Chorea

Chorea (or choreia, occasionally) is an abnormal involuntary movement disorder, one of a group of neurological disorders called dyskinesias. The term chorea is derived from the Ancient Greek: χορεία ("dance"; see choreia), as the quick movements of the feet or hands are comparable to dancing.

Not to be confused with Korea or Cholera.
For the ancient Greek dance, see Choreia. For other uses, see Chorea (disambiguation).
Chorea
SpecialtyNeurology 

The term hemichorea refers to chorea of one side of the body, such as chorea of one arm but not both (analogous to hemiballismus).

Presentation

Chorea is characterized by brief, semi-directed, irregular movements that are not repetitive or rhythmic, but appear to flow from one muscle to the next. These 'dance-like' movements of chorea often occur with athetosis, which adds twisting and writhing movements. Walking may become difficult, and include odd postures and leg movements. Unlike ataxia, which affects the quality of voluntary movements, or Parkinsonism, which is a hindrance of voluntary movements, the movements of chorea and ballism occur on their own, without conscious effort. Thus, chorea is said to be a hyperkinetic movement disorder. When chorea is serious, slight movements will become thrashing motions; this form of severe chorea is referred to as ballism, or ballismus.

Causes

Huntington's disease

Huntington's disease is a neurodegenerative disease and most common inherited cause of chorea. The condition was formerly called Huntington's chorea but was renamed because of the important non-choreic features including cognitive decline and behavioural change.[1]

Other genetic causes

Other genetic causes of chorea are rare. They include the classical Huntington's disease 'mimic' or phenocopy syndromes, called Huntington's disease-like syndrome types 1, 2 and 3; inherited prion disease, the spinocerebellar ataxias type 1, 3 and 17, neuroacanthocytosis, dentatorubral-pallidoluysian atrophy (DRPLA), brain iron accumulation disorders, Wilson's disease, benign hereditary chorea, Friedreich's ataxia, mitochondrial disease and Rett syndrome.[2]

Acquired causes

The most common acquired causes of chorea are cerebrovascular disease and, in the developing world, HIV infection—usually through its association with cryptococcal disease.[2]

Sydenham's chorea occurs as a complication of streptococcal infection. Twenty percent (20%) of children and adolescents with rheumatic fever develop Sydenham's chorea as a complication. It is increasingly rare, which may be partially due to penicillin, improved social conditions, and/or a natural reduction in the bacteria (Streptococcus) it has stemmed from. Psychological symptoms may precede or accompany this acquired chorea and may be relapsing and remitting. The broader spectrum of paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection can cause chorea and are collectively referred to as PANDAS.[2]

Chorea gravidarum refers to choreic symptoms that occur during pregnancy. If left untreated, the disease resolves in 30% of patients before delivery but, in the other 70%, it persists. The symptoms then progressively disappear in the next few days following the delivery.[2]

Chorea may also be caused by drugs (commonly levodopa, anti-convulsants and anti-psychotics).[2]

Other acquired causes include CSF leak,[3] systemic lupus erythematosus, antiphospholipid syndrome, kappa light-chain monoclonal gammopathy of undetermined significance,[4] thyrotoxicosis, polycythaemia rubra vera,[2] transmissible spongiform encephalopathies and coeliac disease.[5]

Treatment

There is no standard course of treatment for chorea. Treatment depends on the type of chorea and the associated disease. Although there are many drugs that can control it, no cure has yet been identified.

FormTreatment
Huntington's-relatedA common treatment is dopaminergic antagonists, although treatment is largely supportive. Tetrabenazine is the only FDA approved drug for the treatment of Huntington's disease-related chorea.
Sydenham's choreaHaloperidol, carbamazepine and valproic acid. Usually involves antibiotic drugs to treat the infection, followed by drug therapy to prevent recurrence.
Chorea gravidarumhaloperidol,[6][7][8] chlorpromazine alone or in combination with diazepam, also pimozide can also be used.
Wilson's diseaseReducing levels of copper in the body using D-penicillamine, trientine hydrochloride, tetrathiomolybdate, and other chelating agents
Drug-induced choreaAdjusting medication dosages.
Metabolic and endocrine-related choreasTreated according to their causes.

History

Historically, choreas like Huntington disease and Sydenham's chorea were called Saint Vitus' dance, related to a series of social phenomena of the same name.[9]

See also

Notes
  1. Gillian, Bates; Sarah, Tabrizi; Lesley, Jones (2014). Huntington's disease (4th ed.). Oxford University Press. ISBN 978-0199929146.
  2. Wild, EJ; Tabrizi, SJ (November 2007). "The differential diagnosis of chorea". Practical Neurology. 7 (6): 360–73. doi:10.1136/pn.2007.134585. PMID 18024776. S2CID 31059440.
  3. Mokri, Bahram (December 2014). "Movement disorders associated with spontaneous CSF leaks: a case series". Cephalalgia: An International Journal of Headache. 34 (14): 1134–1141. doi:10.1177/0333102414531154. ISSN 1468-2982. PMID 24728303. S2CID 3100453.
  4. Pitton Rissardo, Jamir; Fornari Caprara, AnaLetícia (2020). "Immune-mediated movement disorders, neuronal antibodies, and paraneoplastic syndromes". Annals of Movement Disorders. 3 (3): 188. doi:10.4103/AOMD.AOMD_37_20. ISSN 2590-3446.
  5. Bushara, Khalafalla O. (2005). "Neurologic presentation of celiac disease". Gastroenterology. 128 (4 Suppl 1): S92–7. doi:10.1053/j.gastro.2005.02.018. PMID 15825133.
  6. Axley, John (1972). "Rheumatic chorea controlled with haloperidol". The Journal of Pediatrics. 81 (6): 1216–7. doi:10.1016/S0022-3476(72)80272-5. PMID 4643046.
  7. Patterson, John F. (1979). "Treatment of Chorea Gravidarum With Haloperidol". Southern Medical Journal. 72 (9): 1220–1. doi:10.1097/00007611-197909000-00044. PMID 472859.
  8. Donaldson JO (March 1982). "Control of choreia gravidarum with haloperidol". Obstetrics and Gynecology. 59 (3): 381–2. PMID 7078886.
  9. Lawrence, David M. (2009). Huntington's Disease. Infobase Publishing. ISBN 9780791095867.
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