Acute choreiform movements in the feet: A case report

Abstract

Abstract A 48-year-old man presented to a tertiary care center with a 1.5-year history of sudden-onset choreiform movements in both feet. The movements were greater in the left foot, with a preceding 1-month history of cocaine and amphetamine/dextroamphetamine use. His symptoms persisted even after discontinuing the use of these substances; the movements were present while awake and absent while asleep and caused extreme discomfort while wearing shoes. Numerous trials of medications did not alleviate his symptoms, except for transient improvement with risperidone. His examination was notable for writhing movements of the toes, which was worse in the left foot than the right foot. The movements occasionally spread to the left knee, and he had length-dependent decreased temperature and vibration sensation in the lower extremities and an unsteady gait. Brain magnetic resonance imaging without contrast obtained 1 year after symptom onset demonstrated T2/fluid-attenuated inversion recovery hyperintense signal with a rim of hypointensity in the bilateral globus pallidi. Magnetic resonance imaging 1 year later displayed stable findings of bilaterally symmetric diffuse hypointensities in the globus pallidi. The patient was diagnosed with chorea, presumed secondary to his cocaine use. He was started on multiagent treatment with clonazepam, tetrabenazine, and onabotulinum toxin A. A thorough history and analysis of his risk factors was essential to determine the underlying cause of his symptoms to guide effective treatment; however, to the best of our knowledge, no effective long-term treatments for chorea in patients such as that in our study have been documented to date. This case of cocaine-induced chorea adds to the growing documentation of scenarios, in which cocaine use can lead to chronic movement disorders.