Objective: To present a sequential clinico-radiological study of a diabetic patient on hemodialysis who developed acute chorea followed by chronic parkinsonism.

Background: Hyperglycemic chorea is associated with hyperintense MRI lesions involving the pallidostriatum on T1, T2, DWI and ADC sequences, consistent with vasogenic edema. Small, central hypointense areas on GRE sequences suggest petechial hemorrhages. Yet, hypointense areas on ADC might indicate hyperviscosity without hemorrhage. Findings in hypoglycemic chorea are similar, except for hypointensity on T1-weighted images suggesting cytotoxic edema. Normoglycemic chorea has rarely been reported after treating severe hyperglycemia. Most cases eventually resolve but few patients develop chronic bradykinesia.

Methods: Case report.

Results: A 47 year-old diabetic man on hemodialysis was started on nightly glargine insulin. During the next 20 days, his glycemias were 76-92 mg/dL and he developed mild generalized chorea. MRI showed cytotoxic and vasogenic edema affecting both putamina. Insulin was switched to sliding scale and chorea improved with glycemias of 124-214 mg/dL. Glargine was eventually restarted and glycemias dropped to 73-94 mg/dL. In two weeks, chorea worsened triggering an amantadine trial. Glargine was discontinued and glycemias improved to 113-228 mg/dL. Chorea resolved but a month later he developed parkinsonism and was started on carbidopa/levodopa. Though cytotoxic edema improved, vasogenic edema extended to the caudate nuclei, pallidi, external capsules and hippocampi, with petechial hemorrhages in the pallidi. Four months later, bradykinesia worsened and carbidopa/levodopa was increased with limited benefit. Cytotoxic edema resolved and vasogenic edema improved, with areas of cystic degeneration and increased petechial hemorrhages.

Conclusions: In diabetic patients on hemodialysis, persistent relative hypoglycemia could trigger acute chorea followed by chronic, treatment-resistant parkinsonism. During the acute hyperkinetic phase, cytotoxic and vasogenic edema initially affect the putamina and subsequently involve surrounding structures. Improvement of edema with additional petechial hemorrhages and areas of cystic degeneration might herald a chronic bradykinetic phase. Timely recognition and treatment of the metabolic insult might prevent this course.

« Back to 2016 International Congress

MDS Abstracts - https://www.mdsabstracts.org/abstract/relative-hypoglycemia-induces-acute-chorea-followed-by-chronic-parkinsonism-in-a-diabetic-patient-on-hemodialysis-a-case-with-sequential-clinico-radiological-correlate/