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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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Trinchillo A, Barchetti F, De Joanna G, Esposito M, Piccirillo G, Miniello S. A case of hemichorea associated with nonketotic hyperglycaemia: A new magnetic resonance spectroscopy (MRS) finding and possible future implications. Clin Physiol Funct Imaging 2024; 44:131-135. [PMID: 37961026 DOI: 10.1111/cpf.12865] [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: 04/22/2023] [Accepted: 10/30/2023] [Indexed: 11/15/2023]
Abstract
BACKGROUND Diabetic Striatopathy (DS) is a rare complication of a poor-controlled Diabetes Mellitus consisting of sudden onset of movement disorders. To date, there is still poor knowledge about the pathogenesis. CASE We describe a 79 year old men affected by sudden onset hemichoreic movements whose cause was a non-ketotic hyperglycaemia diagnosed despite the normal blood glucose levels thanks to brain CT and magnetic resonance imaging. Then, we introduce a new magnetic resonance spectroscopy (MRS) finding never described until today which allowed us to produce a new pathogenetic theory of a phenomenon still without definitive explanations. LITERATURE REVIEW We performed a review of DS cases using the Medline database and we extracted main data regarding imaging findings. CONCLUSIONS Thanks to our MRS we show new imaging findings never described until today, with a new pathogenetic explanation, since all the causative hypotheses produced during the past years have never found evidence.
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Affiliation(s)
- Assunta Trinchillo
- Department of Neurosciences, Reproductive Sciences and Odontostomatology, "Federico II" University, Naples, Italy
| | - Flavio Barchetti
- Neuroradiology Unit, Sant'Anna e San Sebastiano Hospital, Caserta, Italy
| | | | - Marcello Esposito
- Department of Neurophysiology, A.O.R.N. A. Cardarelli, Naples, Italy
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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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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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Nishimura A, Kado T, Tobe K. Characterization of Diabetic Striatopathy With Repeated Follow-Up Using Multiple Imaging Studies. Cureus 2024; 16:e52223. [PMID: 38347980 PMCID: PMC10861287 DOI: 10.7759/cureus.52223] [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: 01/13/2024] [Indexed: 02/15/2024] Open
Abstract
Diabetic striatopathy is a rare condition with a prevalence of less than one in 100,000. Herein, we report a case of diabetic striatopathy exacerbated by hyperglycemia and hypoglycemia, with repeated follow-up with multiple imaging studies. This case suggested that putamen neuronal loss and dysfunction, gliosis, and ischemia are associated with diabetic striatopathy pathophysiology. In addition, striatal hyperintensity on T1-weighted MRI images was more pronounced after symptom remission when evaluated several times over a short period. Therefore, clinicians should be aware that even if MRI findings are normal in the very early stages of the onset of diabetic striatopathy, repeating MRIs at intervals may reveal typical findings.
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Affiliation(s)
- Ayumi Nishimura
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, JPN
| | - Tomonobu Kado
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, JPN
| | - Kazuyuki Tobe
- First Department of Internal Medicine, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, JPN
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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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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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Babici D, Mohamed AA, Mattner O, Demiraj F, Hammond T. Acute Caudate Nucleus Stroke Presenting As Hemiballismus. Cureus 2023; 15:e48209. [PMID: 38050508 PMCID: PMC10693717 DOI: 10.7759/cureus.48209] [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: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 12/06/2023] Open
Abstract
Hemiballismus is defined as irregular, involuntary, large-amplitude flinging movements by the limbs, confined to one side of the body. Hemichorea refers to a state of excessive and irregularly timed, non-repetitive and randomly distributed, spontaneous, involuntary, and abrupt movements. It is widely believed that hemiballismus and chorea are suggestive of a lesion to the basal ganglia and subthalamic nucleus (STN). However, there are other etiologies that may influence the clinical presentation. Patients may present with certain common clinical features corresponding to the affected area of the brain. For example, infarctions of the motor cortex present with hemiplegia or paralysis of one side of the body. Similarly, infarctions involving the language areas of the brain present with aphasia and are detrimental to speech production or comprehension and the ability to read and write. Typically, acute-onset hemichorea is suggestive of a lesion in the STN. Herein, we present a rare case of acute hemiballismus and hemichorea following infarction of the left caudate nucleus, as determined by magnetic resonance imaging (MRI) and computerized tomography (CT) imaging modalities.
