Bilateral acquired chorea: a unique presentation of diabetic ketoacidosis

Acquired hemichorea-hemiballismus, also termed diabetic striatopathy, is an uncommon but established complication of uncontrolled hyperglycemia in patients with diabetes. It typically presents as involuntary, unilateral choreiform movements secondary to nonketotic hyperglycemia with characteristic hyperdensities in the contralateral striatum on brain imaging. Here, we report the case of an 82-year-old female who presented with bilateral acquired chorea-ballismus with corresponding hyperdensities in both basal ganglia on imaging in the setting of diabetic ketoacidosis. Her presentation was also complicated by acute encephalopathy attributed to hyperglycemia and catheter-associated urinary tract infection. Her choreiform movements and encephalopathy improved with correction of hyperglycemia and resolution of ketoacidosis but only fully resolved when starting risperidone therapy. Brain imaging on hospital day 6 showed stable hyperdensities in the striata compared with admission despite improvement in symptoms. The patient re-presented to the hospital for unrelated reasons 3 months later and had sustained resolution of symptoms. This report highlights the variability of symptom presentation in diabetic striatopathy and confirms diabetic ketoacidosis as a setting for this rare complication.