Non-ketotic hyperglycemia and diabetic striatopathy – a rare presentation with hemichorea-hemiballismus

Abstract

Introduction and aim. Non-ketotic hyperglycemia (NKHG), also known as hyperosmolar hyperglycemic state (HHS) is a serious metabolic complication of diabetes mellitus (DM).The mortality rate can be up to 20% and this is much more higher than that of diabetic ketoacidosis (DKA). It is usually precipitated by an event such as pulmonary/urinary infection, myocardial infarction (MI) or stroke. In this state of metabolic derangements, central nervous system (CNS) manifestations including altered mental status with or without focal neurological deficits are prominent clinical presentations. On the other hand, HHS may also be complicated with various other CNS events. Herein, a quite rare presentation of HHS with hemichorea ‒ hemiballismus in a 71 year old female patient with type 2 DM is presented. Description of the case. A 71-year-old female patient type 2 DM presented to our emergency department with progressive involuntary movements on the right upper and lower extremities accompanied by semiconsciousness during the last 24 hours. On neurological examination, cranial nerves and cerebellar signs were found to be normal, as the deep tendon reflexes. However, involuntary non-rhythmic writhing movements at rest were present on her right sided extremities. The fingerstick evaluation showed marked hyperglycemia (HG). The laboratory findings were characterized with high blood glucose level without obvious acidosis compatible with HHS. In urine analysis, glucosuria without significant ketonuria was detected. On head CT, subtle hyperdensity was noted in the left neostriatal regions without any mass effect or perilesional edema, compatible with left sided diabetic striatopathy (DS). Conclusion. Diabetic striatopathy is a quite rare presentation of HHS with hemichorea – hemiballismus. The characteristic computed tomograhy (CT) findings of associated striatopathy should be differentiated from vascular lesions that may also present with unilateral findings in the course of HHS and should not be overlooked in diabetic patients to recognise the ongoing HHS before the coma precedes.