Hyperglycemia-Induced Involuntary Movements: 2 Case Reports and a Review of the Literature

Abstract

Objective: Autonomic and peripheral neurologic manifestations of hyperglycemia are commonly seen in clinical practice; acute hyperglycemia-induced involuntary movements (HIIM) are rarer and less well known. In this article we describe 2 patients with HIIM and review the scientific literature to better characterize the clinical and pathophysiologic features of these disorders.Methods: A literature search was performed using the PubMed database. Whenever possible, the most recent publication on a topic was utilized, with a 20-year cutoff time since publication. Articles were selected based on the quality of presented data or citations utilized.Results: HIIM can present in a variety of ways including seizures, hemichorea-hemiballismus (HCHB) and, very rarely, tremor. While HIIM are more commonly seen in patients with long-standing, uncontrolled diabetes, they can also be the initial presentation of diabetes. The precise pathophysiology of HIIM remains unknown; however, at least for HCHB, it is hypothesized that hyperglycemia increases the metabolism of the inhibitory neurotransmit-Abbreviations: HCHB = hemichorea-hemiballismus; HIIM = hyperglycemia-induced involuntary movements; GABA = gamma aminobutyric acid; EPC = epilepsia partialis continua; MRI = magnetic resonance imaging; NKH = nonketotic hyperglycemia

Hemichorea-Hemiballismus as an Unusual Presentation of Hyperosmolar Hyperglycemic Syndrome

“…Current literature suggest resolution of HCHB after several weeks, and sometimes even months after achieving blood glucose control [3]. Of note, the rapid resolution of HCHB can be attributed to the correction of an endocrine derangement, as opposed to a structural brain dysfunction, however delays in treatment can potentially lead to permanent brain damage [9,10]. In the elderly with T2DM, HCHB has been described as the presenting symptom of HHS and diabetes [8][9][10][11][12].…”

“…Of note, the rapid resolution of HCHB can be attributed to the correction of an endocrine derangement, as opposed to a structural brain dysfunction, however delays in treatment can potentially lead to permanent brain damage [9,10]. In the elderly with T2DM, HCHB has been described as the presenting symptom of HHS and diabetes [8][9][10][11][12]. Furthermore, the classic basal ganglia hyperintensities were not appreciated on CT scan [11].…”

Hemiballismus in Uncontrolled Diabetes Mellitus

“…Hemiballism that occurs in uncontrolled diabetes patient was postulated to be due to marked hyperglycemia. This extreme hyperglycemia causes hyperviscosity of the blood that eventually leads to some degree of ischemia at the basal ganglia level [ 4 , 5 ], leading to decreased production of GABA (gamma-aminobutyric acid) and acetylcholine at the basal ganglia, further causing disruption of normal neuronal impulse transmission and circuit [ 4 , 5 ]. Dopaminergic activity becomes haywire causing the loss of inhibition function; hence, allowing hyperkinetic movement.…”

“…Thus, clinicians must be vigilant and bear in mind that patients with long-standing poorly-controlled blood glucose levels can presents with this abnormal movement, especially among the elderly Asian. Patients need to be admitted for blood sugar normalization and to other potential causes must be excluded [ 5 ].…”

“Dancing belly” in an old diabetic lady

“…Diabetes mellitus is associated with a wide spectrum of movement disorders ranging from epilepsia partialis continua, chorea-ballismus, myoclonus, rubral tremor, dyskinesia, restless leg syndrome, hemifacial spasm to parkinsonism. [ 1 2 ] These abnormal movements can stem from a direct complication of both hyperglycemia and hypoglycemia or may be associated with diabetic vasculopathy, neuropathy, or nephropathy. [ 1 ] These might herald the onset of acute ketotic or non-ketotic complications among previously undiagnosed diabetics.…”