Dominic Stone
Diabetes mellitus (DM) is a multi-system disease characterized by persistent hyperglycemia, which can have both acute and chronic biochemical and anatomical sequelae. In uncontrolled diabetes, glucose (blood sugar) does not reach the insulin receptor sites on muscle cells, depriving them of fuel. This can lead to involuntary contractions or twitching of the muscles, particularly those innervated by the facial nerve, a condition known as hemifacial spasm (HFS). While high blood sugar can cause muscle twitches, it is important to note that low blood sugar may also result in shakiness, but it is not the same as muscle twitching.
| Characteristics | Values |
|---|---|
| Hemifacial spasm (HFS) | A movement disorder characterized by brief or persistent, intermittent twitching of the muscles innervated by the facial nerve |
| Hemifacial spasm causes | Local demyelination of the facial nerve, compression by an ecstatic or aberrant blood vessel, arteriovenous malformation, brainstem lesions, infection, structural abnormalities of the posterior cranial fossa, parotid tumors, Bell's palsy |
| Hemifacial spasm treatment | Control plasma glucose levels, oral hypoglycemic drugs (e.g., metformin, acarbose, gliclazide), insulin |
| Diabetes mellitus (DM) | A multi-system disease characterized by persistent hyperglycemia; Type-2 DM is the most common form |
| Neuromusculoskeletal sequelae of DM | Ligament ossification, cervical spinal canal narrowing, canal stenosis, neck stiffness, reduced neck movement, muscle infarction, diabetic ketoacidosis, dyslipidemias, rhabdomyolysis |
| Muscle infarction treatment | Rest, analgesia, normal daily activities, avoid exacerbating physical therapy; may resolve spontaneously over weeks to months |
| Muscle cell fuel supply | Insulin receptor sites on muscle cells may not receive blood sugar due to inability to take glucose molecules or lack of insulin production by the pancreas |
| Other symptoms of uncontrolled diabetes | Hunger, frequent urination, increased thirst, fatigue, nausea, vomiting, coma |
| Limitations | Case reports and studies focused on hemifacial spasms and diabetes mellitus; no direct evidence linking high blood sugar to muscle twitches |
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What You'll Learn
Hemifacial spasms
The most common cause of primary hemifacial spasm is the local demyelination of the facial nerve due to compression by a blood vessel. However, in people with diabetes, it can be caused by uncontrolled diabetes mellitus (DM), a rare movement disorder mainly seen in elderly patients and more commonly reported in the Asian population. In diabetes, the insulin receptor sites on muscle cells do not receive blood sugar, resulting in a fuel shortage for the muscle cells. This can lead to symptoms like increased thirst, frequent urination, and fatigue.
Secondary hemifacial spasm may be caused by arteriovenous malformation, brainstem lesions, infection, structural abnormalities of the posterior cranial fossa, parotid tumors, or Bell's palsy. However, in the case mentioned earlier, these secondary causes were ruled out due to normal brain MR imaging and the patient's negative medical history.
If you are experiencing persistent and chronic muscle twitching, it is important to consult a doctor as it may be a sign of an underlying medical condition. Early intervention can improve your long-term outlook and treatment options.
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Muscle infarction
The clinical presentation of diabetic muscle infarction often includes concomitant end-organ complications such as nephropathy, neuropathy, and retinopathy. It predominantly affects insulin-dependent patients with poorly controlled diabetes. Magnetic resonance imaging (MRI) is the preferred diagnostic test, as it can effectively distinguish between cases caused by arteriosclerosis obliterans and those caused by emboli.
The treatment of diabetic muscle infarction aims to prevent the enlargement of thrombi and delay the onset of infarction. Low molecular weight heparin is administered to achieve this. Percutaneous aspiration thrombectomy is a rapid and effective procedure for removing thromboembolic occlusions in the legs below the inguinal ligament. With prompt and appropriate treatment, the survival rate for patients with limb infarction is approximately 80%, increasing to 95% after surgery.
While diabetic muscle infarction is a rare complication, it is crucial to consider it in the differential diagnosis of diabetic patients presenting with lower extremity pain and swelling. Early diagnosis and management can significantly impact the outcome and help prevent irreversible damage to nerves and muscles.
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Involuntary contractions
Involuntary muscle contractions, or muscle twitches, can be caused by a variety of factors, and high blood sugar is one of them. While muscle twitching can have many causes, it is important to understand the link between high blood sugar and muscle contractions, especially in the context of diabetes.
Diabetes mellitus (DM) is a common disease that affects a significant portion of the population. It is a multi-system disease characterised by persistent hyperglycemia, which can lead to both acute and chronic complications. One of the key features of diabetes is the disruption of glucose delivery to muscle cells, resulting in a fuel shortage for these cells. This can trigger a range of symptoms, including muscle twitching.
