Category: Diabetes/Prediabetes/Hypoglycemia

Monitor: 16

16 - RARE AND UNDERDIAGNOSED COMPLICATION OF LONG STANDING DIABETES: A CASE REPORT OF DIABETIC MYONECROIS

Saturday, Apr 27
11:00 AM – 11:30 AM

Objective :

Background: Diabetic myonecrosis, also termed diabetic muscle infarct, is a rare and severe complication of longstanding, poorly controlled Diabetes Mellitus. Angervall and Stener first described this condition in 1965 and less than 200 cases have been reported in the literature since. This disorder typically presents as an atraumatic acute onset of pain and swelling of the affected muscle most frequently in the lower extremities and involving the muscles of the thigh. Diabetic myonecrosis usually occurs in patients with an established longstanding history of diabetes in the setting of other associated microangiopathic changes such as retinopathy, neuropathy, and nephropathy. The main treatment involved with this disorder involves strict blood sugar regulation. We present an exceedingly rare case of diabetic myonecrosis in a 54-year-old woman with poorly controlled type II Diabetes Mellitus (DMII).


 


Methods :

Clinical
Case:
A 54-year-old woman with history of longstanding DMII, heart failure with reduced ejection fraction (EF 25%), and hyperlipidemia, presented with a four-week history of atraumatic left medial thigh swelling and pain. She had two courses of broad spectrum antibiotics during this time with no improvement. Erythrocyte sedimentation rate and c-reactive protein were mildly elevated, and she had a normal creatine phosphokinase and anti-nuclear antibody. Hemoglobin A1c done was 10.9%. X-ray of the left femur displayed mild osteoarthritis and soft tissue swelling, however no evidence of fracture or dislocation. Left lower extremity duplex was negative for deep vein thrombosis. MRI of the left thigh showed an area of high T2 signal and nonenhancement within the vastus medialis that measured 9.1 cm craniocaudally, 5.5 cm transversely, 2.3 cm posteriorly along with edema within the vastus medialis muscle both below and above the area of nonenhancement. The MRI findings were consistent with myonecrosis of vastus medialis. In the absence of infectious signs and symptoms along with no improvement in symptoms on broad spectrum antibiotics, she was diagnosed with diabetic myonecrosis.  


 


Results :

As noted in the Method section in the clinical case. 


Discussion :

Patient was diagnosed with diabetic myonecrosis given the support of the imaging study, history, physical exam and  abscence of infectious signs and symptoms with failure to improve with  antibiotics. 


Conclusion :


Conclusion:
We present an exceedingly rare case of diabetic myonecrosis. Being able to recognize the clinical presentation of this complication earlier in its disease course and initiating treatment for the goal of tighter glycemic control is essential in prevention of further complications.

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Loura Khallouf

Internal Medicine Resident
UMASS
Worcester, Massachusetts

Internal Medicine Resident

Erik Holzwanger

Internal Medicine Resident
UMass Memorial Medical Center, Massachusetts

Internal Medicine Chief Resident

Sandeep Jubbal

Assistant Professor of Medicine
University of Massachusetts Medical School
Worcester, Massachusetts

Assistant Professor of Medicine, University of Massachusetts Medical School, Worcester, MA

Christina Gavala, MD

Hospital Medicine Attending
UMASS

Hospital Medicine Attending

Loura Khallouf

Internal Medicine Resident
UMASS
Worcester, Massachusetts

Internal Medicine Resident