A Rare Case of Isolated Spontaneous Myonecrosis

1Mount Sinai Englewood Hospital and Medical Center, Englewood, NJ
2Mount Sinai Englewood Hospital and Medical Center, Englewood, NJ
3Mount Sinai Englewood Hospital and Medical Center, Englewood, NJ
4Mount Sinai Englewood Hospital and Medical Center, Englewood, NJ

Meeting: Hospital Medicine 2013, May 16-19, National Harbor, Md.

Abstract number: 510

Case Presentation:

We present a 65‐year‐old white woman with a history of long‐standing diabetes mellitus complicated by retinopathy, hypertension, coronary artery disease with prior placement of drug‐eluting stents, and chronic systolic heart failure. During a recent admission for heart failure at another hospital she developed pain in her left thigh after a minor fall which was diagnosed as muscle strain and was discharged home. She presented to our emergency room one week later with unremitting and progressive pain in her thigh. She denied fever, chills, or arthralgias since her fall. Her exam was notable for warmth, edema, and tenderness of her left thigh. Although her thigh pain was severe, there was no apparent pain with passive range of motion at the left hip and left knee was without effusion or warmth. CBC, coagulation profile and lower‐extremity Doppler were normal. Metabolic panel was significant for hyponatremia of 128 mg/dL, chloride of 90 mg/dL, glucose of 247 mg/dL, BUN of 23 mg/dL, and creatinine of 1.5 mg/dL. Radiological assessment with x‐rays and bone scan were negative for fractures. CT scan demonstrated mild subcutaneous edema within medial and lateral mid to distal thigh. Other labs showed an elevated ESR of 105, CRP of 57, ferritin of 273, total CK of 386 and normal procalcitonin level. Patient remained afebrile but had persistent pain despite treatment with high‐dose opiate analgesics. MRI of the left thigh showed extensive intramuscular edema throughout vastus medialis and intermedius muscles extending from intertrochanteric region to patella consistent with myositis. Ultrasound guided muscle biopsy was performed and antimicrobial therapy with cefazolin and vancomycin was initiated. Histopathology showed skeletal muscle degeneration consistent with necrotizing myositis with reactive neutrophil infiltration. Culture was negative. Compartment pressures in the left thigh were not elevated and surgical debridement of the necrotic muscle was deferred as the risk of morbidity was felt to be high and the benefit uncertain. She required high doses of parenteral opiates for her pain which subsided after several weeks. During this time she developed progressive renal failure and encephalopathy of unclear etiology. She was started on hemodialysis and underwent renal biopsy which demonstrated moderate nodular diabetic glomerulosclerosis, moderate to severe tubular atrophy, interstitial fibrosis, and moderate to severe arteriolosclerosis consistent with diabetic kidney disease.

Discussion:

This case report describes diabetic myonecrosis, or muscle infarction, which is a rare complication of long‐standing poorly controlled diabetes mellitus. Very few cases have been reported. It often involves thigh and calf muscles and is associated with advanced microvasculopathy. It is usually self‐limited and responds to conservative management but has a poor prognosis.

Conclusions:

Diabetic myonecrosis should be considered in diabetic patients presenting with focal muscular pain and swelling

To cite this abstract:

Krishnamoorthy P, Sharma P, Kurtis S, Hohmuth B. A Rare Case of Isolated Spontaneous Myonecrosis. Abstract published at Hospital Medicine 2013, May 16-19, National Harbor, Md. Abstract 510. Journal of Hospital Medicine. 2013; 8 (suppl 2). https://www.shmabstracts.com/abstract/a-rare-case-of-isolated-spontaneous-myonecrosis/. Accessed May 24, 2019.

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