Case 204: Nonketotic hyperglycemia-induced hemiballism-hemichorea

An 87-year-old white woman presented to our emergency department with a 2-day history of involuntary movements of the right upper and lower extremities. The movements increased with action, decreased with relaxation, and disappeared during sleep. The patient's medical history included diabetes mellitus type 2, congestive heart failure, and hypertension. No history of parkinsonism or other neurologic disorders was reported. Furthermore, the patient had no prior history of dopamine antagonist or estrogen medication use. At admission, she was fully alert and oriented. A physical examination revealed her muscle tone and strength were normal on both sides; however, she reported transient weakness in the right limbs. There was no evidence of sensory impairment, and cranial nerves were normal. The deep tendon reflexes were symmetrically hypoactive. Her skin was pink, warm, and dry. Laboratory tests revealed poorly controlled diabetes mellitus, with a fasting blood glucose level of 410 mg/dL (22.8 mmol/L) and a hemoglobin A1C level of 18.0%. The urine examination was negative for ketones. Shortly after admission, the patient's blood sugar was controlled with insulin; this led to a steady correction of glycemia in the subsequent days. At admission, the patient underwent unenhanced brain computed tomography (CT) (Fig 1). Magnetic resonance (MR) imaging of the brain was performed 2 days later (Fig 2). After she was discharged from the hospital, the involuntary movements progressively decreased over the next few weeks until they disappeared. Two months later, follow-up unenhanced brain CT (not shown) showed the absence of abnormal findings.