The findings were suggestive of non-ketotic hyperglycemic hemichorea based on the clinical, laboratory, and radiological laboratory findings. The patient received insulin therapy according to sliding-scale protocol. The chorea movements gradually improved and completely disappeared after the fourth day of admission with the normalization of glucose level. In view of this, emergency medicine physicians should consider non-ketotic hyperglycemia as a potential underlying etiology of acute hemichorea.
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Affiliation(s)
| | | | | | | | | | - Fahad M Alshalfan
- College of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, SAU
| | - Yousef S Alanazi
- College of Medicine, Jordan University of Science and Technology, Irbid, JOR
| | - Saeed M Alamri
- College of Medicine, King Abdulaziz University, Jeddah, SAU
| | - Amal A Hawsawi
- General Practice, Al Madina Specialist General Hospital, Medina, SAU
| | | | | | | | | | | | - Faisal Al-Hawaj
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, SAU
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48
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Maia M, Moreira AP, Gonçalves AI, Espírito Santo J, Araújo J. Hemichorea-Hemiballism as a Manifestation of Hyperglycemia. Cureus 2021; 13:e19330. [PMID: 34909293 PMCID: PMC8653868 DOI: 10.7759/cureus.19330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2021] [Indexed: 12/04/2022] Open
Abstract
Hemichorea-hemiballism associated with hyperglycemia is a syndrome characterized by a sudden occurrence of hemichorea, or its more severe expression hemiballism, in patients with non-ketotic hyperglycemia. Hemichorea-hemiballism tends to occur more commonly among elderly people and women of Asian origin. The authors present two rare cases of patients who manifested choreiform and ballistic movements of the limbs and concomitant non-ketotic hyperglycemia. Radiological findings were congruent with hyperglycemia etiology. These cases show that it is important to be aware of hemichorea-hemiballism associated with hyperglycemia, as there is a possible treatment and, if detected early on, a direct impact on prognosis.
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Affiliation(s)
- Maria Maia
- Internal Medicine, Hospital Beatriz Ângelo, Lisboa, PRT
| | | | | | | | - José Araújo
- Internal Medicine, Hospital Beatriz Ângelo, Lisboa, PRT
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49
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Salem A, Lahmar A. Hemichorea-Hemiballismus Syndrome in Acute Non-ketotic Hyperglycemia. Cureus 2021; 13:e19026. [PMID: 34853750 PMCID: PMC8608038 DOI: 10.7759/cureus.19026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2021] [Indexed: 11/05/2022] Open
Abstract
Hemichorea/hemiballismus syndrome secondary to non-ketotic hyperglycemia is a movement disorder induced by long-standing poor control of diabetes mellitus. Diagnosis is based on clinical assessment and imaging. Here we report a rare case of a 56-year-old woman presenting with involuntary movements on the left side secondary to acute hyperglycemia. She received antidiabetic and anti-choreic drugs. The patient's glycemic profile was closely monitored, and she, consequently, responded favorably to therapy.
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Affiliation(s)
- Amr Salem
- Hospital Medicine, Boston University School of Medicine, Boston, USA
| | - Abdelilah Lahmar
- Medicine, University Mohammed VI University Hospital, Faculty of medicine and pharmacy in Oujda, Oujda, MAR
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50
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Marian J, Rizvi F, Lew LQ. Nonketotic Hyperglycemic Chorea in a 10-Year-Old Asian Boy with Diabetes Mellitus. JOURNAL OF PEDIATRIC NEUROLOGY 2021. [DOI: 10.1055/s-0040-1718553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractNonketotic hyperglycemic chorea-ballism (NKHCB), also known as diabetic striato-pathy (DS) by some, is a rare complication of diabetes mellitus and uncommon in children. We reported a case of a 10 11/12-year-old male child of Asian descent with uncontrolled type 1 diabetes mellitus (T1DM), Hashimoto's thyroiditis, and multiple food allergies presenting with bilateral chorea-ballism. His brain magnetic resonance imaging revealed developmental venous anomaly in right parietal lobe and right cerebellum, no focal lesions or abnormal enhancements. Choreiform movements resolved with correction of hyperglycemia. Children and adolescents with a movement disorder should be evaluated for diabetes mellitus, especially with increasing prevalence and insidious nature of T2DM associated with obesity.
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Affiliation(s)
- Julia Marian
- Department of Pediatrics, Flushing Hospital Medical Center, Flushing, New York, United States
| | - Firdous Rizvi
- Department of Pediatrics, Flushing Hospital Medical Center, Flushing, New York, United States
| | - Lily Q. Lew
- Department of Pediatrics, Flushing Hospital Medical Center, Flushing, New York, United States
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