Atypical Presentation of New Onset Diabetes: Lessons Learned from a Patient with Hemichorea

Presentation Number: SAT 629
Date of Presentation: April 1st, 2017

Arianna Maria Perez Lopez*, Maria Cristina Espera Caga-Anan and L. Maria Belalcazar
University of Texas Medical Branch, Galveston, TX

Abstract

Background:

Classic symptoms of uncontrolled diabetes include polyuria, polydipsia, nocturia, blurry vision, and weight loss. Neurologic symptoms, including lethargy and obtundation, may be present as a consequence of severe hyperglycemia and dehydration. However, isolated neurological manifestations, such as hemichorea, may be the only clinical sign of uncontrolled and previously undiagnosed diabetes.

Case Presentation:

A 61 year-old African American female presented to the emergency room with a 7 day history of frequent falls due to involuntary movements of her left lower extremity. The purposeless movements developed two weeks after a short course of systemic steroids for treatment of an upper respiratory infection. Patient denied polydipsia, polyuria, polyphagia, blurry vision and weight changes. She did not have a personal or family history of diabetes. She was alert and oriented to person, time, place, and situation on admission physical exam. Cranial nerves examination was intact; muscle strength was 5/5 bilaterally in upper extremities and right lower extremity, and 3/5 in the left lower extremity. Choreiform movements in the left upper and left lower extremities were noted. Laboratory results were pertinent for a blood glucose of 805 mg/dL; ketones were absent. Patient was started on intravenous fluids and insulin infusion. MRI of the brain did not show evidence of acute or subacute stroke or changes in the basal ganglia. A focal seizure was considered and patient was started on levetiracetam which was later discontinued due to lack of clinical improvement. Haloperidol was also administered but stopped once patient’s symptoms resolved with achievement of euglycemia. She was noted to lack typical phenotypic features of type 2 diabetes mellitus and to have low requirements of insulin while inpatient. Glutamic acid decarboxylase antibodies were positive. Patient was diagnosed with Latent Autoimmune Diabetes in Adults and discharged on insulin therapy.

Discussion:

Although hyperglycemia-induced hemichorea/hemiballismus is a rare entity, clinicians should be aware of its occurrence even in the absence of other symptoms of hyperglycemia and a negative history of diabetes. In addition, normal appearing basal ganglia on magnetic resonance imaging does not rule out this condition. Patients presenting with movement disorders should be screened for hyperglycemia. Correction of hyperglycemia will not only lead to resolution of symptoms, but will also avoid exposure to unnecessary therapies.

 

Nothing to Disclose: AMP, MCEC, LMB