HEMICHOREA-HEMIBALLISM SYNDROME CAUSED BY NONKETOTIC HYPERGLYCEMIA IN A NEWLY DIAGNOSED DIABETES MELLITUS TYPE II PATIENT WITH EUGLYCEMIA AT PRESENTATION

Abstract

INTRODUCTION
Nonketotic hyperglycemia among type II diabetic patients has recently been documented to cause the rare movment disorder called hemichorea-hemiballism syndrome. This syndrome is a hyperkinetic movement disorder presenting as continuous, non-patterned, involuntary movements caused by a basal ganglia dysfunction. It has an overall incidence rate of 1 in 500,000 of the general population, while the incidence directly caused by nonketotic hyperglycemia is yet to be determined.

CASE
A 76-year-old male presented with involuntary movements of the right extremities. An increase in the frequency and intensity of the invouluntary movements over a span of 10 days prompted consult. On admission, the patient was conscious with stable vital signs. Involuntary flailing movements of the right upper and lower extremities were observed. He was not a known diabetic and had no prior history of stroke. He presented with normal glucose levels with random blood sugar of 156 mg/dl, with further laboratory investigation confirming uncontrolled diabetes with an HbA1c of 12.6% and fasting blood sugar of 128 mg/dl. The brain MRI with contrast demonstrated T1 hyperintensity signals involving the left caudate and left lentiform nucleus. The t2/FLAIR weighted imaging showed mixed hyperintense and hypointense signals on the left basal ganglia consistent with abnormal MRI findings in patients with HC-HB syndrome caused by nonketotic hyperglycemia. He was treated for diabetes and was maintained on risperidone and clonazepam for the hemichorea-hemiballism. After 5 months, his diabetes has been controlled, and the involuntary movements have completely resolved.

CONCLUSION
This case report highlights hemichorea-hemiballism synsrome in a newly diagnosed patient with type 2 DM who had normal glucose level at presentation. The prompt recognition and correction of uncontrolled newly diagnosed diabetes lead to a rapid improvement of symptoms, less neurologic sequelae and an overall favorable prognosis.