|LETTER TO THE EDITOR
|Year : 2020 | Volume
| Issue : 2 | Page : 118-120
Movement disorders associated with hypoglycemia and hyperglycemia
Jamir Pitton Rissardo, Ana L Fornari Caprara
Medicine Department, Federal University of Santa Maria, Santa Maria, Brazil
|Date of Submission||05-Apr-2020|
|Date of Acceptance||27-Apr-2020|
|Date of Web Publication||28-Jul-2020|
Dr. Jamir Pitton Rissardo
Medicine Department, Federal University of Santa Maria, Rua Roraima, Santa Maria, Rio Grande do Sul.
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Pitton Rissardo J, Fornari Caprara AL. Movement disorders associated with hypoglycemia and hyperglycemia. Ann Mov Disord 2020;3:118-20
|How to cite this URL:|
Pitton Rissardo J, Fornari Caprara AL. Movement disorders associated with hypoglycemia and hyperglycemia. Ann Mov Disord [serial online] 2020 [cited 2020 Aug 11];3:118-20. Available from: http://www.aomd.in/text.asp?2020/3/2/118/291078
We read the article entitled “Sudden jerky head movement in hypoglycemia” on the esteemed Annals of Movement Disorders with great interest. Shah and Sardana reported a case of an elderly female who developed two episodes of hemiparesis and a single episode of jerky head movement. She was diabetic and had a low blood sugar level in both times. It is noteworthy that according to Shah and Sardana their report was the first to describe the occurrence of jerky head movement secondary to hypoglycemia.
Herein, we would like to highlight some important facts about glycemic levels and related movement disorders.
The first point to discuss is that all movement disorders were already reported in association with hypo/hyperglycemia [Table 1]. But not all abnormal movements were already associated. Our literature review shown in the table revealed that the most reported abnormal movements, in decreasing order of frequency, are as follows: tremor, chorea, ballism, ataxia, myoclonus, and Parkinsonism More Details. By the way, tremor, when compared to the other movements, probably represents >99% of the movement disorders secondary to altered glycemic states. Also, its possibly pathophysiological mechanism is distinct from the other abnormal movements. The tremor noted in these reports is probably related to an exacerbation of physiological tremor, in which the movement is associated with the noradrenergic tone.
|Table 1: Abnormal movements associated with hypoglycemia and hyperglycemia|
Click here to view
The explanation for the other movement disorders, except tremors, may be associated with a dysbalanced inhibitory/excitatory effect on the basal ganglia structures. One supporting finding of this theory is the fact that both hypoglycemia and hyperglycemia can lead to restricted diffusion, especially, in these regions. Based on animal models, it was observed that during glycemic abnormalities the cerebral metabolism is adapted, and these adaptations the release of cytokines leads to cerebral ischemia, blood–brain barrier damage, and increased levels of excitatory neurotransmitters. Moreover, the pathological explanation of hypoglycemia and hypoglycemia causing brain damage may have a similar pathway [Figure 1]., Thus, both may have similar movement disorders; for example, abnormal movements that have not yet been reported with hypoglycemia but have been reported with hyperglycemia may in the future be reported in a patient with hypoglycemia, and vice versa.
|Figure 1: Schematic diagram of the neuroinflammatory mechanisms involved in hypo/hyperglycemic states, showing a similar pathway of both glycemic states leading to the neuronal damage|
Click here to view
The hypothesis for the increased excitatory substances in hypoglycemia was proposed by Sutherland et al. They explained that in the occurrence of hypoglycemia there will be a truncation of the Krebs cycle. In this context, the decreased levels of pyruvate, under severe hypoglycemia, would lead to the metabolism of oxaloacetate directly to α-ketoglutarate with the use of glutamate [Figure 2]. In this way, the decrease of glutamine levels and increased levels of aspartate could cause excitation, inhibition, or disinhibition of the direct/indirect pathways and result in an abnormal movement.
|Figure 2: Model proposed by Sutherland et al. describing cerebral metabolism adaption during the hypoglycemic state. OAA = oxaloacetate, α-KG = alpha-ketoglutarate|
Click here to view
Another interesting fact is that the majority of the reports were related to patients affected by diabetes and some hypoglycemic individuals with insulinoma. So, it is worthy of mentioning that when starting or increasing the dose of hypoglycemic agents, the physician should be aware of these side effects and advise the patient to avoid complications such as falls and even fractures.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Shah VS, Sardana V Sudden jerky head movement in hypoglycemia. Ann Mov Disord 2020;3:44-6.
Berz JP, Orlander JD Prolonged cerebellar ataxia: An unusual complication of hypoglycemia. J Gen Intern Med 2008;23: 103-5.
