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Moreira HLC, de Moraes MPM, Fraiman PHA, Braga VL, Marussi VHR, Pedroso JL, Povoas Barsottini OG. Subacute hemichorea and asymmetrical basal ganglia abnormalities: An archetypal scenario for anti-CV2 encephalitis. Parkinsonism Relat Disord 2024; 125:107035. [PMID: 38908053 DOI: 10.1016/j.parkreldis.2024.107035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/25/2024] [Accepted: 06/06/2024] [Indexed: 06/24/2024]
Affiliation(s)
- Heloisa Lopes Cohim Moreira
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Marianna Pinheiro Moraes de Moraes
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Pedro Henrique Almeida Fraiman
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Vinicius Lopes Braga
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Victor Hugo Rocha Marussi
- Hospital Beneficência Portuguesa São Paulo, BP Medicina Diagnóstica, Department of Neuroradiology, São Paulo, SP, Brazil
| | - José Luiz Pedroso
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil
| | - Orlando Graziani Povoas Barsottini
- Division of General Neurology and Ataxia Unit, Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, SP, Brazil.
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Rodin RE, Venna N, Balaban DT. A case of immunotherapy-responsive autoimmune hemichorea. Ann Clin Transl Neurol 2024; 11:1371-1375. [PMID: 38644607 DOI: 10.1002/acn3.52052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 03/22/2024] [Accepted: 03/28/2024] [Indexed: 04/23/2024] Open
Abstract
INTRODUCTION Subacute adult-acquired hemichorea is a striking presentation with a broad differential, including ischemic, metabolic, and inflammatory causes. CASE We encountered a 74-year-old woman with rapid onset of hemichorea and associated encephalopathy. Following a thorough workup without identification of clear imaging or laboratory abnormalities, we empirically treated with IVIg. Her hemichorea dramatically improved. Due to relapses of hemichorea, she required repeat immunotherapy with IVIg or high dose steroids followed by maintenance mycophenolate. DISCUSSION This case of seronegative autoimmune hemichorea highlights the importance of a high index of suspicion for an inflammatory etiology of chorea when other causes are ruled out and performing an immunotherapy trial.
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Affiliation(s)
- Rachel E Rodin
- Department of Neurology, Massachusetts General Hospital, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Nagagopal Venna
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Denis T Balaban
- Division of Neuroimmunology and Neuroinfectious Diseases, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Cincotta MC, Walker RH. Recent advances in non-Huntington's disease choreas. Parkinsonism Relat Disord 2024; 122:106045. [PMID: 38378310 DOI: 10.1016/j.parkreldis.2024.106045] [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: 01/30/2024] [Accepted: 02/10/2024] [Indexed: 02/22/2024]
Abstract
INTRODUCTION Chorea is primarily due to an imbalance of basal ganglia output pathways, often due to dysfunction or degeneration of the caudate nucleus and putamen, and can be due to many causes. METHODS We reviewed the recent literature to identify newly-recognized causes of chorea, including auto-immune, metabolic, and genetic. We also focused upon developments in mechanisms relating to underlying pathophysiology of certain genetic choreas and advances in therapeutics. RESULTS Novel autoantibodies continue to be identified as causes of chorea. Both COVID-19 infection and vaccination are reported to result rarely in chorea, although in some cases causality is not clearly established. Advances in genetic testing continue to find more causes of chorea, and to expand the phenotype of known genetic disorders. Deep brain stimulation can be successful in certain circumstances. CONCLUSION Our understanding of mechanisms underlying this movement disorder continues to advance, however much remains to be elucidated.
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Affiliation(s)
- Molly C Cincotta
- Department of Neurology, Temple University, Philadelphia, PA, USA
| | - Ruth H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center, Bronx, NY, USA; Department of Neurology, Mount Sinai School of Medicine, New York City, NY, USA.
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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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Yu YW, Chung CY, Chiou YH, Fang NW. Recurrent hemichorea in an adolescent with systemic lupus erythematosus and previous ipsilateral cerebral infarction. Int J Rheum Dis 2024; 27:e14886. [PMID: 37606173 DOI: 10.1111/1756-185x.14886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 08/03/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023]
Abstract
Systemic lupus erythematosus (SLE) can present with movement disorders, among which chorea is closely associated with antiphospholipid (aPL) antibodies. Brain imaging results obtained in patients with chorea are generally inconsistent with the clinical manifestation of chorea; moreover, medical tests for hemichorea, which are expected to reveal distinct localization, may show negative findings. Herein, we present a case of a 15-year-old girl with SLE who had a history of left cerebral infarction; tests revealed elevated aPL levels, and she developed recurrent left hemichorea 2 years later. Brain magnetic resonance imaging (MRI) results revealed no acute lesions during each episode of involuntary movements, and an MRI perfusion scan failed to provide an explanation for the asymmetric presentation. Although various hypotheses have been proposed regarding the mechanism underlying the occurrence of chorea, some scenarios still remain unexplained. Further investigation on the pathophysiology of chorea in SLE may be warranted to clarify its prognosis.
