MOVEMENT DISORDER AS A MANIFESTATION OF DIABETIC KETOACIDOSIS

Abstract

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Movement disorders are well-defined presentation of non-ketotic hyperglycemia (NKH) but are rarely associated with diabetic ketoacidosis (DKA). Here we present a rare case of movement disorder in DKA. CASE PRESENTATION: A 50-year-old female with a past medical history of HIV, migraine and hypertension presented to our tertiary care center with a chief complaint of sudden onset involuntary movement of her right upper extremity. She reported 4 days of generalized weakness as well. On physical examination, she was alert and well-oriented with choreiform movements localized to her right upper extremity. Decreased muscle strength (3/5) of her right upper extremity was also noted. No other neurological deficits were observed. Laboratory evaluation revealed serum glucose 1147 mg/dl, sodium 136 mEq/L, potassium 6.3 mEq/L, HCO3 16 mEq/L, chloride 93 mEq/L, creatinine 2.17 mg/dl, TSH 0.88 mIU/L, calcium 9.1 mg/dl and HbA1C 14%. Urinalysis revealed 1+ ketones and serum beta-hydroxybutyrate was positive. CT head was unremarkable. Patient was treated with tissue plasminogen activator (tPA) due to clinical suspicion of stroke and was started on IV fluids and insulin. MRI brain was negative for any acute ischemic process and MR angiogram of head was normal. Her serum glucose gradually normalized with insulin drip. Involuntary right upper extremity movement gradually improved as serum glucose normalized and completely resolved on 3rd day. Patient was back to her baseline with no residual weakness on 6th day of presentation. DISCUSSION: Sudden onset chorea is an uncommon presentation of DKA. Mechanism of DKA induced movement disorder remains unclear although several hypotheses have been proposed to explain the pathophysiology of movement disorder in NKH. Most patients show hemichorea-hemiballism with upper extremity involvement similar to our patient[1,3]. Characteristics MRI findings in basal ganglia were reported but imaging finding is not a prerequisite for the diagnosis of hyperglycemic movement disorder as seen in our patient[3]. Chorea is associated with a large number of hereditary and systemic diseases such as stroke, hyperthyroidism, NKH, hypocalcemia, and renal failure. It is the most common movement disorder to occur as a result of stroke. A variety of drugs have been reported to cause chorea[2]. Significant rapid improvement in symptoms after blood glucose control and anion gap closure in our case proves the role of DKA in movement disorder. CONCLUSIONS: Movement disorders are presenting symptoms for a variety of medical conditions and disorders. It can manifest as a presenting complaint in DKA. Early recognition and appreciation of these disorders will help clinicians narrow the diagnosis and avoid inadvertent use of medications. Reference #1: Jagota P, Bhidayasiri R, Lang AE. Movement disorders in patients with diabetes mellitus. Journal of the Neurological Sciences. 2012 Mar 15;314(1):5–11. Reference #2: Barton B, Zauber SE, Goetz CG. Movement Disorders Caused by Medical Disease. Semin Neurol. 2009 Apr;29(2):97–110. Reference #3: Lee S-H, Shin J-A, Kim J-H, Son J-W, Lee K-W, Ko S-H, et al. Chorea-ballism associated with nonketotic hyperglycaemia or diabetic ketoacidosis: Characteristics of 25 patients in Korea. Diabetes Research and Clinical Practice. 2011 Aug;93(2):e80–3. DISCLOSURES: No relevant relationships by Anisha Adhikari, source=Web Response No relevant relationships by Prashank Neupane, source=Web Response No relevant relationships by Bharadwaj Satyavolu, source=Web Response No relevant relationships by Zed Seedat, source=Web Response