Diabetic Myonecrosis: An Uncommon Complication of a Common Condition

INTRODUCTION: Diabetic myonecrosis is an uncommon complication of diabetes mellitus, most often occurring in patients with poorly controlled, insulin-dependent diabetes. Its etiology is poorly understood, with many suggesting microvascular occlusion to be a key factor resulting in necrosis of skeletal muscle. CASE PRESENTATION: A 28-year-old male with a history of poorly controlled type I diabetes mellitus and end-stage renal disease requiring dialysis presented to the emergency department with severe pain of the lower extremities bilaterally. RESULTS: Work-up included an x-ray, which demonstrated no acute fractures but extensive vascular calcification of the lower extremities, and Doppler ultrasonography, which showed no DVT. MRI demonstrated severe muscular edema with patchy, geographic areas of sparing, which, in conjunction with the patient’s clinical presentation, allowed for a diagnosis of diabetic myonecrosis. He underwent conservative treatment, consisting of rest and pain management, leading to resolution of symptoms. DISCUSSION: Diabetic myonecrosis, although uncommon, can be easily diagnosed with a high degree of clinical suspicion. It typically presents in a patient with poorly controlled diabetes, and will commonly involve the proximal muscles of the lower extremity unilaterally, but may present bilaterally and involve the distal muscles, as demonstrated in this case. Diagnosis is made via MRI, and it is treated conservatively with pain management and rest. Most cases resolve with conservative management but recurrence is common. LEARNING POINTS: Diabetic myonecrosis is an uncommon complication of diabetes mellitus, most often occurring in patients with poorly controlled, insulin-dependent diabetes presenting with significant unilateral lower extremity pain, although bilateral presentation is also possible. A diagnosis of diabetic myonecrosis can be easily made with MRI, which demonstrates highly characteristic muscular edema with patchy areas of geographic sparing, but a high degree of clinical suspicion is necessary to reach a diagnosis. Recurrence of diabetic myonecrosis is common, and should be suspected in patients who have a history of this condition presenting with recurrent musculoskeletal pain, even if this pain is localized to a different muscle group.