MON-138 Why Is My Thigh Hurting so Much?: A Rare Case of Diabetic Myonecrosis.

Background: Diabetic myonecrosis is a rare complication of long-standing, poorly controlled Type I and II Diabetes mellitus. It classically presents with sudden onset of pain and swelling of involved muscle, most often in lower extremities, which can mimic DVT. Clinical Case: A 32-year old lady with Insulin dependent type 2 diabetes mellitus since age 14, ESRD on peritoneal dialysis, came in to our hospital with worsening right thigh swelling and pain of 3 days duration. On physical exam, her vital signs were stable, and she had diffuse swelling in her right thigh without any erythema, with prominent tenderness on medial aspect of the thigh. Right thigh measured 22 inches circumferentially at midpoint, which is 17 cm from inguinal region, while her left thigh measured 18 inches circumferentially at midpoint. On admission, she had an elevated white count of 15,100, and creatinine kinase was normal. Her hemoglobin A1C was 7.2% in the setting of anemia of ESRD, where her hemoglobin was 8.5g/dL. Lower extremity venous doppler was negative for DVT. MRI of right lower extremity showed diffuse nonspecific polymyositis throughout proximal right thigh, small areas of decreased enhancement in vastus medialis and lateralis, and stated that in the setting of diabetes, evolving diabetic muscle infarctions are to be strongly considered. Infectious Disease saw the patient and concluded that there was no evidence of infection. Patient was diagnosed with Diabetic myonecrosis and was managed conservatively including with rest, analgesia, and aggressive glycemic control. During her 1-month follow-up visit, uniform swelling of right thigh decreased to 19.5 inches from 22 inches circumferentially at midpoint, and her right thigh tenderness has resolved. Conclusion: Diabetic myonecrosis should be suspected in any patient with Diabetes who presents with acute muscular pain and swelling, especially in the lower extremities. MRI is the modality of choice to confirm clinical diagnosis. Muscle biopsy can provide definitive diagnosis but is not currently recommended due to the risk of procedure-associated complications and prolonged recovery secondary to poor wound healing. Treatment consists of rest, analgesia, and rigorous glycemic control. Reference: (1) Horton WB, Taylor JS, Ragland TJ. Diabetic muscle infarction: a systematic review. BMJ Open Diabetes Research and Care 2015