PSUN245 Non-ketotic Hyperglycemic Hemichorea-Hemiballismus Precipitated by Antipsychotics

BACKGROUND: Non-ketotic hyperglycemic hemichorea-hemiballimus is a rare complication of uncontrolled diabetes mellitus characterized by sudden, unilateral and involuntary flailing movements. It is associated with basal ganglia lesions contralateral to the side of involuntary movements. We present a case with this complication after the initiation of olanzapine. CLINICAL CASE: A 44-year-old male with anxiety, depression and diabetes mellitus type 2 with a recent increase of glycohemoglobin from 8.0 to 14.6% over 4 months presented with a 2-week history of worsening involuntary jerky movements of his right upper extremity, which eventually progressed to his right lower extremity. He was on metformin monotherapy for his diabetes initially. Olanzapine had been prescribed in place of quetiapine 2 months prior and then he presented to a different hospital with diabetic ketoacidosis a month later. Insulin therapy was initiated at that time and olanzapine was discontinued about 2 weeks prior to the current presentation. Physical examination showed spontaneous, irregular and involuntary flailing movements in his right upper and lower extremities that subsided during sleep. Laboratory tests revealed a random plasma glucose of 124 mg/dL and a glycohemoglobin of 14.6% but otherwise diagnostic studies including heavy metal screening, C-reactive protein, cerebrospinal fluid analysis and electroencephalogram were unremarkable. A CT of brain showed increased attenuation of the left lateral basal ganglia and caudate nucleus, and an MRI of brain showed increased T1 and T2 signal within the left lateral basal ganglia, and decreased T2 signal in the left caudate nucleus. Along with a consistent carbohydrate diet, a basal-bolus insulin regimen was initiated and adjusted to optimize glycemic control between 80 to 150 mg/dL. Clonazepam and Quetiapine were prescribed for his motor symptoms. Over the span of 3 months, his motor symptoms gradually improved, his insulin requirements decreased, and eventually excellent glycemic control was achieved with metformin alone. CONCLUSION: This case highlights a unique presentation of hemichorea-hemiballismus as a rare complication of uncontrolled diabetes mellitus precipitated by olanzapine, an atypical antipsychotic with a higher risk of metabolic adverse effects. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.