Disclosures: Kevin Machino, DO: No financial relationships or conflicts of interest

Case Description: The patient presented to the emergency department with uncontrollable movements of the left upper and lower extremities for two days. Her exam was notable for choreoathetoid and flailing movements of the left arm and leg in varying frequencies. She had no other neurological deficits. She had diabetic ketoacidosis with anion gap of 25, ketonuria of 40 mg/dL, beta-hydroxybutyrate of 0.9 mmol/L, blood glucose of 374 mg/dL, and HgA1c of 14.3%. Initial CT Head, EEG, drug and metal screen were unremarkable. MRI Brain showed calcifications in the right posterior putamen.

Setting: Tertiary Care Hospital/Acute Inpatient Rehabilitation Hospital

Patient: A 70 year-old White female with history of diabetes, hypertension, hypothyroidism, depression, and anxiety. Assessment/

Results: The patient was given one dose of subcutaneous regular insulin and her blood glucose was eventually controlled with glargine, glimepiride, and metformin. Her symptoms improved with better glycemic control. She had deficits in self-care, transfers, and mobility. She completed a 10-day course of acute inpatient rehabilitation and was discharged home independent on all ADLs, transfers, and ambulation.

Discussion: The incidence of hemichorea-hemiballismus syndrome (HCHB) is extremely rare with an estimated prevalence of less than 1 in 100,000. Majority of cases are associated with nonketotic hyperglycemia and found in elderly Asian females. There are very few reported cases of ketone-positive HCHB, all confirmed by urinalysis. This is the first reported case, to our knowledge, of HCHB secondary to ketotic hyperglycemia with both a positive serum beta-hydroxybutyrate and urine ketone findings. The hemiballistic movements are presumed to be due to contralateral basal ganglia involvement from hyperglycemia, as seen in our patient.

Conclusion: HCHB should be considered in patients with uncontrolled diabetes presenting with involuntary movements of the hemi-body. Early detection and correction of hyperglycemia can result in symptom resolution and favorable functional outcomes.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/a-rare-case-of-hemichorea-hemiballism-induced-by-ketotic-hyperglycemia-a-case-report/