Movement Disorders

Vol. 5 , No. 2, 1990, pp. 176-177, 0 1990 Movement Disorder Society

Brief Report

A Movement Disorder as a Presenting Feature of Recurrent Hypoglycaemia J . B. Winer, D. R. Fish, D. Sawyers, and C. D. Marsden Institute of Neurology and the National Hospital .for Nervous Diseases, London, England

Hypoglycaemia is a common cause of altered awareness and abnormal behaviour in insulin-dependent diabetics. Rarely, attacks of hypoglycaemia may be seen in patients with insulin-secreting tumours of the pancreas. Recognition of the cause of symptoms in such patients is often difficult and attacks can resemble transient ischaemic events or completed stroke (1). Occasional cases have been reported in which abnormal movements have been noted during hypoglycaemic attacks (2,3), but these were not fully described. We report a patient who presented with these movements that were documented using video cable telemetry.

eralised slow activity that resolved immediately after intravenous glucose administration, although it was in this stage that her abnormal movements and posturing developed (see videotape segment 1). A blood glucose level of 1.4 mmol/L was recorded with both raised C-peptide (1,100 pmol/L) and insulin levels (26.5 U). Results of a subsequent CT scan of the abdomen were normal but angiography revealed a tumour blush in the body of the pancreas. She underwent laparotomy with the removal of a 1-cm-diameter islet cell tumour. She made a good postoperative recovery and was completely free of attacks on review 3 months later.

CASE HISTORY

DISCUSSION

A 58-year-old part-time nursing assistant who was taking no medication presented with a 3-year history of attacks of abnormal movements and unusual behaviour. These attacks increased in frequency from one every few months to two to three a day and lasted for 15 min to 4 h. The attacks were precipitated by fasting or exercise and were more frequent in the morning. A typical attack had a gradual onset with increasing confusion, difficulty in finding words, garbled speech, sweating, and facial flushing. After approximately a half hour, towards the end of the attack, she would develop tonic posturing of all four limbs, lasting for up to 10 min. Loss of consciousness had occurred on a few occasions during the 3 months before presentation. She had noticed that the severity of the attacks could be reduced by frequent meals and as a result had gained two stone (-12.7 kg) in weight. Results of computerised tomography (CT scan) and the resting electroencephalograph (EEG) were normal. However, she had persistently low blood glucose measurements (1-4 mmoUL), particularly in the morning. An attack occurred during EEG telemetry with simultaneous video recording. The EEG during the attack showed gen-

Altered blood glucose levels in diabetes mellitus may have various neurological manifestations. Generalised disturbances such as drowsiness, coma, and behavioural disorders are most frequent. Focal disorders can occur in the absence of an identifiable structural lesion. Of these focal disorders, transient neurological deficit simulating stroke is the most common (1). Nonketotic hyperosmolar coma may be associated with tonic spasms (4) and paroxysmal choreoathetosis (5). Choreoathetosis has been reported in a few patients after insulin-induced hypoglycaemia (3). However, the nature of these movements has never been well documented. The case we report demonstrates sustained dystonic posturing of all four limbs, the neck, and trunk after the features of a brief, classic hypoglycaemic attack. It is of interest that these movements appeared to be markedly increased after reversal of the hypoglycaemia and subsequent resolution of the EEG changes. This would suggest that the rate of change of blood glucose is more relevant to the production of abnormal movements than are the absolute values. These unusual paroxysmal movements had persisted for 3 years before recurrent hypoglycaemia was suspected and had at one stage been considered to be hysterical. This case illustrates the need to consider hypoglycaemia as a rare but treatable cause of such movement disorders.

A videotape segment accompanies this article. Address correspondence and reprint requests to Dr. J. B. Winer at Institute of Neurology and the National Hospital for Nervous Diseases, Queen Square, London, 1J.K.

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MOVEMENT DISORDER IN RECURRENT HYPOGLYCAEMIA LEGEND TO THE VIDEOTAPE At 12.31.12 the patient is sitting quietly reading. The simultaneous electrophysiological monitor shows six channels of electroencephalography (EEG) (bitemporal montage) and two channels of electrocardiogram. The patient becomes unresponsive by 14.37, with tonic extension of the right arm. The EEG then showed generalised slow-wave activity. Fifty milliliters of 50% glucose was administered at 14.45. Within a minute the patient begins to talk gibberish, puts her right hand to her face, and the EEG returns rapidly to normal. From 14.46.45 the patient is responsive and oriented but from 14.47.35 she begins to develop abnormal posturing culminating in tonic flexion of the elbows and hands, extension of the lower limbs, laterocollis, and flexion of the trunk. At 14.48.24 she is

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asked to move her arms but cannot. From 14.48.44 the spasms begin to relax with stereotyped leg movements.

REFERENCES 1 . Meyer SS, Portnoy HD. Localised cerebral hypoglycaemia simulating stroke. Neurology 1958;8:601-614. 2. Golden LA. Neurologic manifestations in hypoglycaemic shock. Ann Intern Med 1937;11:819-822. 3. Newman RP, Kinkel WR. Paroxysmal choreoathetosis due to hypoglycaemia. Arch Neurol 1984;41:341-342. 4. Maccario M, Brooklyn MD. Neurological dysfunction associated with nonketotic hyperglycaemia. Arch Neurol 1968; 19:525-534. 5. Rector WG, Herlong HF, Moses H. Nonketotic hyperglycaemia appearing as choreoathetosisor ballism. Arch Intern Med 1982;142:154-155.

Movement Disorders, Vol. 5 , No.2, 1990

A movement disorder as a presenting feature of recurrent hypoglycaemia.

Movement Disorders Vol. 5 , No. 2, 1990, pp. 176-177, 0 1990 Movement Disorder Society Brief Report A Movement Disorder as a Presenting Feature of...
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