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Título

CASE REPORT: HEMICHOREA IN A PATIENT WITH NON-KETOTIC HYPEROSMOLAR HYPERGLYCEMIC STATE AFTER KIDNEY TRANSPLANTATION

RESUMO

Case presentation
A 76-year-old woman was admitted to the emergency room with involuntary movements in the left hemibody that started suddenly four days ago. Medical history revealed diabetes mellitus since 2005, systemic arterial hypertension and renal transplantation 5 months before admission, after nephropathy due to the underlying diseases. Pre-transplantation tests showed 6% glycated hemoglobin in oral hypoglycemic use, but after transplantation there was decompensation of glycemia, attributed to the use of corticosteroids, with the need for insulin therapy
On neurological examination, she presented continuous choreoathetoid movements in the distal region of the upper and lower limbs on the left.
She had a note of blood glucose tests, most of them above 250mg/dL. Glycated hemoglobin was 11.6% and venous blood gas was normal. Brain MRI showed mild T1 hypersignal in the globus pallidus and putamen on the right.
The diagnosis of hemichorea secondary to a non-ketotic hyperosmolar hyperglycemic state was established and the patient was managed with intensive diabetes control and haloperidol 2.5mg orally twice daily. There was significant improvement in the following days and the patient was discharged with almost no symptoms.

Discussion
This case describes the clinical presentation and imaging findings of hemichorea in a non-ketotic hyperosmolar hyperglycemic state. This condition is relatively rare, with an estimated prevalence of 1 in 100,000 people, and it occurs more frequently in women with uncontrolled type II diabetes.
Brain MRI typically demonstrates a hyperintense signal in the putamen and caudate nuclei on T1-weighted images, usually more prominent on the side contralateral to the hemichorea. Proposed etiologies include petechial hemorrhage, temporary ischemia (with or without hyperviscosity), or decreased synthesis of GABA and acetylcholine secondary to metabolic changes.
Treatment is based on blood glucose control, but chorea may continue for months after hyperglycemia resolves and require specific medication.

Final comments
The present case illustrates a condition that, although rare, is treatable and, therefore, must be recognized. A thorough physical examination and compatible clinical history and imaging are essential tools for diagnosing and treating metabolic chorea. In this case of symptoms secondary to diabetes decompensation due to corticosteroid use after transplantation, glycemic control and central dopaminergic inhibitor were effective.