CASE 7 – CASES OF INVOLUNTARY MOVEMENTS IN DIABETES

Original case : Alejandra Borensztein et al. (AACE Case reports)

A 58 year-old male with hypertension and rheumatoid arthritis presented with weakness, blurred vision, polydipsia, and polyuria for 1 week and shaking of the left leg for 4 days. He also complained of poor appetite, nausea, and vomiting. The neurologic examination revealed normal motor tone and strength. Deep tendon reflexes were reduced throughout, and Babinski reflexes were plantar bilaterally. He had nonsuppressible episodes of rhythmic, clonic jerking of the left leg that consisted of simultaneous partial flexion of the hip and knee and dorsiflexion of the foot. These movements occurred spontaneously as well as in response to provocation (i.e., forced plantar flexion, pressure). Although the patient was ambulatory, these movements would at times interfere with his activities. The rest of the physical exam was unremarkable.

Q Can movement disorder be presenting complaint of diabetes ?

Yes

Q In which patients with diabetes are movement disorders commonly seen ?

They are more common in patients with Hyperosmolar hyperglycemia state (HHS). It is more common in elderly women with uncontrolled diabetes.

Q Is the chorea seen with HHS reversible ?

Yes. It often reverses with the correction of hyperglycemia

Q What is the characteristic Neuroimaging picture seen in studies in patients with movement disorder and diabetes ?

Hyperdensity in putamen/caudate lobe are common in patients with Diabetes and movement disorder

Q Which other endocrinal conditions presents with Movement disorders ?

  1. Hypoparathyroidism, Pseudohypoparathyroidism and Fahr’s disease on account on basal ganglia calcification can present with abnormal movements and Parkinson like features
  2. Hypothyroidism can be mistaken for Parkinsonism
  3. Hyperthyroidism can present with chorea
  4. Hashimoto’s encephalitis can also present with chorea
  5. Hypoglycemia is a cause of chorea
  6. Hyperthyroidism is associated with fine tremors

The serum glucose was 891 mg/dL (65–115 mg/dL), and calculated serum osmolality was 313 mOsm/kg (285–295 mOsm/kg). Other pertinent admission data can be found in Table 1.

Q What is your conclusion from these lab reports ?

We are probably dealing with a case of Hyperglycemic hyperosmolar state.
Q What is the diagnostic criteria for HHS ?

  1. Blood glucose >600 mg/dl
  2. Serum osmolality >320 mosm/kg
  3. Absence of significant ketosis

The neurology consultant made a presumptive diagnosis of Epilepsia Partialis continua. He was treated with aggressive intravenous hydration and an insulin drip.

Q Summarize the management of HHS ?

FLUIDS

  1. 1 litre of 0.9% Normal saline is given over 1 hr
  2. Reassess the fluid status
    1. If patient in hypovoluemic shock – 1 litre of NS every hour till blood pressure improves
    2. If patient not in shock see below
  3. Patient not in shock- check the Serum sodium
    1. Hypernatremia/Normal sodium- give 0.45% Saline @10 ml/kg/hr
    2. Hyponatremia- give 0.9% Saline @10ml/kg/hr
  4. This is continued till blood glucose <300 mg/dl – then start 0.45% + Dextrose @100-200 ml/hr

INSULIN

  1. 15 units/kg IV stat followed by
  2. 1 units/kg/hr till blood glucose <300 mg/dl
  3. Double the rate of insfusion if the blood sugar doesn’t fall by >50 mg/dl/hr
  4. Once blood glucose <300 mg/dl- then reduce the rate to half and maintain the blood glucose in range of around 250 mg/dl

Potassium

  • If K < 3.3 meq/l
    • donot give insulin
    • 2 ampules of 11.2% KCl in 500ml of NS @200ml/hr
  • If K – 3.3- 5 meq/l
    • Can start insulin
    • 1 ampule of 11.2% KCl in 500ml of NS@ 200ml/hr
  • If K >5.0 – don’t give insulin
  • Ideally must be given as a mixture of 2/3rd of KCl and 1/3rd KPO4
  • 20-30 meq of K in 1 litre of fluid is generally adequate

On the second day, his glucose decreased to the 189 mg/dL. An electroencephalogram performed that day showed diffuse cerebral dysfunction without an epileptogenic focus. After glucose normalization, the abnormal movements disappeared and did not recur. Magnetic resonance imaging (MRI) performed 1 month later revealed diffuse periventricular microvascular changes without focal abnormality

 

Case 2

A 77 year-old male with type 2 diabetes and pancreatic cancer metastatic to the peritoneum presented to the emergency department with a 1-week history of uncontrollable jerking movements of his left arm. The movements were nonsuppressible, and according to the patient, appeared to worsen in concordance with an increase in his glucose finger stick values. He also complained of polydipsia, polyuria, nocturia, nausea, and sweating.

The neurological examination was remarkable for mild dysdiadochokinesia (an inability to perform rapid alternating movements) and a coarse, regular, 2–3/second, action-induced tremor at the left elbow, wrist, and fingers. These movements were not present at rest. The jerking disrupted voluntary repetitive movements and persisted on attempted relaxation, consistent with a rubral tremor. The initial laboratory evaluation showed a glucose level of 577 mg/dL (65–115 mg/dL) and calculated serum osmolality of 294 mOsm/kg (285–295 mOsm/kg). Additional clinical and laboratory data can be found in Table 1. Brain computed tomography showed a trace periventricular hypodensity without mass effect, suggestive of chronic microvascular disease.

He was started on insulin, with normalization of the blood glucose level by the second day. MRI performed on day 2 of admission showed mild chronic microvascular change without focal lesions. Repeat neurologic evaluation on day 2 revealed complete resolution of all abnormal movements; these did not recur during follow-up.

GENERAL DISCUSSION

 

Q Which is the most common movement disorder in diabetics (Hyperglycemia induced involuntary movement- HIIM) ?

Hemichorea-hemiballismus is the most common .

Q What is the theory which explains HIIM ?

  1. Hyperglycemia causes a Shift away from Kreb’s cycle to anerobic pathway. This causes depletion of GABA in CNS leading to increase of seizure threshold.
  2. Hyperglycemia can produce reduction in regional blood flow that can lead to reversible ischemia
  3. HHS can lead to increase viscosity of the blood which can lead to reversible ischemic state

Learning points from this case

  1. Hyperglycemia (especially HHS) can be associated with hyperkinetic movement disorder. Hemichorea-Hemiballismus is the most common movement disorder in such patients.
  2. The entity is known as ‘Hyperglycemia Induced involuntary movements’ which is often reversed completely by control of hyperglycemia.
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