(P28) Hemichorea Hemiballismus Due to Diabetic Straitopathy: A Rare Complication of Diabetes

Chief Complaint : Involuntary Arm Movements

History of Present Illness : 70 yo male with a history of ischemic stroke x2 with no residual neurological deficits, CAD, and diabetes presented for evaluation of 3 weeks of involuntary movements to his left side. He had been noticing generalized weakness over the last three weeks as well but denied any numbness, tingling, slurred speech. Of note, he stated hat he does not take his home diabetes medications, and that his blood sugar readings at home have been “high”. Denies any recent falls or injuries.

Pertinent Physical Exam: Alert & Oriented x4, normal clear speech, no facial asymmetry, Involuntary rapid movements of the Left Upper and lower extremity and left side of face, unable to complete finger to nose on the left side due to involuntary movements, staggers to the left with ambulation, sensation to light touch equal throughout

Pertinent Laboratory Data: Labs:
WBC 7.0
Hb 13.2
Plt 237
HsTrop 2
Na 128
K 4.2
Cl 96
Cr 0.9
Anion gap 9.0
Glucose 513
Beta-hydroxy 0.2

Case Discussion: The patient had a non contrast CT scan revealing a hyperdense right basal ganglia consistent with Non-Ketotic Hyperglycemia Hemichorea (NHH), also known as diabetic striatopathy (DS). he patient was then started on insulin and admitted for glucose control.

Hemichorea hemiballismus is most often caused by basal ganglia infarction, and presents with unilateral involuntary jerking movements. In DS, patients will have eversible striatal abnormalities in neuroimaging, choreiform movements as well as significantly elevated blood glucose levels. While the pathophysiology of DS is not yet understood, the hyperdensity seen on CT imaging and hyperintensities on MRI are indicative of focal microhemorrhages.

DS is usually associated with non-ketotic hyperglycemia and poor diabetes control, however it has also been reported in ketotic hyperglycemia as well. The treatment for DS is blood glucose control which will reverse symptoms in the majority of cases. Long-term poor glucose control can result in irreversible symptoms, so prompt diagnosis and treatment is key to prevent caudate atrophy.

References and Acknowledgements (Optional): Markowska, K., Koziorowska-Gawron, E., Papier, P., Koszewicz, M., Budrewicz, S., Bladowska, J., et al. (2021). Easily missed or misinterpreted: diabetic striatopathy in the course of ketotic hyperglycaemia. Postgrad. Med. J. 97, 539–540. doi: 10.1136/postgradmedj-2020-139499

Lucassen, E. B., Delfyett, W. T., and Stahl, M. C. (2017). Persistent hemichorea and caudate atrophy in untreated diabetic striatopathy: a case report. Case Rep. Neurol. 9, 299–303. doi: 10.1159/000484201