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Table of Contents    
LETTER TO EDITOR
Year : 2017  |  Volume : 65  |  Issue : 2  |  Page : 397-398

Hemichorea secondary to non-ketotic hyperglycemia as the presenting manifestation of diabetes mellitus


Department of Neurology, S.C.B. Medical College, Cuttack, Odisha, India

Date of Web Publication10-Mar-2017

Correspondence Address:
Dr. Lulup Kumar Sahoo
Department of Neurology, S.C.B. Medical College, Cuttack
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/neuroindia.NI_1180_15

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How to cite this article:
Sahoo LK, Mallick AK, Mohanty G, Swain KP, Sahoo SK. Hemichorea secondary to non-ketotic hyperglycemia as the presenting manifestation of diabetes mellitus. Neurol India 2017;65:397-8

How to cite this URL:
Sahoo LK, Mallick AK, Mohanty G, Swain KP, Sahoo SK. Hemichorea secondary to non-ketotic hyperglycemia as the presenting manifestation of diabetes mellitus. Neurol India [serial online] 2017 [cited 2017 Nov 24];65:397-8. Available from: http://www.neurologyindia.com/text.asp?2017/65/2/397/201825


Sir,

Chorea is characterized by involuntary randomly appearing irregular movements that are not rhythmic or repetitive. Hemichorea is a hyperkinetic disorder involving one side of the body, which is caused by lesions of the contralateral striatum. [1] Hyperglycemia is the most common metabolic cause of chorea-ballism.[2] Non-ketotic hyperglycemic (NKH) chorea is more common in elderly patients,[3] especially females.

A 71-year-old female patient presented with involuntary purposeless non-repetitive movements of the left upper and lower extremities involving both the proximal and distal parts, since the last 8 days. These movements were interfering with her daily activities prompting her to come to our hospital. She did not have abnormal behaviour, altered sensorium, weakness of any side, or sensory disturbances. She was not a known hypertensive or diabetic. No past history of similar illness or stroke was reported. On examination, she was conscious, alert, and oriented. Her pulse rate was 84/min and regular, and her blood pressure was 120/80 mm Hg. The cranial nerve examination was normal. Motor examination revealed normal power; however, hypotonia, hyporeflexia, and intermittent non-repetitive involuntary choreiform movements involving the left upper and lower extremities were noted. Plantar reflexes were flexor bilaterally. Her sensations were intact. Complete blood count, liver, and renal function tests were normal. Her serum glucose was 416 mg/dl, HbA1c level was 9.2%, and urine ketone bodies were negative. Computed tomography (CT) of the brain revealed hyperdensity in the right caudate nucleus and right lentiform nucleus [Figure 1].
Figure 1: Axial Computed tomography (CT) brain demonstrated increased density within the right caudate nucleus and right lentiform nucleus (arrow)

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The patient was started on insulin, haloperidol 2 mg/day, and tetrabenazine 50 mg/day. After 5 days, her symptoms improved with marked decrease in involuntary movements. Two weeks later, the abnormal movements disappeared completely and the patient was discharged. The patient refused to have a follow-up CT brain.

NKH chorea might be the first presentation of hyperglycemia,[3] or it might be secondary to poorly controlled diabetes mellitus. Cerebral vascular insufficiency, petechial hemorrhage, hyperviscosity,[4] and depletion of both gamma-aminobutyric acid and acetylcholine secondary to metabolic changes [5] have been suggested as possible mechanisms of NKH chorea. The prognosis of NKH chorea has been reported to be excellent. The prognosis depends on the prompt identification of the undiagnosed diabetes or proper control of blood sugar in previously diagnosed patients. The mainstay of treatment is aggressive glycemic control.

In summary, hemichorea can be a manifestation, and rarely, a presenting sign of diabetes mellitus, as seen in our patient.

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Conflicts of interest

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  References Top

1.
Qi X, Yan Y, Gao Y, Zheng Z, Chang Y. Hemichorea associated with non-ketotic hyperglycaemia: A case report. Diabetes Res Clin Pract 2012;95:e1-3.  Back to cited text no. 1
    
2.
Lee S, Shin J, Kim J. Chorea-ballism associated with nonketotic hyperglycaemia or diabetic ketoacidosis: Characteristics of 25 patients in Korea. Diabetes Res Clin Pract 2011; 93:e80-3.  Back to cited text no. 2
    
3.
Felicio AC, Chang CV, Godeiro-Junior C, Okoshi MP, Ferraz HB. Hemichorea-hemiballism as the first presentation of type 2 diabetes mellitus. Arq Neuropsiquiatr 2008;66:249-50.  Back to cited text no. 3
    
4.
Ohara S, Nakagawa S, Tabata K, Hashimoto T. Hemiballism with hyperglycemia and striatal T1-MRI hyperintensity: An autopsy report. Mov Disord 2001;16:521-5.  Back to cited text no. 4
    
5.
Oh SH, Lee KY, Im JH, Lee MS. Chorea associated with non-ketotic hyperglycemia and hyperintense basal ganglia lesion on T1-weighted brain MRI study: A meta-analysis of 53 cases including four present cases. J Neurol Sci 2002;200:57-62.  Back to cited text no. 5
    


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