A 29‐year‐old man with long‐standing, poorly controlled diabetes mellitus presented with change of mental status. Past medical history included: chronic kidney disease, diabetic retinopathy and neuropathy, left UE occluded AV fistula, congestive heart failure, and chronic osteomyelitis of the foot. Uremic encephalopathy was diagnosed and hemodialysis was initiated. Early in the hospital stay he developed progressive pain, swelling, and limited range of motion of his left elbow. Physical examination revealed limited range of motion, tenderness, induration and swelling in the distal arm extending to the proximal forearm. No fever, fluctuance, crepitus, venous cords, or articular pathology was noted and neurovascular status was intact. HgA1C was 12.7, erythrocyte sedimentation rate (ESR) > 100, C‐reac‐tive protein (CRP) was 6.69, and white blood cell (WBC) count and creatine kinase (CK) were normal. UE duplex ultrasound was negative for deep venous thrombosis. Plain film revealed soft tissue swelling. MRI demonstrated massive edema of the forearm muscles on the inversion recovery and T2 weighted sequences, along with extensive infiltration and thickening of the fatty tissue. The clinical presentation along with these characteristic MRI findings led us to the diagnosis of diabetic myonecrosis (DMY). The patient improved with glycemic control, analgesia, and progressive physical therapy.
DMY is a rare complication of long‐standing diabetes mellitus (DM). Fewer than 100 cases have been reported (the first in 1965), with most involving the lower extremities. We report a case of upper extremity (UE) DMY, a presentation not found in our review of the literature.
DMY is an infrequent complication of poorly controlled DM. More common in women, DMY has an average age at presentation of 37 years. Presumed to be a sign of severe vascular disease, it suggests a poor prognosis, with most patients dying within 5 years. Patients typically present with an atraumatic, painful, swollen limb, and limited mobility secondary to pain. Affected muscle groups include the quadriceps (62%), hip adductors (13%), hamstrings (8%), and hip flexors (2%). Routine laboratory findings (CK, ESR, CRP, WBC) are variably elevated. MRI findings (gadolinium enhanced) characteristic of DMY are increased signal intensity of the involved muscles on T2‐weighted sequences and intramuscular edema. Excisional biopsy is not recommended, as pathological findings are nonspecific and surgical morbidity is high. Pathogenesis is unclear. Local atherosclerosis, diabetic microangiopathy, and alteration in the coagulation‐fibrinolytic system have all been proposed as potential causes of DMY.
DMY should be suspected in patients with long‐standing uncontrolled diabetics who develop acute atraumatic muscle swelling.
A. Chaaya, None; E. Kupersmith, Merck, consulting fees or other remuneration (payment); sanofi‐aventis, consulting fees or other remuneration (payment); sanofi‐aventis, research grants; Pfizer, consulting fees or other remuneration (payment); T. Comerci, None.
To cite this abstract:Chaaya A, Kupersmith E, Comerci T. Diabetic Myonecrosis: An Uncommon Complication of a Common Disease. Abstract published at Hospital Medicine 2007, May 23-25, Dallas, Texas Abstract 113. Journal of Hospital Medicine. 2007; 2 (suppl 2). https://www.shmabstracts.com/abstract/diabetic-myonecrosis-an-uncommon-complication-of-a-common-disease/. Accessed July 17, 2019.