Pain and Swelling in Left Thigh in a Poorly-Controlled Diabetic Patient

Program: Abstracts - Orals, Featured Poster Presentations, and Posters
Session: SAT 758-785-Diabetes Case Reports: Type 1, Type 2, MODY & Complications
Clinical
Saturday, June 15, 2013: 1:45 PM-3:45 PM
Expo Halls ABC (Moscone Center)

Poster Board SAT-781
Yang Shen*1, Andrew Levy1, James Woodruff1 and Dorothy Santos Martinez2
1University of Chicago Medical Center, Chicago, IL, 2UCLA, Los Angeles, CA
Introduction: Diabetic patients are at increased risk for systemic infections as well as infections in the soft tissues and muscles. Limb swelling and pain in a diabetic patient are often cellulitis. Other common etiologies include trauma, thrombosis, infectious or inflammatory myositis (1). Diabetic muscle infarct (DMI), a spontaneous ischemic necrosis of skeletal muscle, is an underreported diabetic complication that needs to be considered (2).

Case Report: A 40 year old man with a 20 year history of poorly controlled DM type II, HTN and PVD presented to the ER with a 2 day history of sudden onset swelling and pain in the left thigh. There was no history of trauma to the area, fever or chills.  Physical exam revealed a discrete area of swelling measuring 10cm x 14cm which was extremely tender to palpation but had no associated erythema. His WBC was 4.0 x 109 cells/L with a normal differential. His electrolytes were normal and his serum creatinine was 1.0 mg/dL. His blood glucose was 284 mg/dL with negative ketones. A LE Doppler examination was negative for DVT. Patient was discharged to home to complete a 7 day course of Bactrim for presumed cellulitis. The patient returned to his PCP 5 days later without improvement and was admitted to the hospital. His WBC remained normal at 4.7 x 109 cells/L. His blood glucose was elevated at 381 mg/dL without an anion gap acidosis. His hgA1c level was 15.2%. MRI of the thigh with IV contrast showed extensive subcutaneous soft tissue edema along the anterior and lateral thigh. Foci of probable necrosis were seen with a thin crescent of fluid surrounding the muscles of the lateral and medial compartments. Orthopedics was consulted for muscle biopsy. Intra-operatively there was no evidence of infection.  Bacterial and fungal cultures were negative. Muscle biopsies revealed the presence of focal muscle infarction with associated reactive changes, findings consistent with DMI. The patient’s blood glucose was controlled and he was discharged to home 2 days later. 

Conclusion: DMI or diabetic myonecrosis is an unusual complication of diabetes with scattered case reports (3). Prevalence may be underestimated given that a muscle biopsy, gold standard for diagnosis, is rarely performed. A high suspicion of DMI should be raised in patients with limb pain and swelling who lack infectious signs and symptoms and whose complaints are refractory to antibiotics.

(1)Kapur S, Brunet JA, McKendry RJ. J Rheumatol 2004; 31; 190-194 (2) Litvinov I., Radu A, Garfield N. BMC Res Not 2012, 5:701. (3)Hoyt J, Wittich C. J Clin Endocrinol Metab 2008, 93(10): 3690

Nothing to Disclose: YS, AL, JW, DSM

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