Dear Editor,
We read with interest the paper by Danve et al. which reports a case of non-ketotic hyperglycemic hemichorea (NKHHC) as the initial manifestation of diabetes mellitus in a 63-year-old Hispanicman.1 The authors have elegantly presented the case, wherein prompt diagnosis of NKHHC was made and treatment was initiated early without delay, emphasizing the crucial significance of timely intervention in such cases. However, we would like to provide a clarification regarding a specific aspect of the article that pertains to the presence of bilateral basal ganglia hyperintense signals in patients with non-ketotic hyperglycemic hemichorea.
In the meta-analysis by Oh et al. including 53 patients, 46 patients demonstrated hyperintense signals in the basal ganglia contralateral to hemichorea on T1-weighted brain MRI, and six patients with bilateral chorea exhibited hyperintense lesions in the bilateral basal ganglia. Notably, one patient presented with a lesion at the basal ganglia ipsilateral to the hemichorea.2
In the article by Danve et al., the authors mention that patients with NKHHC can also have bilateral basal ganglia hyperintense signals on T1W images, quoting the meta-analysis by Oh et al. But, we would like to clarify that all these six patients in the meta-analysis by Oh et al. had bilateral chorea and, indeed, bilateral hyperintense basal ganglia signals on MRI.3 Therefore, it is essential to acknowledge that while some patients with NKHHC presenting as bilateral chorea may display bilateral basal ganglia hyperintensity on T1-weighted images, this is not a universal finding.
Furthermore, we would like to discuss the specific case presented in the article. The patient described by the authors presented with right-sided hemichorea, and as expected, the MRI findings revealed left-sided basal ganglia involvement, encompassing the caudate and putamen. However, the MRI also depicted a subtle hyperintensity on the right side near the caudate region. This observation may suggest an exceptionally rare case and, in fact, the first documented instance in which bilateral basal ganglia hyperintensities have been observed in a patient presenting with unilateral chorea.
Footnotes
Conflict of interest: No conflicts of interest.
References
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