Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Clinical Medicine Journal

  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Clinical Medicine Journal

clinmedicine Logo
  • ClinMed Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About ClinMed
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

Diabetes and neurology: hemichorea–hemiballism in hyperglycaemia

Kim Yen Galloway, Osman Younus, Graziella Quattrocchi, Bazo Raheem, George Dervenoulas and Eli Silber
Download PDF
DOI: https://doi.org/10.7861/clinmed.20-2-s21
Clin Med March 2020
Kim Yen Galloway
ALewisham and Greenwich NHS Trust, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Osman Younus
ALewisham and Greenwich NHS Trust, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Graziella Quattrocchi
ALewisham and Greenwich NHS Trust, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Bazo Raheem
ALewisham and Greenwich NHS Trust, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
George Dervenoulas
ALewisham and Greenwich NHS Trust, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Eli Silber
ALewisham and Greenwich NHS Trust, London, UK
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Figures & Data
  • Info & Metrics
Loading

Introduction

Diabetes affects a large proportion of the population, with the incidence rising. It also has a wide range of complications. We describe here an uncommon neurological complication of poor diabetic control. Prompt recognition of this condition is essential to improve the outcome.

Case presentation

A 71-year-old Chinese man with longstanding diabetes presented with a 4-day history of progressively worsening uncontrollable continuous non-rhythmic right upper limb movements which resolved during sleep. One week prior, his general practitioner noted poor glycaemic control and started him on sitagliptin. Two days later, he reported right shoulder tingling, gradually spreading down the right arm. This was followed, a few days later, by right hand involuntary movements, gradually affecting his entire right upper limb. The patient visited a Chinese medicine practitioner who performed acupuncture and cupping, eventually presenting to hospital after no improvement.

His past medical history included hypertension, hypothyroidism and type 2 diabetes mellitus with poor control, partially due to refusal of insulin because of needle phobia. His regular medications included metformin 500 mg bd, sitagliptin 25 mg od, amlodipine and levothyroxine.

Neurological examination showed right upper and lower limb involuntary movements consistent with hemichorea–hemiballism (HCHB). Blood tests including full blood count, coagulation, liver and kidney function, bone profile and C-reactive protein (CRP) were normal. His blood sugar was 42.4 mmol/L (range 3.0–7.7) with ketones of 0.8 mmol/L (0.6–1.5) and serum osmolality of 297 mOsm/kg (275–295) with Osm gap 12.0 mOsm/kg (<10). His HbA1c was 141 mmol/mol (20–41).

Computed tomography (CT) of the head showed unilateral left striatum faint hyperdensity, with sparing of the internal capsule and with no mass effect, suggestive of HCHB due to hyperglycaemia. Subsequent magnetic resonance imaging (MRI) of the brain was normal.

Intensive glycaemic control was started with insulin. He was treated with clonazepam 500 μg three times a day (tds), to be uptitrated to 1 mg tds. He improved and was discharged, with diabetic clinic follow-up and plan to start risperidone.

Discussion

HCHB presents as continuous involuntary high-amplitude movements affecting one side of the body. HCHB is a rare syndrome with a prevalence of less than 1/100,000; the majority of individuals affected are Asian women in their 7th decade.1 The increased incidence in Asian populations suggests a genetic predisposition.2 Ischaemic/haemorrhagic stroke is the most common cause of HCHB, followed by non-ketotic hyperglycaemia. Other aetiologies are shown in Table 1. 3

View this table:
  • View inline
  • View popup
Table 1.

Less common causes of hemichorea–hemiballism

The pathophysiology of HCHB due to hyperglycaemia (also known as C-H-BG: chorea, hyperglycaemia, basal ganglia syndrome) is still uncertain. One suggested mechanism is disruption of the blood–brain barrier (BBB) and transient ischaemia of vulnerable neurons caused by hyperviscosity-related hyperglycaemia. Additionally, hyperglycaemia may also impair cerebral autoregulation, causing anaerobic metabolism activation and depletion of gamma-aminobutyric acid (GABA), the main striatal inhibitory neurotransmitter.2 Interestingly, HBHC may present a few weeks after blood glucose levels are controlled, suggesting a delayed reaction to severe hyperglycaemia.

The majority of described cases have a good prognosis. In conclusion, a low threshold in screening for hyperglycaemia in HCHB, even when there is no known history of diabetes,4 is essential, as prompt diagnosis and management may significantly improve the outcome.

Conflicts of interest

None declared.

  • © Royal College of Physicians 2020. All rights reserved.

References

  1. ↵
    1. Jaafar J
    , Rahman RA, Draman N, et al. Hemiballismus in uncontrolled diabetes mellitus. Korean J Fam Med 2018;399:200–3.
    OpenUrl
  2. ↵
    1. Bizet J
    , Cooper CJ, Quansah R, et al. Chorea, hyperglycaemia, basal ganglia syndrome (C-H-BG) in an uncontrolled diabetic patient with normal glucose levels at presentation. Am J Case Rep 2014;15:143–6.
    OpenUrlCrossRefPubMed
  3. ↵
    1. Fielder E
    , Biller J. Case report: Hemichorea in a woman with diabetes. Pract Neurol 2019;19:44–6.
    OpenUrl
  4. ↵
    1. Pinsker JE
    , Shalileh K, Rooks VJ, Pinsker RW. Hemichorea-hemiballism secondary to non-ketotic hyperglycemia. J Clin Med Res 2015;7:729–30.
    OpenUrl
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Diabetes and neurology: hemichorea–hemiballism in hyperglycaemia
Kim Yen Galloway, Osman Younus, Graziella Quattrocchi, Bazo Raheem, George Dervenoulas, Eli Silber
Clinical Medicine Mar 2020, 20 (Suppl 2) s21-s22; DOI: 10.7861/clinmed.20-2-s21

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Diabetes and neurology: hemichorea–hemiballism in hyperglycaemia
Kim Yen Galloway, Osman Younus, Graziella Quattrocchi, Bazo Raheem, George Dervenoulas, Eli Silber
Clinical Medicine Mar 2020, 20 (Suppl 2) s21-s22; DOI: 10.7861/clinmed.20-2-s21
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • Introduction
    • Case presentation
    • Discussion
    • Conflicts of interest
    • References
  • Figures & Data
  • Info & Metrics

Related Articles

  • No related articles found.
  • PubMed
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Haemopoietic stem cell transplantation is a curative treatment option with minimal transplant-related complications for patients with severe Glanzmann's thrombasthenia
  • The monitoring and incidence of hyperglycaemia in inflammatory bowel disease patients treated with intravenous steroids
  • Clinical dynamics of nephropathy in patients with diabetes mellitus type 2 and concomitant essential hypertensive disease
Show more Clinical

Similar Articles

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home
clinmedicine Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2021 by the Royal College of Physicians