Diabetic Myonecrosis

Abstract

A 40-yr-old woman with type I diabetes mellitus and diabetic nephropathy, retinopathy, and neuropathy presented with a 7-month history of left leg pain with no antecedent trauma.Physical examination revealed enlargement and tenderness over the anterior and lateral aspect of the left thigh.Pulses, venous ultrasound, and arterial Doppler were normal.Laboratory tests revealed a mild leukocytosis of 11.0 ϫ 10(9)/liter and normal creatine kinase.Magnetic resonance imaging (MRI) showed extensive edema in the anterior and lateral aspect of the left thigh, localizing to the vastus intermedius and medialis muscles, associated with an area of hemorrhagic myonecrosis (Fig. 1).Diabetic myonecrosis (DM) is a rare complication of diabetes first described in 1965 by Angarwall and Stener (4).Most patients have poorly controlled diabetes and present with acute pain (80%) and swelling (75.9%), often localized to the thigh (83.7%) (1).Pathogenesis may involve hypoxiareperfusion injury, atherosclerotic occlusion, or vasculitis with thrombosis (2).DM is often initially unrecognized, leading to delayed diagnosis and patient suffering (3).The differential diagnosis includes tumor, thrombus, and infection.MRI shows increased signal within the muscle and can detect tumor.Biopsy with cultures and ultrasound can determine whether infection or thrombus are present, respectively.Treatment for DM is control of diabetes and pain.Most patients die within 5 yr of diagnosis (3).In summary, DM should be considered when a diabetic patient presents with severe muscular pain.