In some cases, muscle twitching can be an early sign of uncontrolled diabetes or hyperglycemia. A case study reported a 46-year-old male patient who experienced involuntary contractions of his left facial expression muscles. These episodes occurred multiple times a day, particularly during speaking and eating, and each episode lasted less than a minute. The patient was diagnosed with hemifacial spasm (HFS), a movement disorder characterised by brief or persistent, intermittent twitching of the muscles controlled by the facial nerve. In this case, the patient's symptoms completely resolved after controlling his plasma glucose levels, highlighting the connection between high blood sugar and involuntary muscle contractions.
Additionally, neuromusculoskeletal complications of diabetes are well-recognised, and chiropractors, for instance, need to be alert to these conditions. One such complication is muscle infarction, which is often a result of ischemia or diabetic ketoacidosis. This condition presents with acute pain and swelling over days or weeks in the affected muscle groups, commonly in the thigh or calf. While muscle infarction is rare, it is life-threatening and requires immediate medical attention.
It is important to note that muscle twitching can have other causes besides high blood sugar. For instance, new-onset muscle twitching, whether localised or widespread, often raises concerns about ALS (amyotrophic lateral sclerosis), a fatal neurological disease. Therefore, while high blood sugar can be a factor in involuntary muscle contractions, a comprehensive medical evaluation is necessary to determine the exact cause and rule out other potential conditions.
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Insulin receptor dysfunction
Genetic factors also play a significant role in insulin receptor dysfunction. Certain mutations in the INSR gene can cause variable insulin receptor dysfunction and are associated with rare syndromes such as leprechaunism (Donahue syndrome), Rabson-Mendenhall syndrome, and type A insulin resistance. These syndromes are characterised by profound insulin-resistant diabetes and can present with or without acanthosis nigricans. Additionally, specific polymorphisms within the IRS1 and IRS2 insulin receptor substrate genes are linked to decreased insulin sensitivity and a predisposition to type 2 diabetes (T2D).
Over time, insulin receptor dysfunction and insulin resistance can contribute to the development of various diseases. Type 2 diabetes is a common consequence of prolonged insulin resistance, as progressive insulin resistance compromises carbohydrate metabolism. Additionally, insulin resistance is linked to metabolic disorders, cardiovascular disease, neurodegenerative diseases, and other complications.
One approach to counter insulin resistance is to reintroduce precise physiologic insulin delivery. Currently, patients with type 1 diabetes (T1D) and T2D receive continuous insulin administration through injections or subcutaneous insulin pumps. However, these methods do not mimic the natural oscillatory secretion pattern of insulin. Therefore, emerging evidence supports the benefits of intravenous insulin administration that replicates healthy pancreatic insulin secretion patterns, potentially improving insulin resistance and restoring metabolic function.
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Hyperglycaemia and hemichorea
Non-ketotic hyperglycemic hemichorea (NHH), also known as diabetic striatopathy, is a rare neurological complication of non-ketotic hyperglycemia. It is characterised by chorea or ballismus, which can develop rapidly and affect the arms, legs, or face, either unilaterally or bilaterally. The condition predominantly occurs in elderly females with type 2 diabetes mellitus, although it has also been reported in a few patients with type 1 diabetes mellitus.
The pathogenesis of NHH is hypothesised to be related to the depletion of gamma-aminobutyric acid (GABA) in the striatum, leading to disinhibition of the subthalamus and basal ganglia, resulting in hyperkinetic movements. Additionally, there may be an association with hyperviscosity secondary to hyperglycemia, causing regional blood-brain barrier disruption and metabolic damage. The exact underlying pathophysiology is not yet fully understood.
Neuroimaging plays a crucial role in the diagnosis of NHH. While initial brain CT scans may appear normal, subsequent scans can reveal hyperdensity in the striatal region, particularly in the caudate nuclei and putamen. MRI is the preferred modality, typically demonstrating signal changes in the putamen and/or caudate, with T1 hyperintensity being the most consistent finding. These imaging abnormalities gradually resolve with the correction of hyperglycemia but may take longer to return to baseline compared to clinical improvements.
The treatment of NHH involves addressing the underlying hyperglycemia and managing the chorea or ballismus. In the reported cases, treatments such as clonazepam, risperidone, and insulin compliance have been used to improve blood glucose control and manage symptoms. The resolution of symptoms typically occurs upon the normalisation of glucose levels.
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Frequently asked questions
Yes, high blood sugar can cause muscle twitches. Hemifacial spasm (HFS) is a movement disorder characterized by brief or persistent, intermittent twitching of the facial muscles. It is commonly caused by compression of the seventh cranial nerve and can be secondary to abnormal metabolic conditions like hyperglycemia.
Other symptoms of high blood sugar include increased thirst and frequent urination, fatigue, nausea, and vomiting. In severe cases of extremely high blood sugar, individuals may even experience coma.
High blood sugar, or hyperglycemia, is often associated with diabetes mellitus (DM), a common disease affecting a large portion of the population. It can be managed through insulin administration and oral hypoglycemic drugs.
If left untreated, high blood sugar can lead to neuromuscular complications such as muscle infarction, which presents as acute pain and swelling, and elevated CPK-MM levels. This condition requires immediate medical attention as it can be life-threatening.