Indiran V, Maduraimuthu P Rare presentation of unilateral weakness, involuntary movements and ataxia with subcortical t2 hypointensity in a diabetic patient: A case report. Case Rep Radiol 2012;2012:768189.
Vittal P, Comella C, Shannon K Acute recurrent, persistent hypoglycemia-induced chorea/ballism in a diabetic patient on hemodialysis. Neurology 2014;82:P4.059.
Takahashi S, Ohkawa S [Paroxysmal bilateral ballism induced by hypoglycemia]. Rinsho Shinkeigaku 2006;46:278-80.
Jagota P, Bhidayasiri R, Lang AE Movement disorders in patients with diabetes mellitus. J Neurol Sci 2012;314:5-11.
Cosentino C, Torres L, Nuñez Y, Suarez R, Velez M, Flores M Hemichorea/hemiballism associated with hyperglycemia: Report of 20 cases. Tremor Other Hyperkinet Mov 2016;6:402.
Lai SL, Tseng YL, Hsu MC, Chen SS Magnetic resonance imaging and single-photon emission computed tomography changes in hypoglycemia-induced chorea. Mov Disord 2004;19: 475-8.
Wolz M, Reichmann H, Reuner U, Storch A, Gerber J Hypoglycemia-induced choreoathetosis associated with hyperintense basal ganglia lesions in T1-weighted brain MRI. Mov Disord 2010;25:966-8.
Newman RP, Kinkel WR Paroxysmal choreoathetosis due to hypoglycemia. Arch Neurol 1984;41:341-2.
Ahlskog JE, Nishino H, Evidente VG, Tulloch JW, Forbes GS, Caviness JN, et al
. Persistent chorea triggered by hyperglycemic crisis in diabetics. Mov Disord 2001;16:890-8.
Kandiah N, Tan K, Lim CT, Venketasubramanian N Hyperglycemic choreoathetosis: Role of the putamen in pathogenesis. Mov Disord 2009;24:915-9.
Tan NC, Tan AK, Sitoh YY, Loh KC, Leow MK, Tjia HT Paroxysmal exercise-induced dystonia associated with hypoglycaemia induced by an insulinoma. J Neurol 2002;249:1615-6.
Clark JD, Pahwa R, Koller C, Morales D Diabetes mellitus presenting as paroxysmal kinesigenic dystonic choreoathetosis. Mov Disord 1995;10:353-5.
Jaladyan V, Darbinyan V Insulinoma misdiagnosed as juvenile myoclonic epilepsy. Eur J Pediatr 2007;166:485-7.
Matsumura K, Sonoh M, Tamaoka A, Sakuta M Syndrome of opsoclonus-myoclonus in hyperosmolar nonketotic coma. Ann Neurol 1985;18:623-4.
Gil YE, Yoon JH Hypoglycemia-induced parkinsonism with vasogenic basal ganglia lesion. Parkinsonism Relat Disord 2018;49:112-3.
Teodoro T, Lobo PP, Ferreira J, Sousa R, Reimão S, Peralta R, et al
. Delayed Parkinsonism after acute chorea due to non-ketotic hyperglycemia. J Neurol Sci 2015;354:116-7.
Nakajima N, Ueda M, Nagayama H, Katayama Y Hypoglycemiainduced spontaneous unilateral jerking movement in bilateral internal capsule posterior limb abnormalities. J Neurol Sci 2014;338:220-2.
Debruyne F, Van Paesschen W, Van Eyken P, Bex M, Vandenberghe W Paroxysmal nonkinesigenic dyskinesias due to recurrent hypoglycemia caused by an insulinoma. Mov Disord 2009;24:460-1.
Bandyopadhyay SK, Dutta A Hemifacial spasm complicating diabetic ketoacidosis. J Assoc Physicians India 2005;53:649-50.
Tan JH, Chan BP, Wilder-Smith EP, Ong BK A unique case of reversible hyperglycemic Holmes’ tremor. Mov Disord 2006;21:707-9.
Jagota P, Bhidayasiri R, Lang AE Movement disorders in patients with diabetes mellitus. J Neurol Sci 2012;314:5-1.
Smaga S Tremor. Am Fam Physician 2003;68:1545-52.
Shukla V, Shakya AK, Perez-Pinzon MA, Dave KR Cerebral ischemic damage in diabetes: An inflammatory perspective. J Neuroinflammation 2017;14:21.
Sutherland GR, Tyson RL, Auer RN Truncation of the Krebs cycle during hypoglycemic coma. Med Chem 2008;4:379-85.
Rissardo JP, Caprara ALF Buspirone-associated movement disorder: A literature review. Prague Med Rep 2020;121: 5-24.
[Figure 1], [Figure 2]