The Journal of Emergency Medicine, Vol. 49, No. 2, pp. e57–e58, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter

http://dx.doi.org/10.1016/j.jemermed.2015.02.016

Visual Diagnosis in Emergency Medicine

HYPERDENSE BASAL GANGLIA IN NONKETOTIC HYPERGLYCEMIA Satheesh Krishna, MD,* Kushaljit Singh Sodhi, MD, MAMS, FICR,* Akshay Kumar Saxena, MD, DNB, FICR,* Pratibha Singhi, MD,† and Niranjan Khandelwal, MD, DNB, FICR* *Department of Radiodiagnosis and Imaging and †Department of Radiodiagnosis and Pediatrics, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India Reprint Address: Kushaljit Singh Sodhi, MD, MAMS, FICR, Department of Radiodiagnosis and Imaging, Department of Radiodiagnosis, PGIMER, Chandigarh 160012, India

could also be appreciated in the right arm. The child was on improper glycemic control for the previous 3–4 years, with random blood glucose levels fluctuating between 200 and 300 mg% without any insulin titration. HbA1c level at presentation was 9.2%. Blood and urinary ketones were negative. Common causes of chorea in childhood (rheumatic Sydenham chorea, juvenile Huntington disease, benign

CASE REPORT A 12-year-old girl, a known case of type 1 diabetes mellitus since the age of 5 years, came to us with acute-onset abnormal, swift, nonjerky involuntary movements of the left upper and lower limbs for the past 20 days, which persisted even during sleep. On examination, left hemichorea was noted and subtle semi-purposive movements

Figure 1. Noncontrast computed tomography of the head shows relatively symmetric hyperdensities involving both the globus pallidi (black arrows).

RECEIVED: 8 October 2014; FINAL SUBMISSION RECEIVED: 20 January 2015; ACCEPTED: 21 February 2015 e57

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Figure 2. (A) T1-weighted images of magnetic resonance imaging of the head shows hyperintensity in bilateral globus pallidi (black arrows). Note that the distribution of the hyperintense signal is asymmetric, with the degree of involvement more on the right side when compared with the left. (B) T2-weighted images of the same areas show hypointense signal (white arrows).

hereditary chorea, autoimmune chorea) were considered and were ruled out by appropriate investigations (normal anti-streptolysin O titres, normal echocardiogram, absent family history, and negative antinuclear antibodies). A noncontrast computed tomography (CT) scan of the head revealed relatively symmetric hyperdensities in the bilateral globus pallidi (Figure 1). Magnetic resonance imaging showed altered signal intensity in the same region, which was hyperintense on T1- and hypointense on T2-weighted images (Figure 2). The involvement was, however, asymmetric, with the right side showing more extensive changes, which was consistent with our clinical profile of asymmetric chorea. Diffusion weighted imaging did not show areas of restricted diffusion. DISCUSSION Choreoathetosis is an uncommon presentation of diabetes mellitus seen in nonketotic hyperglycemia and is more common in elderly females (1). Bilaterality is uncommon (11.4%) (2). The cause of the basal ganglia changes have been variously attributed to petechial hemorrhages, myelinolysis, or calcification. However, this condition can be under-recognized by clinical radiologists. Nonketotic hyperglycemia should be a part of the differential diagnosis

for high T1-weighted signal in the basal ganglia. The other differentials include: Wilson disease, manganese toxicity, chronic liver failure, calcium metabolism abnormalities, and hypoxic brain injury. Classically, in patients with hyperglycemia associated with hemichorea-hemiballismus, there is high T1- and low T2-weighted signal in the putamen of the basal ganglia and high density on CT (3,4). It is essential to recognize this condition early, as significant recovery of chorea is seen after good glycemic control, as was seen in our case (3). REFERENCES 1. Chang KH, Tsou JC, Chen ST, et al. Temporal features of magnetic resonance imaging and spectroscopy in non-ketotic hyperglycemic chorea-ballism patients. Eur J Neurol 2010;17:589–93. 2. Oh SH, Lee KY, Im JH, Lee MS. Chorea associated with non-ketotic hyperglycemia and hyperintensity basal ganglia lesion on T1weighted brain MRI study: a meta-analysis of 53 cases including four present cases. J Neurol Sci 2002;200:57–62. 3. Zaitout Z. CT and MRI findings in the basal ganglia in non-ketotic hyperglycaemia associated hemichorea and hemi-ballismus (HCHB). Neuroradiology 2012;54:1119–20. 4. Scozzafava J, Alladin Y, Jickling G, Block H, Nizam Ahmed S, Kalra S. MRI changes in a patient with hemichorea–hemiballismus and non-ketotic hyperglycaemia. Univ Alberta Health Sci J 2009;5: 24–5.

Hyperdense Basal Ganglia in Nonketotic Hyperglycemia.

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