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Query: UMLS:C0011849 (diabetes)
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Involuntary movements of the mouth can present as palatal tremor, which is frequently associated with hypertrophy of the inferior olivary nucleus and can be accompanied by contraction of other muscles of the head. We report the case of a 39-year-old man with autoimmune thyroiditis and diabetes who complained of involuntary rhythmic tremor involving the muscles of the floor of the mouth, which interfered with breathing and swallowing. Cerebrospinal fluid (CSF) examination showed the presence of oligoclonal bands and screening for anti-neuronal antibodies revealed high titres of anti-glutamic acid decarboxylase autoantibodies (GAD-Ab). Tremor responded to treatment with benzodiazepines. The correlation between the tremor and antibody positivity is unclear although an alteration of the gabaergic system mediated by the antibodies may be hypothesised on the basis of an inflammatory CSF profile.
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PMID:Tremor of the mouth floor and anti-glutamic acid decarboxylase autoantibodies. 1294 Aug 31

We report herein the case of a 28-year-old man presenting with hyperglycemic chorea-ballism (HCB) in addition to mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes (MELAS). He was admitted to a local hospital due to weight loss, general fatigue and thirst. The patient had diabetes mellitus, with a blood glucose level of 738 mg/dl and HbA1c of 19.8%. Although insulin therapy improved hyperglycemia, he noticed involuntary movements in the right upper and lower limbs, which subsequently extended to the left side. The patient was thus transferred to our hospital. He displayed short stature (154 cm) and emaciation, and a maternal family history of diabetes mellitus was elicited. He had no history of stroke-like episode, headache, vomiting and seizure. Neurological examination revealed low intelligence (IQ 57), mild sensorineural deafness, and chorea-ballism in the extremities and head without ptosis or eye movement disturbance. Brain computed tomography (CT) demonstrated areas of high density, while T1-weighted magnetic resonance imaging (MRI) revealed extreme hyperintensity and T2-weighted MRI showed hyperintensity in bilateral caudate nuclei, putamina and globi pallidus. HCB was diagnosed. In, CSF, lactate level was increased to 43.9 mg/dl (n, 4-16), pyruvate level was 1.65 mg/dl (n, 0.3-0.9) and total protein concentration was 59 mg/dl. Histological examination of a biopsy sample from the biceps brachii muscle demonstrated ragged-red fibers. An A3243G point mutation in the tRNA(Leu(UUR)) gene was detected, indicating the presence of MELAS. Involuntary movements improved on treatment with haloperidol up to 4.5 mg/day. HCB usually appears in elderly individuals, and cases less than 40-years-old are very rare. The mitochondrial dysfunction in MELAS may accelerate development of HCB.
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PMID:[A case of MELAS presenting juvenile-onset hyperglycemic chorea-ballism]. 1611 32

Ballism is a kind of involuntary movement presenting as irregular but stereotyped jerking and writhing movements of the limbs with proximal dominance. The most common type is hemiballism, and bilateral ballism is extremely rare. In contrast to hemiballism with preferential involvement of the contralateral subthalamic nucleus, bilateral ballism results from diffuse lesions on both sides of the basal ganglia. Here, we present a patient in whom bilateral ballism occurred as a result of hypoglycemia. A 75-year-old man with long-standing insulin-dependent diabetes mellitus had suffered recurrent episodes of paroxysmal and transient involuntary movements of all 4 limbs over a 6-week period. When he visited our hospital first, he was alert and well-oriented. Neurological examination revealed no deficits except right hemianopsia. Violent involuntary movements suddenly manifested 10 days later during MRI scans. Involuntary movements occurred in all 4 limbs, more prominently on the left side, lasted over 15 min in total, and ceased spontaneously. These movements were considered as bilateral ballism. The patient was awake, but rather confused. Serum glucose level during this attack was 25 mg/dl. Intravenous glucose was administered, and he became aware. Brain CT and MRI showed no evilence of ischemic or other basal ganglia pathology and no significant vascular lesions were detected by MR angiograhy. EEG revealed no epileptic discharges. He was admitted to our hospital and insulin dosage was adjusted. No further episodes occurred during a 6-month follow up. Our patient experienced an episode of bilateral ballism associated with documented hypoglycemia. In addition, good control of serum glucose with an appropriate insulin treatment has abolished the involuntary movement episodes described above. Conversely, the basal ganglia is known to be vulnerable to hypoglycemia, due to large metabolic demand and poor vascularization. Recurrent episodes of bilateral ballism in this case may thus have been caused by transient dysfunction of the basal ganglia due to hypoglycemia. We proposed a hypothesis to explain why the involuntary movements disappeared spontaneously.
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PMID:[Paroxysmal bilateral ballism induced by hypoglycemia]. 1676 96

The accurate and objective measurement of abnormal, involuntary movements remains highly desirable, whether the movements are secondary to pharmacotherapy or an expression of the primary illness. In a previous study, we found that the prevalence of tardive dyskinesia in a sample of 100 subjects ranged from 28% when using the Abnormal Involuntary Movement Scale (AIMS) or the Dyskinesia Identification Scale, Condensed User Version (DISCUS) to 62% using an instrumental measurement (IM) of peripheral dyskinesia. The goal of this study was to examine the relationship between various risk factors for tardive dyskinesia as predictor variables, and the AIMS, DISCUS, and IMs of dyskinesia, tremor, and velocity of motor movement as dependent variables. The sample consisted of 100, mostly patients with schizophrenia. Poor performance on the Mini-Mental State Examination (MMSE) and increasing age were the most consistent predictors of dyskinetic and parkinsonian movements. Various predictors were associated with specific abnormal movements. Head injury was related to slower speed of motor movements and the total DISCUS score. A history of smoking was associated with less IM dyskinesia. For those with coexisting parkinsonism and dyskinesia, significant associations were found with head injury, diabetes mellitus, and an AIMS score of 2 or greater in 2 body areas. Various classes of psychotropic agents seemed to have little influence on the MMSE or the development of dyskinesia and parkinsonism. Increasing age and a lower score on the MMSE seem to be particularly helpful in gauging the risk for parkinsonian and dyskinetic movements.
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PMID:Predictors of neuroleptic-induced dyskinesia and parkinsonism: the influence of measurement methods and definitions. 1711 Aug 11