An 81-year-old female, who was a diagnosed case of type 2 diabetes mellitus presented to the OPD with history of involuntary movements of right upper and lower limbs since one month which had increased in severity over the past one week. She was on irregular oral anti diabetic medication (tablet metformin 500 mg BD, tablet glimepiride 2 mg OD). On examination her vitals were stable. Involuntary semi purposeful, rapid and jerky movements were noticed in right upper and lower limbs . Jack in box movements were noticed in relation to the tongue. Tone, power, reflexes, sensory system were normal. Cardiovascular, respiratory systems and abdominal examination did not reveal any abnormalities. Our potential differentials based on the presentation (subacute onset hemichorea in an elderly lady) included senile chorea, Huntington's chorea, late onset Wilson's disease, lacunar stroke/haemorrhage, hypo/hyperthyroid state, Sydenham's chorea, drug induced movement disorder, metabolic disorders (hyperglycemia, uremia, hypoparathyroidism). Her routine haemogram showed normal haemoglobin (13 gm/dl), platelet count (1.77 lakh/µl) and total leukocyte count (7200/µl). Random blood sugar was 400 mg/dl with HbA1c value of 17.4%. Urine ketones were 40 mg/dl. Arterial blood pH was 7.39 and electrolytes were normal (potassium: 4.3 mmol/l, sodium: 135 mmol/l, calcium: 9 mmol/l). Serum urea and creatinine were normal. Prothrombin time of 13.4 secs and aPTT 26 secs were noted. TSH was within normal limits (3.5 uU/ml) and MRI brain showed hyperintensities
AbSTRACTChorea has often been associated with lesions in the basal ganglia and in the sub thalamic nucleus. It is possible for a patient with chorea-ballismus to have hyperglycemia at the initial presentation. We hereby present a case of an 81-year-old female, who was on treatment for type 2 diabetes mellitus and presented to us with sub acute onset of abnormal movements of right side of the body. She had semi purposeful, rapid and jerky movements of right upper limb and lower limb along with abnormal tongue movements. Laboratory data showed very high blood glucose levels, urine ketones were positive and pH of arterial blood was normal. MRI brain showed hyperintensities in right basal ganglia. So, hyperglycemia induced hemichorea was considered as a possibility and she was treated with insulin. These abnormal movements decreased subsequently with treatment and patient is doing better in the follow-up visits. This presentation is extremely rare, as review of literature showed similar presentations in patients with non ketotic hyperglycemia but not reported so far in diabetic ketosis.in right basal ganglia [Table/ Fig-1,2]). Based on the examination findings and laboratory values the diagnosis were narrowed down to hyperglycemia induced hemichorea. She was initially treated with intravenous insulin infusion till her blood sugar was near normalised and then switched over to subcutaneous insulin with which she improved. Patient improved with the treatment dramatically and she was discharged w...