New-Onset Diabetes Presenting as Monoballism Secondary to a Mixed Hyperglycemic Crisis

Abstract

Monoballism secondary to a mixed hyperglycemic crisis is a rare initial symptom of new-onset diabetes, which commonly affects the elderly and Asian women having inadequate glycemic control. In hyperglycemic states, the elevated serum glucose levels raise the viscosity of the blood reducing cerebral perfusion, decreasing gamma-aminobutyric acid levels, the latter being an inhibitory neurotransmitter of thalamocortical stimuli. In this case, we report a previously healthy 41-year-old male who attended the emergency department because of an abrupt onset movement disorder of the left arm, this being compatible with monoballism. He was diagnosed with a mixed hyperglycemic crisis.

Hemiballismus in Patients With Poorly Controlled Type 2 Diabetes Mellitus

“…As with Case 2, past literature describes many cases of acute hyperglycemic episodes with glucose ranging from 500 to 1,000 mg/mL presenting with hemiballismus. 1,3 However, there are many cases that describe hemiballismus occurring after glycemic correction, persisting despite glycemic correction, and presenting without an acute hyperglycemic episode, but in the setting of elevated HbA 1c , as in Case 3. 12,13 Notably, all 3 cases in this series had marked elevation in their HbA 1c levels, which suggests that a more chronic hyperglycemic state or multiple shorter periods of hyperglycemia may be necessary to produce the described hyperkinetic movements.…”

“…While the exact etiology remains unclear, the hyperintensity is hypothesized to be related to metabolic derangements caused by hyperviscosity of the blood in the small end arteries feeding the basal ganglia. 3,11 These abnormalities in turn interrupt the signaling cascade with abnormal firing rates or firing patterns, leading to reduced inhibition of the motor thalamus and ultimately present as hemiballismus. 1,3,7 While most cases presented with unilateral hyperkinesis and associated contralateral basal ganglia abnormalities, there are reports of both unilateral and bilateral movements associated with bilateral basal ganglia hyperintensities on imaging.…”

“…hemichorea-hemiballismus are stroke and hyperglycemia, with an incidence of 4% and unknown incidence, respectively. 1,3,4 Other causes include HIV, traumatic brain injury, encephalitis, vasculitis, mass effect, multiple sclerosis, and adverse drug reactions. [4][5][6][7] Acute or subacute hemiballismus is classically attributed to a lesion in subthalamic nucleus (STN), but this is true only in a minority of cases.…”

“…8 Although not commonly recognized, hyperglycemia in patients with type 2 diabetes mellitus (T2DM) is the second most common cause of hemichoreahemiballismus. 3 Over the past 90 years, numerous case reports have described patients with DM with acute and subacute onset of hemiballistic and hemichoreiform movements while in a hyperglycemic state or after its resolution. Reported cases have been limited to small numbers of patients with only a few larger-scale reviews of more than 20 patients.…”

“…1 Movements usually involve both the arm and leg, and in half of cases, facial movements such as tongue clucking and grimacing are seen. 2,3 Presentations of hemiballismus vary in severity from intermittent to nearly continuous movements, which, in some cases, may lead to exhaustion, injury, or disability. Some patients are unable to ambulate or feed themselves with the affected limb.…”