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Hemi-ballismus as a presentation of hyperglycaemia and the classical neuro-imaging findings

Campioni-Norman D, Casey F, Darby L, Shah P, Das G, Department of Endocrinology, Ashford and St Peters hospital NHS Trust

We present the case of a 70 year old male who presented to Accident and Emergency with a 4-day history of progressively worsening right sided hemi-ballismus. Alongside this he had widespread joint pain, synovitis and dactylitis.† There was no other neurological deficit, and he had no other presenting symptoms. The patient had a background of poorly controlled diabetes, managed with Metformin recent diagnosis of prostate cancer, ischemic heart disease and psoriatic arthritis.

On admission the patient was afebrile with stable observations. Routine blood tests results were within normal range. His Hb A1C was grossly elevated at 134mmol/mol, and his blood glucose was 29mmol/L. CT imaging showed no acute large vessel ischaemia or haemorrhage, but showed subtle high attenuation of the left caudate and lentiform nucleus. MRI confirmed no acute haemorrhage or infarct, and showed the T1 attenuation in the left basal ganglia to be most likely due to calcification or mineralisation.

Patient was treated along the line of hyperglycemic hyperosmolar state with ongoing hemiballismus. He was also treated for a flare of his psoriatic arthropathy during this admission. The patientís diabetes medication regime was intensified to improve his blood sugar control. On successful management of the hyperglycaemia the patientís hemi-ballismus resolved within 4 days

Discussion: Hemi-ballismus is a disorder of involuntary, continuous irregular movement involving one side of the body. It is caused in most cases by decrease in activity of the subthalamic nucleas of the basal ganglia. Causes of hemi-ballismus include stroke, malignancy, non-ketotic hyperglycaemia, Wilsonís disease, as well as infective causes such as HIV associated toxoplasmosis.

Hyperglycaemia and severe non ketotic hyperglycemia is thought to be the second most common cause of hemi-ballismus in elderly, and this case has highlighted to our trust the need to be aware of hyperglycaemia as a potential diagnosis. While hyperglycemia itself is not the cause of the hemiballistc movements, it has been postulated that hyperviscosity of blood leads to some degree of ischemia at the basal ganglia causing decreased production of GABA and acetylcholine which causes further disruption of normal neuronal impulse transmission and circuit.

Another interesting point from this case is the characteristic findings of hyper intensity in the basal ganglia, the current hypotheses surrounding the pathogenesis of this and how the potential mistake of diagnosing it as a small haemorrhagic stroke on neuro- imaging can be made.

References:

1. Hemichorea/Hemiballismus associated with hyperglycemia: report of 20 cases-NCBI-NIH

2. Hemiballismus in Uncontrolled diabetes mellitus Korean J Fam Med.2018 May:39(3)200-203