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Affiliation(s)
- Denis Babici
- Department of Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Ali A Mohamed
- Department of Medicine, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Olivia Mattner
- Department of Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Francis Demiraj
- Department of Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
| | - Thomas Hammond
- Department of Neurology, Florida Atlantic University Charles E. Schmidt College of Medicine, Boca Raton, USA
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Otaka Y, Harada Y, Sugawara N, Shimizu T, Yasui-Furukori N. Relationship Between Diabetic Chorea and Timing of MRI Findings: A Systematic Review with Case Reports. Int J Gen Med 2023; 16:4465-4476. [PMID: 37808208 PMCID: PMC10557969 DOI: 10.2147/ijgm.s423400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/19/2023] [Indexed: 10/10/2023] Open
Abstract
Background Diabetic chorea is a rare complication of diabetes mellitus for which head MRI is the most common diagnostic imaging modality. Cases have been reported where CT and/or MRI findings are inconsistent or clinical symptoms and imaging findings do not appear simultaneously. We aimed to compile the cases in which imaging findings appeared on MRI retests and to examine in a systematic review whether temporal differences in the appearance of imaging findings correlate with clinical characteristics. Case Presentation An 80-year-old man with type 2 diabetes mellitus came to a hospital with abnormal movements of the left upper and lower extremities. Two days after the first visit, his symptoms flared up, and his head MRI showed an old cerebral infarction and no new lesion. On day 14, he retested T1-weighted imaging and showed a high signal in the right putamen, which was considered diabetic chorea. Blood glucose was controlled with insulin, and the involuntary movements disappeared. Methods PubMed and ICHUSHI were searched to identify patients with diabetic chorea who had undergone MRI retests. Patients grouped by the temporal change in the presence/absence of imaging findings were compared on age, sex, duration of diabetes mellitus, blood glucose level, HbA1c level, side of involuntary movement, time to first MRI, and follow-up MRI. Results Of the 64 cases analyzed, 43 (67.2%) were female. The mean age was 69.0 years. 16 (25.0%) had worsening findings upon MRI retesting, 37 (57.8%) had improvement, and 10 (15.6%) had unchanged findings. There were no significant differences in age, sex, mean blood glucose level or HbA1c at onset among the groups. Conclusion There was no association between the pattern of appearance of imaging findings over time and clinical characteristics, including glucose levels. If initial MRI findings are negative, MRI retesting after a certain time may help diagnose diabetic chorea.
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Affiliation(s)
- Yumi Otaka
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, School of Medicine, Tochigi, Japan
| | - Yukinori Harada
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, School of Medicine, Tochigi, Japan
| | - Norio Sugawara
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
| | - Taro Shimizu
- Department of Diagnostic and Generalist Medicine, Dokkyo Medical University, School of Medicine, Tochigi, Japan
| | - Norio Yasui-Furukori
- Department of Psychiatry, Dokkyo Medical University, School of Medicine, Tochigi, Japan
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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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Mahnashi MH, Alam W, Huneif MA, Abdulwahab A, Alzahrani MJ, Alshaibari KS, Rashid U, Sadiq A, Jan MS. Exploration of Succinimide Derivative as a Multi-Target, Anti-Diabetic Agent: In Vitro and In Vivo Approaches. Molecules 2023; 28:molecules28041589. [PMID: 36838577 PMCID: PMC9964140 DOI: 10.3390/molecules28041589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 01/27/2023] [Accepted: 01/31/2023] [Indexed: 02/10/2023] Open
Abstract
Diabetes mellitus (DM) is counted among one of the leading challenges in the recent era, and it is a life-threatening disorder. Compound 4-hydroxy 3-methoxy phenylacetone (compound 1) was previously isolated from Polygonum aviculare. This compound was reacted with N-benzylmaleimide to synthesize the targeted compound 3. The purpose of this research is to exhibit our developed compound 3's ability to concurrently inhibit many targets that are responsible for hyperglycemia. Compound 3 was capable of inhibiting α-amylase, α-glucosidase, and protein tyrosine phosphatase 1 B. Even so, outstanding in vitro inhibition was shown by the compound against dipeptidyl peptidase-4 (DPP-4) with an IC50 value of 0.07 µM. Additionally, by using DPPH in the antioxidant activity, it exhibited good antioxidant potential. Similarly, in the in vivo activity, the experimental mice proved to be safe by treatment with compound 3. After 21 days of examination, the compound 3 activity pattern was found to be effective in experimental mice. Compound 3 decreased the excess peak of total triglycerides, total cholesterol, AST, ALT, ALP, LDL, BUN, and creatinine in the STZ-induced diabetic mice. Likewise, the histopathology of the kidneys, liver, and pancreas of the treated animals was also evaluated. Overall, the succinimde moiety, such as compound 3, can affect several targets simultaneously, and, finally, we were successful in synthesizing a multi-targeted preclinical therapy.
