title: Chorea, Hyperglycemia, Basal Ganglia Syndrome (C-H-BG) in an uncontrolled diabetic patient with normal glucose levels on presentation.
abstract: METHODS
  Female, 66 FINAL DIAGNOSIS: Chorea • hyperglycemia • Basal Ganglia Syndrome (C-H-BG) Symptoms: Hemibalism • hemichorea
  
  
  METHODS
  - Clinical Procedure: - Specialty: Endocrinology and Metabolic.
  
  
  OBJECTIVE
  Challenging differential diagnosis.
  
  
  BACKGROUND
  Hemichorea-hemiballism (HCHB) is a spectrum of involuntary, continuous non-patterned movement involving 1 side of the body. Possible causes of HCHB include hemorrhagic or ischemic stroke, neoplasm, systemic lupus erythematosus, HHNK, Wilson's disease, and thyrotoxicosis. This case illustrates the need to be aware of hyperglycemia as a cause of hemiballism/hemichorea, which is now referred to in the medical literature as C-H-BG (chorea, hyperglycemia, basal ganglia) syndrome.
  
  
  METHODS
  A 66-year-old Hispanic woman presented to our care with hemiballism/hemichorea of the right arm and leg of 1 week duration. She had been admitted 3 months prior with toxic metabolic encephalopathy secondary to hyperosmolar hyperglycemic non-ketotic syndrome with a blood glucose level of 984 mg/dL. Her blood glucose level was normal but hemoglobin A1C was 12.2%. A brain MRI revealed an asymmetric T1 hyperintensity of the left putamen. This specific finding was compatible with hyperglycemia-induced hemichorea hemiballism syndrome. The hemiballism/hemichorea slowly improved over the course of the hospitalization with strict glycemic control. At the 3-month follow-up visit she had no involuntary movements of her extremities, and she had well controlled blood glucose levels and a hemoglobin A1C of 9.0.
  
  
  CONCLUSIONS
  In a patient with normal glycemic levels but a history of uncontrolled diabetes, C-H-BG syndrome should be on the top of the differential list when the characteristic MRI findings of a hyperintensity in the basal ganglia are observed. This is a rare disease that deserves attention because it is reversible with correction of hyperglycemia. Thus, prompt recognition and treatment is essential to avoid adverse outcomes.
authors.affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A.
authors.forename: Jorge
authors.initials: J
authors.lastname: Bizet
authors.affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A.
authors.forename: Chad J
authors.initials: CJ
authors.lastname: Cooper
authors.affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A.
authors.forename: Raphael
authors.initials: R
authors.lastname: Quansah
authors.affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Rodriguez
authors.affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A.
authors.forename: Mohamed
authors.initials: M
authors.lastname: Teleb
authors.affiliation: Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, U.S.A.
authors.forename: German T
authors.initials: GT
authors.lastname: Hernandez
keywords: Basal Ganglia Diseases; Chorea; Dyskinesias; Hyperglycinemia, Nonketotic
references.citation: BMJ Case Rep. 2011 Oct 04;2011:
references.pmid: 22679165
references.citation: Metab Brain Dis. 2013 Mar;28(1):107-10
references.pmid: 23154926
references.citation: J Neurol Neurosurg Psychiatry. 1994 Jun;57(6):748-50
references.pmid: 8006661
references.citation: Neuroradiology. 2012 Oct;54(10):1119-20
references.pmid: 22383069
references.citation: Iran J Radiol. 2011 Mar;8(1):47-9
references.pmid: 23329917
references.citation: Parkinsonism Relat Disord. 2001 Oct;7(4):319-321
references.pmid: 11344017
references.citation: J Emerg Med. 2012 Sep;43(3):442-4
references.pmid: 20566257
references.citation: Neurol Sci. 2009 Jun;30(3):179-83
references.pmid: 19305947
references.citation: J Neurol. 2013 Dec;260(12):2986-92
references.pmid: 24008760
references.citation: J Magn Reson Imaging. 2006 Apr;23(4):564-8
references.pmid: 16514597
references.citation: Diabetes Care. 2013 Apr;36(4):e55-6
references.pmid: 23520380
references.citation: J Neurol Sci. 2002 Aug 15;200(1-2):57-62
references.pmid: 12127677
references.citation: J Clin Neurosci. 2011 Feb;18(2):293-4
references.pmid: 21159513
references.citation: Ann Indian Acad Neurol. 2011 Apr;14(2):124-6
references.pmid: 21808477
references.citation: Diabetes Res Clin Pract. 2012 Jan;95(1):e1-3
references.pmid: 21995866