effects on glucose responses and insulin requirements in subjects with insulin- dependent diabetes .... insulin lispro may be an attractive new therapeutic option ...
Letters
These cases could exemplify the multi1998 6. Peters AL, Davidson MB: Protein and fat factorial pathogenesis of chorea associated effects on glucose responses and insulin with hyperglycemia. We attributed a main requirements in subjects with insulin- causal role to the high blood glucose dependent diabetes mellitus. Am J Clin because we observed a temporal relationNutr 58:555-560, 1993 ship between the onset and the disappear7. Wolfsdorf JI, Plotkin RA, Laffel LMB, ance of the involuntary movements and Crigler JF: Continuous glucose for treatment of patients with type 1 glycogen- the hyperglycemia and its correction. Nevstorage disease: comparison of the effects ertheless, other neurological or metabolic of dextrose and uncooked cornstarch on factors must be considered in our patients. biochemical variables. Am J Clin Nutr In the first patient, the neuroradiological 52:1043-1050, 1990 findings indicate a possible concurrent role 8. Kaufman FR, Halvorson M, Kaufman ND: of the subcortical lesions. The second e agree with Schernthaner et al. (1) A randomized, blinded trial of uncooked patient was subsequently admitted to the that postprandial injection of cornstarch to diminish nocturnal hypogly- hospital because of severe metabolic insulin lispro may be an attractive cemia at diabetes camp. Diabetes Res Clin decompensation, with ill-controlled erratic new therapeutic option, from our point of Pract 30:205-209, 1995
COMMENTS AND RESPONSES
Early Preprandial Hypoglycemia After Administration of Insulin Lispro
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Chorea in Hyperglycemia
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horea is a movement disorder that may occur in several diseases (1). Although rarely, derangement of glucose metabolism can cause diskinesias (2). Cases of generalized chorea and hemichorea as initial presenting symptoms of diabetes are reported (3). Chorea has been described in nonketotic hyperglycemia, even as the very first sign (4). Also, hypoglycemia may cause chorea that is either paroxysmal (5) or persistent (6). We report two patients who developed chorea associated with hyperglycemia. The first patient (MJ.) was an 84year-old woman. She had history of diabetes treated with oral antidiabetic drugs (glybenclamide, metformin) and hypertension. The onset of chorea was subacute, and the involuntary movements were localized to the right limbs. No other neurological signs were evident. Laboratory evaluation showed a blood glucose of 557 mg/dl with ketoacidosis. Magnetic resonance imaging (MRI) showed leukoaraiosis, multiple subcortical ischemias, and iron deposits in both putamens. The second patient (PA.) was an 85year-old woman affected by diabetes and hypertension. She acutely presented bilateral diffuse choreic movements without other neurological signs. Blood glucose was 369 mg/dl. Computed tomography (CT) and MRI were normal. Control of the hyperglycemia was achieved, and after treatment with neuroleptic drugs, we observed suppression of the choreic movements in both patients.
DIABETES CARE, VOLUME 21, NUMBER 10, OCTOBER
blood glucose concentrations. On this occasion, the patient showed no more chorea or other neurological symptoms. We suggest that glucose metabolism disorder is not the single causal agent in hyperglycemic chorea. This factor may trigger a movement disorder only in those cases in which other etiologic factors are active on a possible coexisting dopamine hypersensitivity in the stria turn.
view, mainly in adolescent patients with IDDM. Even if the use of insulin analog lispro has been associated with reduced risk of late hypoglycemia because of the more rapid postpeak decrease of insulin levels in comparison with regular insulin (2,3), little is reported on the risk of early hypoglycemia after a low-carbohydrate meal (4). We observed three episodes of severe hypoglycemia immediately after the administration of lispro (Humalog; Eli Lilly, IndiIMMACOLATA PICCOLO, MD anapolis, IN) and before the meal in two ROBERTO STERZI, MD well-controlled IDDM adolescents who GIUSEPPE THIELLA, MD switched from regular to insulin lispro. These two patients are part of a study in From the Departments of Neurology (I.R, R.S.) and progress conducted on 30 patients aged Medicine (G.T.), Niguarda Ca Granda Hospital, Milan, between 8 and 18 years. Patient 1, D.L.M., Italy was a boy aged 15 years. The insulin dose Address correspondence to Immacolata Piccolo, was 0.9 U • kg"1 • day"1 in four daily Division of Neurology, Hospital Niguarda Ca Granda, Piazza Ospedale Maggiore, 20162 Milan, Italy. administrations (lispro at breakfast and dinner, lispro plus intermediate insulin at lunch, and intermediate insulin at bedtime). Two severe episodes of hypoglycemia References 1. Padberg GW, Bruyn GW: Chorea: differen- occurred on two separate occasions a month apart immediately after insulin administratial diagnosis. In Handbook of Clinical Neurology: Extrapyramidol Disorders. Vol. tion and before the breakfast. Blood glucose 5(49). Vinken PJ, Bruyn GW, Klawans HL, was normalized by oral carbohydrate Eds. Amsterdam, Elsevier Sciences, 1986, adminstration. The electroencephalogram p.549-564 performed after 4 h was normal. The second 2. Crausman RS, Wen J, Al-Shalabi S: episode required glucagon administration. Choreoathetosis and diabetes (Letter). Patient 2, G.G., was a girl aged 11 Diabetes Care 20:1209-1210, 1997 years. Insulin therapy followed the same 3. Haan J, Kremer HP, Padberg GW: Paroxysmal choreoathetosis as presenting symp- scheme as the preceding patient. She pretom of diabetes mellitus (Letter). ] Neurol sented hypoglycemia after the administraNeurosurg Psychiatry 52:133, 1989 tion of insulin lispro before and during the 4. Lin J-J, Chang M-K: Hemiballism-hemi- breakfast. Hypoglycemia disappeared with chorea and non-ketotic hyperglycaemia. J the administration of fruit juice. Few data Neurol Neurosurg Psychiatry 57:748-750, are reported in the literature on lispro 1994 administration in pediatric or adolescent 5. Newman RP, Kinkel WR: Paroxysmal choreoathetosis due to hypoglycemia. Arch patients. The two patients did not evaluate their blood glucose before lispro. Thus, it Neurol 41:341-342, 1984 6. Hefter H, Mayer P, Benecke R: Persistent is impossible to say whether low blood chorea after recurrent hypoglycemia. Eur glucose before administration was a causal Neurol 33:244-247, 1993 or concausal factor. The problem could be 1998
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