A 71 year old woman with a past medical history of type 2 diabetes mellitus, atrial fibrillation, hypothyroidism and hypertension presented for evaluation of one month history of right sided involuntary hyperkinetic movements. Physical exam was significant for lip smacking, distal choreic movements, and proximal ballistic swings of the right arm and leg. Laboratory results showed blood glucose of 822 mg/dL, normal venous blood gas pH, and negative serum ketones. HgA1c of >16 was consistent with a prolonged period of uncontrolled diabetes mellitus. MRI brain demonstrated hyperdense lesions of bilateral basal ganglia. The patient was treated for hyperosmolar hyperglycemic state with intravenous fluids and insulin and started on Keppra and clonazepam for the hemiballismus. Patient was discharged with insulin but despite optimizing glucose control, the patient continued to have persistent movements that did not resolve.
Chorea is an abnormal involuntary movement disorder caused by a variety of disorders including metabolic disorders, hypoxic-ischemic events, structural abnormalities, drugs/toxins, and infectious and inflammatory diseases. The presentation of hemichorea as a symptom of hyperosmolar hyperglycemic state is rare and in the literature documented mainly as isolated case reports. Cases described in the literature are mostly in the elderly, females, and people of Asian descent. Hemichorea-hemiballismus is normally treated with anticonvulsants and neuroleptics by blocking dopamine receptors. In addition, dopamine depleting agents like reserpine and tetrabenazine can be used. Given her prolonged QTc on electrocardiogram, this patient was started on a benzodiazepine which is often used as an adjunct for treatment of chorea. In most cases of chorea resulting from diabetes mellitus, optimizing blood glucose control is the most effective therapy and can result in complete resolution of symptoms.
This case highlights a little known cause of hemichorea-hemiballismus. Recognition of the link between hyperglycemia and chorea is essential for hospitalists, as early diagnosis and control of the blood glucose is the key to a favorable prognosis.
To cite this abstract:George JS, Bowling GD. The Sweet Dance. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 517. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/the-sweet-dance/. Accessed July 22, 2019.