Disclosures: Nicole Diaz-Segarra, MD: No financial relationships or conflicts of interest

Case Description: Balint’s Syndrome after Hypoglycemic Coma

Setting: Hospital and Rehabilitation Facility

Patient: A 41-year-old male with a history of type-1 diabetes was found unresponsive after eight hours of hypoglycemia with a blood glucose of 20 mg/dl. In the hospital, head imaging showed diffuse cerebral edema. Assessment/

Results: Electroencephalography revealed no evidence of sleep-wake cycles, supporting a diagnosis of hypoglycemic coma. His mental status and cognition improved, emerging by day 28. During this time, he was started on amantadine for arousal, quetiapine for agitation, and dextromethorphan/quinidine for pseudobulbar affect. After transfer to rehabilitation, he exhibited optic ataxia, oculomotor apraxia, and simultagnosia, consistent with Balint’s syndrome. After intensive visuospatial rehabilitation, his visual symptoms significantly improved. Visual symptoms resolved at 3-year follow-up with persistent higher-level cognitive deficits and frontal symptoms.

Discussion: Hypoglycemia is an uncommon cause of non-traumatic brain injury, termed hypoglycemic coma, encountered in diabetics who use insulin or insulin-secretagogue medication. Developing hypoglycemic coma and persistent deficits depend on the duration and magnitude of hypoglycemia prior to achieving normoglycemia. Once plasma blood glucose decreases below 30-50mg/dl and remains at these levels for hours, seizures and coma can occur resulting in neuronal damage with subsequent glutamate release. Balint’s syndrome is a visuospatial disorder associated with a triad of optic ataxia, oculomotor apraxia, and simultagnosia classically associated with bilateral inferior parieto-occipital brain injury, but has been reported in diffuse brain injury. It has been seen after traumatic brain injury, anoxic brain injury, stroke, metastasis, infection, and Alzheimer’s disease with no reported cases in the literature of Balint’s syndrome occurring after hypoglycemic coma.

Conclusion: This is the first reported case of Balint’s syndrome occurring after hypoglycemic coma. In addition, this case details the presentation, course, neuropharmacologic management, and outcome in this uncommon non-traumatic brain injury. This case emphasizes the importance of intensive visuospatial rehabilitation in patients with Balint’s syndrome to optimize functional outcome.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/balints-syndrome-after-hypoglycemic-coma-a-case-report/