Paper Title
Diabetic Striatopathy in Ketotic Hyperglycemia

Abstract
INTRODUCTION Acute severe hyperglycemia is well known to produce neurological manifestations, with the spectrum ranging from seizures to dyskinesias and coma. Diabetic striatopathy (DS) refers to a constellation of neurological features defined by the characteristic dyskinesia of chorea-ballism together with striatal abnormalities on neuroimaging. It is most frequently described in association with nonketotic hyperglycaemic hyperosmolar state, while reports in ketotic hyperglycaemia remain relatively uncommon 1. CASE REPORT A 50-year-old woman with no prior comorbidities presented with acute-onset involuntary movements involving the left upper and lower limbs, suggestive of hemichorea–hemiballismus. On examination, she was conscious, cognitively intact, and had no motor or sensory deficits. Laboratory evaluation revealed a blood glucose of 600 mg/dL, HbA1c of 13.5% with ketonuria, metabolic acidosis with a pH of 7.28 and bicarbonate of 14, and high serum osmolarity of 330 mOsm/kg, consistent with ketotic hyperglycaemia. Neuroimaging showed hyperdensity in the right caudate and lentiform nuclei on CT and T1 hyperintensity with no changes on other sequences on MRI, establishing the diagnosis of diabetic striatopathy. She was managed with intravenous fluids, insulin infusion and tetrabenazine, followed by a basal–bolus regimen, and achieved complete recovery within 1 week. DISCUSSION Diabetic striatopathy (DS) is a rare but under-recognized complication of poorly controlled diabetes, most often reported in elderly Asian women2. It usually presents with acute hemichorea–hemiballismus and shows characteristic T1 hyperintensity in the striatum3. The proposed mechanism involves hyperglycaemia-induced GABA depletion, leading to thalamic disinhibition and hyperkinetic movements4. Management focuses on correction of hyperglycaemia and hydration, though some patients may require anti-chorea agents such as haloperidol or tetrabenazine, SSRI, GABAergic drugs5. With prompt treatment, the condition is usually self-limiting and reversible. CONCLUSION Hyperglycemia can present with movement disorders such as chorea, hemiballismus, and hemichorea. Early recognition is crucial, as these are reversible with prompt treatment. Screening for hyperglycemia is recommended in all patients presenting with involuntary movements, even without a known history of diabetes.