Nonketotic hyperglycaemia associated hemichorea-hemiballismus in an elderly woman with type 2 diabetes mellitus

Abstract

Hyperglycaemia-induced chorea, also referred to as Diabetic Striatopathy (DS), is a rare but clinically significant neurological complication of uncontrolled diabetes mellitus. It is most frequently associated with non-ketotic hyperglycaemia and manifests as hemichorea or hemiballismus, occasionally progressing to generalised choreiform movements. Although uncommon, DS is increasingly recognized as the second most frequent cause of hemichorea- hemiballismus after basal ganglia cerebrovascular events and the most common metabolic etiology of this syndrome. The condition is typically characterized by severe hyperglycaemia in the absence of ketosis accompanied by either choreiform movements or radiological abnormalities of the basal ganglia on CT or MRI. However, normal neuroimaging does not exclude the diagnosis and clinical suspicion remains paramount. Misdiagnosis is common, particularly when basal ganglia hyper density on CT mimics intracerebral haemorrhage leading to unnecessary interventions and delayed treatment. We present the case of a 71-year-old woman with long-standing type 2 diabetes mellitus and chronic kidney disease who developed acute onset hemichorea in the setting of profound hyperglycaemia. Despite unremarkable neuroimaging, the diagnosis of DS was established based on clinical features and metabolic derangements. The patient demonstrated partial improvement with strict glycaemic control and symptomatic therapy, though abnormal movements persisted beyond three months. This case underscores the importance of recognizing DS even in the absence of classical imaging findings. Early diagnosis and prompt initiation of glycaemic control, supplemented by symptomatic pharmacotherapy, when necessary, can significantly improve outcomes. Greater awareness among clinicians is essential to prevent misdiagnosis and ensure timely management of this rare but reversible complication of diabetes mellitus.