When eighty four year old Mr. Kathirvel came to us, other than a history of decreased food intake he had no history of seizures, fever, headache, vomiting or diarrhoea, chest pain, or breathing difficulty. However, he had a four day old onset of acute weakness in the right upper and lower limb.
On examination and after reviewing past history a provisional diagnosis was made. Acute CVA-right Hemiplegia.
Further investigations were kicked off. His GRBS was high, his random blood sugar was 720 mg%, and Urea was 46 mg%. These tests were followed up with Acid based gas analysis, Lipid profile tests, ECG, CT of the brain, carotid and vertebral doppler, MRI of the brain, Echocardiogram, and an USG of the abdomen.
The diagnosis : Nonketotic hyperosmolar Syndrome.
The patient was treated with Insulin infusion and put on other supportive measures such as IV fluids, antihypertensives, antiplatelets, and statins.
His weakness improved completely after the insulin infusion brought down his blood sugar.
The final diagnosis: After ruling out other causes of weakness he was finally diagnosed with Nonketotic Hyperosmolar Syndrome (NKHS) induced Reversible Hemiplegia.
Closing Note: NKHS is very rare, with an incidence of <1/1000 person years. Its neurological manifestations include encephalopathy, focal seizures, hyperkinetic movement disorders, and acute stroke-like symptoms.