SAT-597 - Beyond Movement Disorders: Putamen Hyperintensity and Suicidal Ideation in Diabetic Striatopathy

Background: Diabetic striatopathy is a rare complication of poorly controlled diabetes characterized by hyperglycemia, movement disorders (most commonly hemichorea/hemiballism), and reversible basal ganglia abnormalities on neuroimaging. While neuropsychiatric manifestations including cognitive impairment and behavioral changes are increasingly recognized, the association with suicidal ideation has not been previously documented [1]. The putamen, a dopamine-rich region critical for reward processing and mood regulation, has been implicated in depression, with reduced putamen volume prospectively predicting major depressive disorder episodes and associated with familial risk for depression [2].

Clinical

Case: A 69-year-old male with type 2 diabetes, hypertension, hyperlipidemia and prior strokes presented with 2 weeks of progressive weakness, slurred speech, and episodic left upper extremity myoclonus. Initial blood glucose was 454 mg/dL (normal 70-99 mg/dL). Neurology was consulted, ruled out recurrent stroke, and concluded that the incidentally found T1 hyperintensity in the right putamen on brain MRI was consistent with diabetic striatopathy. The patient left against medical advice before being admitted but returned 2 days later after intentional insulin overdose (6 pens of NPH) in a suicide attempt, reporting one week of suicidal ideation attributed to frustration with functional decline following his recent stroke. He was placed on a psychiatric hold and treated with sertraline 25 mg daily. Management of refractory hypoglycemia required ICU-level care with D10 infusion and glucose monitoring. After 5 days of glycemic stabilization, the patient was discharged on low-dose basal-bolus insulin (glargine 3 units, lispro 1 unit TID) with continuation of sertraline and close outpatient follow-up. Suicidal ideation resolved completely during hospitalization.

Conclusion: This case demonstrates that diabetic striatopathy can present with diverse neuropsychiatric manifestations beyond movement disorders, including suicidal ideation. Hyperglycemia-induced putaminal dysfunction may disrupt dopaminergic reward circuitry involved in mood regulation. This case emphasizes the need for systematic psychiatric screening in patients with diabetic striatopathy.

References:
(1) Chatterjee S, Ghosh R, Biswas P, et al. Diabetic Striatopathy and Other Acute Onset De Novo Movement Disorders in Hyperglycemia. Diabetes Metab Syndr. 2024;18(3):102997.

(2) Talati A, van Dijk MT, Pan L, et al. Putamen Structure and Function in Familial Risk for Depression: A Multimodal Imaging Study. Biol Psychiatry. 2022;92(12):932-941.

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