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Affiliation(s)
- Ya-Wen Yu
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Cheng-Yu Chung
- Division of Neurology, Department of Internal Medicine, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Yee-Hsuan Chiou
- Division of Pediatric Allergy Immunology and Rheumatology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Medical Laboratory Science and Biotechnology, Fooyin University, Kaohsiung, Taiwan
| | - Nai-Wen Fang
- Division of Pediatric Nephrology, Department of Pediatrics, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Pingtung Veterans General Hospital, Pingtung, Taiwan
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Mahler S, Braun M, Thapa K. Resolving the Dance: A Case Study on Non-Ketotic Hyperglycemic Hemichorea-Hemiballismus in a Patient with Long-Standing Type 2 Diabetes. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941443. [PMID: 38064410 PMCID: PMC10721340 DOI: 10.12659/ajcr.941443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 11/01/2023] [Accepted: 09/26/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Non-ketotic hyperglycemic hemichorea-hemiballism (HCHB) is a rare complication of diabetes, which is mainly described in case reports. This condition occurs more commonly in older women and is known to be associated with T1 hyperintensity basal ganglia lesions on magnetic resonance imaging (MRI). The pathophysiology of non-ketotic hyperglycemic HCHB is not well defined, although a combination of regional metabolic failure and ischemia due to hyperglycemia is suspected to occur. Treatment entails tight blood glucose control, although antipsychotic medications such as risperidone may be helpful in refractory cases. CASE REPORT We describe a case of a middle-aged man with long-standing type 2 diabetes who experienced 3 weeks of progressive unilateral arm, leg, and face choreiform movements. Laboratory testing performed just prior to symptom onset was notable for a hemoglobin A1C of >15% and a serum blood glucose of 566 mg/dl. MRI revealed diffuse T1 hyperintensity in the left lentiform nucleus. Our patient's insulin regimen was adjusted, resulting in improvement in average serum glucose (A1C of 9.4%). However, his symptoms did not improve significantly. A trial of benzodiazepine was attempted, without success. When risperidone was started, the patient experienced resolution of symptoms. Recurrence of non-ketotic hyperglycemic HCHB while off risperidone has not occurred to date. CONCLUSIONS Non-ketotic hyperglycemic HCHB is a rare but important diagnosis to consider in patients with hyperglycemia and new-onset choreiform movements. Patients with long-standing type 2 diabetes may be affected, especially when glycemic control worsens. When tight blood glucose control does not resolve symptoms, a short course of antipsychotic agents may provide relief.
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Affiliation(s)
- Stewart Mahler
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Melanie Braun
- Department of Neurology, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
| | - Kriti Thapa
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
- Division of Hospital Medicine, Department of Medicine, NYU Langone Health, New York City, NY, USA
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Saft C, Burgunder JM, Dose M, Jung HH, Katzenschlager R, Priller J, Nguyen HP, Reetz K, Reilmann R, Seppi K, Landwehrmeyer GB. Differential diagnosis of chorea (guidelines of the German Neurological Society). Neurol Res Pract 2023; 5:63. [PMID: 37993913 PMCID: PMC10666412 DOI: 10.1186/s42466-023-00292-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Choreiform movement disorders are characterized by involuntary, rapid, irregular, and unpredictable movements of the limbs, face, neck, and trunk. These movements often initially go unnoticed by the affected individuals and may blend together with seemingly intended, random motions. Choreiform movements can occur both at rest and during voluntary movements. They typically increase in intensity with stress and physical activity and essentially cease during deep sleep stages. In particularly in advanced stages of Huntington disease (HD), choreiform hyperkinesia occurs alongside with dystonic postures of the limbs or trunk before they typically decrease in intensity. The differential diagnosis of HD can be complex. Here, the authors aim to provide guidance for the diagnostic process. This guidance was prepared for the German Neurological Society (DGN) for German-speaking countries. RECOMMENDATIONS Hereditary (inherited) and non-hereditary (non-inherited) forms of chorea can be distinguished. Therefore, the family history is crucial. However, even in conditions with autosomal-dominant transmission such as HD, unremarkable family histories do not necessarily rule out a hereditary form (e.g., in cases of early deceased or unknown parents, uncertainties in familial relationships, as well as in offspring of parents with CAG repeats in the expandable range (27-35 CAG repeats) which may display expansions into the pathogenic range). CONCLUSIONS The differential diagnosis of chorea can be challenging. This guidance prepared for the German Neurological Society (DGN) reflects the state of the art as of 2023.
