Movement Disorder - A Rare Presentation of Diabetic Ketoacidosis

Dr Sanjiv Maheshwari at JLN Medical College, Ajmer, Rajasthan and colleagues have reported a rare case of Movement Disorder due to Diabetic Ketoacidosis. The case has appeared in the Journal of Association of Physicians of India.

An 18-year-old female, married, one parity, presented to us in casualty medicine unit in altered sensorium. As per history given by the mother and brother she had complains of irrelevant talking, abnormal movements of the right arm and right side of face since one day. The onsets of these symptoms were described as gradual and then she was in altered sensorium when brought to hospital. She also had a complaint of generalized abdominal pain, moderate in intensity, dull in character and without any precipitating/relieving factor since 10 days. She had no history of vomiting or aspiration. She had no significant past medical/surgical history, no history of seizure disorder, and no psychiatric illness and no significant family history.

On examination, the patient was fairly built and nourished, was not fully conscious and oriented, her Glasgow Come scale was E2M4V2.

Her vitals were: pulse rate – 138/min; BP 140/70 mmHg; RR- 34/min; afebrile; oxygen saturation- 98% on room air. Pupils were round, regular and reactive.

Her nervous system examination revealed GCS- 6, no signs of meningeal irritation, generalized increase in tone in all four limbs, with normal deep tendon reflexes and superficial reflexes. Planter reflexes were bilateral mute. She was having choreiform movements on right side of the body along with facial tics on the same side.

At the time of admission, her random blood sugar was 452 mg% and urine ketones were large. Complete blood count, peripheral blood smear, renal function tests, liver function tests, serum electrolytes, ECG, chest skiagram, and USG abdomen, all were within normal limits.

On the basis of the above evaluation, the patient was shifted into ICU and treatment of diabetic ketoacidosis was started. After 2 days when the ketones were nil in the urine, the patient was taken on the basal-bolus insulin regime.

Even after regaining full consciousness, her choreiform movements involving the right arm and tics on right side of face persisted which could not be suppressed with voluntary effort, although marked reduced during sleep.

For further neurological evaluation detail, fundoscopy by expert ophthalmologist and EEG were performed and found unremarkable.

MRI brain showed significant subcortical T2 and FLAIR hyperintensity seen predominantly in the left parieto-occipital lobe and part of left temporal lobe with subtle hyperintensity in the overlying cortex, which includes possibilities of either hyperglycemic injury or subacute hypoxic insult (Figures 1, 2, 3).

The frequency and the amplitude of choreiform movements decreased as the serum glucose approached normal levels. She was discharged on insulin basal-bolus regimen.

On follow up after one month she was alert and oriented with the disappearance of chorieform movements. Only the facial tics persisted which were milder in intensity as compared to when she was admitted.