A 28-year-old woman with a history of type 1 diabetes mellitus comes to the hospital due to abdominal pain, nausea, and vomiting. She is found to have severe hyperglycemia, high anion gap metabolic acidosis, and an elevated beta-hydroxybutyrate level. While being evaluated in the emergency department, the patient develops involuntary, rhythmic jerking of her right upper extremity that lasts for about a minute. She remains fully alert during and after the event. The patient has never had similar symptoms in the past and has no other medical conditions. Physical examination shows no weakness or sensory loss in the right upper extremity. Which of the following is the most likely diagnosis?

Question

A 28-year-old woman with a history of type 1 diabetes mellitus comes to the hospital due to abdominal pain, nausea, and vomiting.  She is found to have severe hyperglycemia, high anion gap metabolic acidosis, and an elevated beta-hydroxybutyrate level.  While being evaluated in the emergency department, the patient develops involuntary, rhythmic jerking of her right upper extremity that lasts for about a minute.  She remains fully alert during and after the event.  The patient has never had similar symptoms in the past and has no other medical conditions.  Physical examination shows no weakness or sensory loss in the right upper extremity.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_39da_e1b3_9249_dfa97a418487_MD0001_00 This patient with abdominal pain, vomiting, hyperglycemia, anion gap metabolic acidosis, and elevated beta-hydroxybutyrate has diabetic ketoacidosis. Metabolic derangements (eg, hyperglycemia, acidosis) in patients with diabetic ketoacidosis may cause neurologic dysfunction manifesting as altered mental status, focal neurologic deficits, and/or seizure. Seizures occur due to abnormal, synchronous discharges of neurons in the cerebral cortex. They are classified as either focal onset (previously known as partial) if they originate from a localized region of one cerebral hemisphere or generalized if they involve both hemispheres at onset. Focal seizures can be subclassified based on level of consciousness: The manifestations of focal seizure depend on the brain region in which the seizure activity is occurring. This patient's episodic right upper limb rhythmic jerking suggests a focal seizure with retained awareness originating in the contralateral motor cortex. (Choice A) Acute dystonia is a sustained, involuntary muscle contraction with abnormal posturing (eg, torticollis); it often occurs after exposure to dopamine antagonists (eg, haloperidol). Rhythmic jerking is more consistent with seizure activity. (Choice C) Generalized absence seizure involves both hemispheres at onset and presents as a brief (<10 sec) staring spell with impaired consciousness. It typically occurs in children, and patients may have hundreds of episodes a day. (Choice D) Generalized tonic-clonic seizure is characterized by loss of consciousness with diffuse, bilateral muscle contractions of the limbs followed by rhythmic jerking. Associated features may include tongue biting and urinary/bowel incontinence. (Choice E) Hemiballism is characterized by involuntary, unilateral, nonrhythmic, wide-amplitude movements of the extremities (eg, arm flailing). It often occurs with Huntington chorea, an autosomal dominant disease that also causes psychiatric symptoms and dementia. (Choice F) Motor tics are sudden, brief movements that may include arm jerking but are characterized by an overwhelming urge to perform the movement followed by feelings of relief. They can be voluntarily suppressed for brief periods. Educational objective: Seizures are classified as either focal onset if they originate from a localized region of one cerebral hemisphere or generalized if they involve both hemispheres at onset. Focal seizures can be subclassified as retained awareness (patients remain interactive) or impaired awareness (patients appear awake but do not interact appropriately). Manifestations of focal seizure depend on the brain region in which the seizure activity occurs. __________ References: The 2010 revised classification of seizures and epilepsy. (http://www.ncbi.nlm.nih.gov/pubmed/23739099)

A 28-Year-Old Woman with a History of Type 1 Diabetes