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Affiliation(s)
- Carsten Saft
- Department of Neurology, St. Josef-Hospital, Huntington-Zentrum NRW, Ruhr-Universität Bochum, Bochum, Germany.
| | - Jean-Marc Burgunder
- Department of Neurology, Schweizerisches Huntington-Zentrum, Bern University, Bern, Switzerland
| | - Matthias Dose
- Kbo-Isar-Amper-Klinikum Taufkirchen/München-Ost, Munich, Germany
| | - Hans Heinrich Jung
- Department of Neurology, University Hospital Zürich, Zurich, Switzerland
| | - Regina Katzenschlager
- Department of Neurology, Karl Landsteiner Institute for Neuroimmunological and Neurodegenerative Disorders, Klinik Donaustadt, Vienna, Austria
| | - Josef Priller
- Department of Psychiatry and Psychotherapy, Klinikum Rechts der Isar, School of Medicine and Health, Technical University of Munich, Munich, Germany
- Neuropsychiatry, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Huu Phuc Nguyen
- Department of Human Genetics, Huntington-Zentrum NRW, Ruhr-Universität Bochum, Bochum, Germany
| | - Kathrin Reetz
- Department of Neurology, Euregional Huntington Centre Aachen, RWTH Aachen University Hospital, Aachen, Germany
| | - Ralf Reilmann
- George-Huntington-Institute, Muenster, Germany
- Department of Radiology, Universitaetsklinikum Muenster (UKM), Westfaelische Wilhelms-University, Muenster, Germany
- Department of Neurodegenerative Diseases and Hertie-Institute for Clinical Brain Research, University of Tuebingen, Tuebingen, Germany
| | - Klaus Seppi
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Cincotta MC, Walker RH. Diagnostic Uncertainties: Chorea. Semin Neurol 2023; 43:65-80. [PMID: 36882120 DOI: 10.1055/s-0043-1763506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Chorea is a hyperkinetic movement disorder with a multitude of potential etiologies, both acquired and inherited. Although the differential diagnosis for new-onset chorea is extensive, there are often clues in the history, exam, and basic testing that can help to narrow the options. Evaluation for treatable or reversible causes should take priority, as rapid diagnosis can lead to more favorable outcomes. While Huntington's disease is most common genetic cause of chorea, multiple phenocopies also exist and should be considered if Huntington gene testing is negative. The decision of what additional genetic testing to pursue should be based on both clinical and epidemiological factors. The following review provides an overview of the many possible etiologies as well as a practical approach for a patient presenting with new-onset chorea.
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Affiliation(s)
- Molly C Cincotta
- Department of Neurology, Temple University, Philadelphia, Pennsylvania
| | - Ruth H Walker
- Department of Neurology, James J. Peters Veterans Affairs Medical Center and Mount Sinai School of Medicine, Bronx, New York
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Lin R, Lai TH, Chen MH. Recurrent hemichorea with different etiologies in one patient. Oxf Med Case Reports 2023; 2023:omad006. [PMID: 36860955 PMCID: PMC9969826 DOI: 10.1093/omcr/omad006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/17/2022] [Accepted: 12/13/2022] [Indexed: 03/02/2023] Open
Abstract
Hemichorea is a unilateral movement disorder caused by acute ischemic or hemorrhagic stroke of contralateral cerebral lesions. It is followed by hyperglycemia, and other systemic diseases. Several cases of recurrent hemichorea associated with the same etiology have been reported, but cases with different etiologies have rarely been reported. We report a case in which the patient experienced both strokes and post-stroke-related hyperglycemic hemichorea. Magnetic resonance imaging of the brain appeared different in these two episodes. Our case demonstrates the importance of evaluating every patient presented with recurrent hemichorea carefully, as the disorder may be caused by different conditions.
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Affiliation(s)
- Rong Lin
- Department of Internal Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan
| | - Tzu-Hsien Lai
- Department of Neurology, Far Eastern Memorial Hospital, New Taipei City, Taiwan,School of Medicine, National Yang Ming Chiao Tung University, Taipei City, Taiwan
| | - Mei-Hsiu Chen
- Correspondence address. Tel: +886-2-89667000 ext. 1341, Fax: +886-2-89665576; E-mail:
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Clinical and Radiological Follow-Up of a Pfizer-BioNTech COVID-19 Vaccine-Induced Hemichorea-Hemiballismus; Insights Into Mechanisms of Basal Ganglia Dysfunction. Tremor Other Hyperkinet Mov (N Y) 2022; 12:17. [PMID: 35646425 PMCID: PMC9122000 DOI: 10.5334/tohm.697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/14/2022] [Indexed: 11/20/2022] Open
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