‘I can't walk straight doc’ – A case of hemiballismus in non-ketotic hyperglycaemia

Uncontrolled hyperglycaemia produces a range of symptoms but neurological signs such as hemiballismus can be rare. This case report was produced after encountering a patient who presented in AMU who had difficulties in walking. A history was taken and the patient was examined before conducting a series of investigations to elicit the cause of his symptoms. Further to this, an article search into the proposed cause of his symptoms was done to learn how similar cases are managed. An 87 year old gentleman attended with his wife who had a 3 day history of veering off to one side whilst walking as well as repeated involuntary movements of his left arm. Vision loss, dysphasia, facial droop, or other sensory/motor deficits were not evident. Co-morbidities included T2DM (previous HbA1c 117) controlled with metformin and gliclazide, and a previous lacunar infarct, treated with clopidogrel. He was normally independent of ADL's, a non-smoker and did not drink alcohol. Observations were unremarkable with NEWS 0 and a normal neurological and cerebellar examination. Bloods were unremarkable aside from a blood glucose of 32 mmol/L and ketones 0.1 mmol/L. A CT Head scan excluded an infarct or haemorrhage. The stroke team were contacted who advised for a further MRI which also did not show any acute findings. The patient was given a stat dose of 80 mg gliclazide and on discharge, his normal gliclazide regime was increased from 40 mg OD to 80 mg OD. He was referred to outpatient stroke clinic but due to a combination of resolved symptoms, unlikely presentation of a stroke/TIA and unremarkable radiological findings, he was discharged back to his GP. Hyperglycaemic non-ketotic hemiballismus refers to ballismus secondary to hyperglycemia with a reversible abnormality of basal ganglia that may be seen on CT/MRI. Similar cases have been published in multiple journals including the BMJ, which discusses the case of a 70 year old female with right sided hemi-chorea who had significant MRI findings1. This case highlights that unusual presentations do not always equate to a rare diagnosis; hemiballismus is uncommon in the context of T2DM but considering metabolic causes as well as neurological diagnoses may be crucial in the management of such patients. Zhang B, Lu Z. Hemichorea in non-ketotic hyperglycaemia. BMJ. 2021;375:e066994.