Diabetic Myonecrosis: A Rare Complication of Uncontrolled Diabetes Mellitus

Abstract

\n Background: Diabetic myonecrosis is a rare complication of long-standing, poorly controlled diabetes mellitus, and is more common in patients with microvascular complications. The diagnosis is frequently missed due to symptoms mimicking other conditions associated with diabetes mellitus.\n Clinical Case: A 31-year-old woman with a past medical history of long-standing type I diabetes mellitus, end-stage renal disease, diabetic retinopathy, and cataracts presented to our hospital with a chief complaint of right thigh pain and swelling for a week. She did not have any other relevant symptoms and denied a history of trauma. On admission, physical examination revealed right thigh edema, induration, tenderness on palpation, more pronounced in the medial aspect of the thigh, and decreased range of motion of the right hip. Laboratory analysis showed leukocytosis of 13.29 k/uL (normal = 4.23 - 9.71 k/uL) with neutrophilic predominance of 91.4 %, elevated inflammatory markers (ESR > 130 mm/h (normal = 0 - 30 mm/h), CRP 33.84 mg/dL (normal <= 0.49 mg/dL)) and elevated CK levels of 1675 U/L (normal = 29 - 168 U/L). Additionally, the patient was anemic with a hemoglobin level of 8.4 g/dL (normal = 11.0 - 15.0 g/dL) and had a creatinine level of 2.67 mg/dL (normal = 0.55 - 1.11 mg/dL). Hemoglobin A1C level was 10.8 % (normal = 4.0 - 6.0 %). Blood cultures were drawn and did not grow any organisms. A doppler ultrasound of the right leg was negative for a deep venous thrombosis. CT angiogram of right lower extremity revealed diffuse calcifications in the walls of small and medium vessels and edematous changes in thigh musculature associated with subcutaneous edema. Noncontrast MRI revealed localized edema within the vastus medialis, sartorius, and right thigh adductor muscles. The patient improved with analgesics, rest, and gentle physical therapy. She was counseled on compliance with insulin and advised for a close follow up with her endocrinologist.\n Conclusion: This case reinforces the importance of including diabetic myonecrosis in the differential diagnosis of acute to subacute nontraumatic muscular pain in diabetic patients, particularly in patients with poor glycemic control and known complications. While muscle biopsy can be performed for histological confirmation, the typical imaging findings and clinical presentation can lead to the diagnosis, making further invasive testing unnecessary. In most described cases, the course of this condition is self-limiting.