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Affiliation(s)
- Mater H. Mahnashi
- Department of Pharmaceutical Chemistry, College of Pharmacy, Najran University, Najran 55461, Saudi Arabia
| | - Waqas Alam
- Department of Pharmacy, Abdul Wali Khan University Mardan, Mardan 23200, Pakistan
| | - Mohammed A. Huneif
- Pediatric Department, Medical College, Najran University, Najran 55461, Saudi Arabia
| | - Alqahtani Abdulwahab
- Pediatric Department, Medical College, Najran University, Najran 55461, Saudi Arabia
| | | | - Khaled S. Alshaibari
- Pediatric Department, Medical College, Najran University, Najran 55461, Saudi Arabia
| | - Umar Rashid
- Department of Chemistry, COMSATS University Islamabad, Abbottabad 22060, Pakistan
| | - Abdul Sadiq
- Department of Pharmacy, University of Malakand, Chakdara 18800, Pakistan
- Correspondence: (A.S.); (M.S.J.)
| | - Muhammad Saeed Jan
- Department of Pharmacy, Bacha Khan University, Charsadda 24420, Pakistan
- Correspondence: (A.S.); (M.S.J.)
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12
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Saroufim R, Hannon T. Nonketotic hyperglycemic hemichorea-hemiballismus in a pediatric patient: A case report. Clin Case Rep 2023; 11:e6857. [PMID: 36698526 PMCID: PMC9851085 DOI: 10.1002/ccr3.6857] [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: 10/04/2022] [Revised: 12/26/2022] [Accepted: 01/03/2023] [Indexed: 01/20/2023] Open
Abstract
Nonketotic hyperglycemic hemichorea-hemiballismus (NHHH) is an infrequent complication of diabetes mellitus, and rarely occurs in children. We present an adolescent boy with recent diagnosis of type 1 diabetes who presented with hemichorea and brain imaging findings consistent with NHHH. His symptoms resolved with euglycemia and valproic acid after few weeks.
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Affiliation(s)
- Rita Saroufim
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisIndianaUSA
| | - Tamara Hannon
- Division of Pediatric Endocrinology, Department of Pediatrics, Riley Hospital for Children at IU HealthIndiana University School of MedicineIndianapolisIndianaUSA
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13
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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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14
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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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15
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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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17
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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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18
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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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19
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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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20
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Huang X, Qi J, Li Y, Li J, Yang MG. Diabetic Striatopathy Complicated With Acute Ischemic Stroke: A Case Report. Front Neurosci 2022; 16:877479. [PMID: 35903807 PMCID: PMC9315246 DOI: 10.3389/fnins.2022.877479] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 06/15/2022] [Indexed: 12/19/2022] Open
Abstract
Diabetic striatopathy (DS) is a rare complication secondary to hyperglycemia, featured by the choreiform movements and reversible striatal abnormalities on neuroimaging. Several studies have described the clinical characteristics of DS, however, the simultaneous occurrence of DS and acute ischemic stroke (AIS) in the striatum has not been reported. Herein, we report a 68-year-old man with uncontrolled type 2 diabetes who experienced the progressive involuntary movement of the right upper and lower limbs for 10 days. We initially considered this patient as an AIS with hemorrhage in the left basal ganglia and adjacent area because his brain magnetic resonance imaging (MRI) showed hyperintensity on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging (DWI) images, as well as slight T1-hyperintensity around T1-hypointensity. However, his symptoms worsen persistently, which was inconsistent with neuroimaging findings. Further computed tomography (CT) scan revealed an extensive hyper-density and focal low-density in the left striatum, suggesting the diagnosis of DS and AIS. His symptoms were in complete remission after 2 months of glucose control. However, striatal hyperintensity on T1 images was significantly increased compared to the initial images, which disappeared 18 months later. Additionally, DWI hyperintensity on infarction lesions disappeared, while softening lesions and gliosis were observed on the follow-up MRI images. Therefore, we finally diagnosed the patient as DS complicated with AIS. This report highlights that DS and AIS could occur simultaneously in the striatum after hyperglycemia, which is easily misdiagnosed as AIS with hemorrhage and requires clinicians to pay more attention to avoid misdiagnosis and delayed treatment.
