Teaching Points

• Hemiballismus, although uncommon, can be seen in acute ischemia and other pathologies.³ When imaging is not consistent with ischemia, other diagnoses, including hyperglycemia, need to be considered.
• Although this patient did not meet standard HHS criteria as his glucose was less than 600 and osmolality less than 320, he had obvious neurologic symptoms that resolved with glucose control. It is important to consider that HHS may be a spectrum of disease that can be treated earlier with knowledge of various presentations.²
• In NKHH, as in this case report, patients may have unilateral rhythmic, jerking movements that develop sub-acutely. Movements will worsen with activity and patients may report worsening symptoms towards the end of the day. Once confirmed with lab work, patients should be admitted for strict glucose control as symptoms will improve with resolution of their hyperglycemia.

Dr. Mahon is a critical care fellow and emergency medicine physician at Wellstar MCG Health in Augusta, Ga., and a current GCEP leadership fellow.

References

1. Bacon J, Trager J, Ackerman D, et al. 728. Critical Care Medicine. 2020;48:344.
2. Rosager EV, Heltø ALK, Fox Maule CU, et al. Incidence and characteristics of the hyperosmolar hyperglycemic state: a danish cohort study. Diabetes Care. 2024;47(2):272-279.
3. Huang H, Goh SH. Acute hemiballismus as the initial manifestation of ischemic stroke: a case report. Clinical Practice and Cases in Emergency Medicine. 2021;5(3):350-352.