Endocrine Abstracts

Introduction: Hemiballism is a rare hyperkinetic movement disorder characterized by involuntary, violent, coarse and wide-amplitude movements involving the ipsilateral arm and leg. Here, we aimed to present a case diagnosed as hemiballism due to non-ketotic hyperglycemia.

Case Report: A 60-year-old female patient presented to the emergency department with involuntary movements in the right half of the trunk for 10 days. It was a large amplitude proximal extremity movement in the right arm and also occurred in the right lower extremity. Movements did not continue during the night’s sleep. On physical examination, she was conscious and well oriented to time and place. Hemodynamics and vital signs were stable. There was no sign of facial paralysis. Osteotendinous reflexes were symmetrical. Cranial nerves were intact. There were no other accompanying physical examination findings. She had type 2 diabetes for 10 years. She was using gliclazide 30 mg and linagliptin 5 mg, but she did not have regular doctor checks and did not measure blood glucose. She had no history of alcohol or substance abuse. Laboratory results showed a high plasma glucose of 540 mg/dl and a serum osmolarity of 302 mOsm/kg. The patient’s kidney and liver functions were normal and there was no accompanying serious electrolyte imbalance. There was no finding compatible with metabolic acidosis in venous blood gas, there was no ketone positivity in urinalysis, and glucosuria was present. No signs of intracranial hemorrhage or ischemia were detected in the brain computerized tomography (CT) imaging, and there was an increase in asymmetric density at the right putamen compared to the left. Similarly, there was hyperintensity on T1-weighted sequences at the right putamen in brain magnetic resonance imaging (MRI). As a result of clinical, laboratory and radiological evaluations, the patient was accepted as non-ketotic hyperglycemia-associated hemibalism syndrome. The patient was first hydrated, crystallized insulin infusion was started with close blood glucose monitoring, and then intensive insulin therapy was started. When plasma glucose began to improve, involuntary extremity movements also decreased. At 3-month follow-up, both normoglycemia and hemiballism were almost completely resolved.

Conclusion: Non-ketotic hyperglycemia-associated hemiballism syndrome is a rare initial manifestation of diabetes and is usually seen in elderly diabetic patients with poor glycemic control. It should be kept in mind that hemiballism may be the first sign of undiagnosed diabetes, and this rare neurological complication should be recognized as it is easily resolved with hyperglycemia treatment.