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Affiliation(s)
- Xiao Huang
- Department of Neurology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Junli Qi
- Department of Neurology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Yiding Li
- Department of Orthopaedic Surgery, The Second Affiliated Hospital, Henan University of Science and Technology, Luoyang, China
| | - Jianhui Li
- Department of Neurology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Meng-Ge Yang
- Department of Neurology, The Second Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
- Department of Neurology, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Meng-Ge Yang
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21
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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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22
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Rodríguez MM, Guerra JMM, Liaño HA, González JPM. Chorea in a diabetic patient with poor metabolic control. PRACTICAL DIABETES 2022. [DOI: 10.1002/pdi.2379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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23
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Nelson CC, Ohnoutka C, Ulen M. Non-Ketotic Hyperglycemic Hemichorea-Hemiballismus in the Setting of Antipsychotics and Methamphetamine. Cureus 2021; 13:e19094. [PMID: 34858747 PMCID: PMC8614164 DOI: 10.7759/cureus.19094] [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: 10/27/2021] [Indexed: 11/05/2022] Open
Abstract
The management of common chronic conditions presenting in uncommon ways is an important facet of medical education and patient care. We report a 54-year-old patient who developed left arm dystonia precipitated by several potential factors. These include laboratory findings notable for significant hyperglycemia, methamphetamine positive on urine drug testing and patient history consistent with bipolar II managed with Lurasidone, a second-generation antipsychotic medication. The potential etiology of this uncommon presentation is discussed below.
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Affiliation(s)
- Colbert C Nelson
- Family and Community Medicine, University of Missouri, Columbia, USA
| | - Cole Ohnoutka
- Family and Community Medicine, University of Missouri, Columbia, USA
| | - Michael Ulen
- Family and Community Medicine, University of Missouri, Columbia, USA
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24
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Dong M, E JY, Zhang L, Teng W, Tian L. Non-ketotic Hyperglycemia Chorea-Ballismus and Intracerebral Hemorrhage: A Case Report and Literature Review. Front Neurosci 2021; 15:690761. [PMID: 34248493 PMCID: PMC8260933 DOI: 10.3389/fnins.2021.690761] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 05/11/2021] [Indexed: 11/13/2022] Open
Abstract
Non-ketotic hyperglycemia chorea-ballismus (NKH-CB) is a rare metabolical syndrome secondary to the hyperglycemic condition, which is characterized by a triad of acute or subacute hemichorea-hemiballismus, hyperglycemic state, and unique abnormalities limited to the striatum on neuroimaging. Several related case studies on this disorder have been reported previously, but NKH-CB had never been associated with intracerebral hemorrhage (ICH). Herein, we report an uncommon case of NKH-CB and ICH that occurred simultaneously in one patient, which provides a challenge for clinicians in making a correct diagnosis. An 88-year-old woman with a long-term history of poor-controlled type 2 diabetes mellitus and hypertension, who presented with a sudden-onset headache, restlessness, severe bilateral choreiform and ballistic movements, elevated levels of glucose and osmolality in the serum, an increased white blood cell count, and two-type hyperdense signs on CT imaging, was finally diagnosed with NKH-CB and ICH. Despite administrated active treatments, the patient's clinical status did not improve and ultimately passed away. This case is reported to remind clinicians to consider the possibility of NKH-CB when patients present sudden-onset choreiform and ballistic movements. It is also the first entity with two-type hyperdense signs on CT imaging simultaneously, which helps us distinguish NKH-CB from ICH more intuitively.
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Affiliation(s)
- Mingming Dong
- Department of Neurology, The Fourth People's Hospital of Shenyang, Shenyang, China.,Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Jian-Yu E
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Liyang Zhang
- Department of Neurology, The Fourth People's Hospital of Shenyang, Shenyang, China
| | - Weiyu Teng
- Department of Neurology, The First Hospital of China Medical University, Shenyang, China
| | - Li Tian
- Department of Geriatrics, Shengjing Hospital of China Medical University, Shenyang, China
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