Diabetic Myonecrosis in a Previously Healthy Woman and Review of a 25-Year Mayo Clinic Experience

Abstract

To describe a case of diabetic myonecrosis, an unusual complication of diabetes mellitus, and to provide an overview of an institutional experience with this condition. We report the clinical, laboratory, and imaging findings in a 50-year-old woman with no history of diabetes, who was hospitalized because of weakness in her left lower extremity and an infection in her right hand. A morbidly obese woman had sustained several falls attributable to left leg weakness, which had resulted in repetitive trauma to, and subsequent infection of, her right hand. Laboratory studies showed a fasting blood glucose level of 204 mg/dL, a glycated hemoglobin of 12.8%, and a calculated hemoglobin Alc of 10.6%. Results of evaluations for retinopathy and nephropathy were negative. Electromyography of the left leg suggested the presence of a diabetic plexopathy. Two weeks after admission of the patient, severe left lower extremity pain and swelling developed abruptly. Ultrasound evaluation of the leg was negative for deep venous thrombosis. Laboratory data revealed a leukocyte count of 7.1 x 10(3)/mL and a creatine kinase level of 26 U/L. Magnetic resonance imaging of the left leg demonstrated extensive muscle edema and collections of fluid surrounding the femur and posterior compartment of the thigh and extending into the left calf. Gram stain and cultures of aspirated fluid were negative. The patient was managed with supportive care, including strict glycemic control, periodic analgesia, and physical therapy. A review of medical records for a 25-year period at the Mayo Clinic disclosed only five patients with the diagnosis of diabetic myonecrosis. All five patients had insulin-treated diabetes and severe end-organ disease. The current case is the first report of myonecrosis as the initial manifestation of diabetes. This case also demonstrates that myonecrosis, although typically involving the thigh, can extend abruptly to the calf. Diabetic myonecrosis should be included in the differential diagnosis of an acutely painful lower extremity mass in patients with diabetes.