Rare complication of a common disease
Today’s case discussion was of a 42 yo M who presented multiple times to the ED for evaluation of persistent L thigh pain and swelling. It started acutely while he was walking on a treadmill about 2 mos ago and has been constant since then. Reports subjective fevers. Due to the severity of the pain, his ambulation is now limited. On exam, low grade temp with tachycardia, no neurological deficits/ muscle weakness noted but there was exquisite tenderness on superficial palpation over medial aspect of L thigh assoc with swelling.
He had 4 prior ED visits during this time with work up neg for DVT (Dopplers) and fractures (plain films) and pain getting worse.
The working diagnosis is Diabetic Myonecrosis. Differential diagnosis includes pyomyonecrosis, spontaneous gangrenous myonecrosis, necrotizing fasciitis etc.
– it is a very rare complication (<100 cases reported in the literature) of diabetes
– usually acute or subacute onset, thigh is the commonest location
– labs, CK may be normal to mildly elevated
– definitive diagnosis is made by MRI (showing necrosis/edema/loss of intramuscular septa) and the to be followed by muscle biopsy (necrosis and occlusion of small vessels with fibrin)
– conservative treatment with anti platelet agents demonstrated the least time to recovery, recovery rate and mortality comapred to surgical management