Rare Complication Of Diabetes Mellitus Research Articles

6541 Recurrent Euglycemic Diabetic Ketoacidosis And Myonecrosis In A Patient Previously Thought To Have Type 2 Diabetes Mellitus

Abstract Disclosure: K. Haridas: None. M.M. McConnell : None. Introduction: Euglycemic diabetic ketoacidosis (DKA) is a well-recognized complication with the use of sodium linked cotransport of glucose-2 (SGLT2) inhibitors. Diabetic myonecrosis is a rare complication of diabetes mellitus caused by spontaneous death of muscle due to microvascular ischemia. Clinical Case: A 48-year-old male diagnosed with Type 2 Diabetes Mellitus with HbA1c 11.3%, treated with Empagliflozin and basal-bolus insulin was admitted to the hospital with left thigh pain and anorexia. Physical examination was notable for BMI of 19kg/m2 and left lateral thigh induration. Laboratory evaluation revealed venous pH 7.1, bicarbonate 10mmol/L (20-30), anion gap 32mmol/L(8-12), glucose 168mg/dl (65-99), ESR 67mm/h (<=12), Creatinine Kinase 31 U/L (63-473), glucosuria (4+) and ketonuria (4+). He was diagnosed with euglycemic DKA due to SGLT2 inhibitor. He was also diagnosed with Type 1 Diabetes Mellitus (T1DM) based on undetectable C-peptide and GAD antibody titer 64.3IU/ml(<5). MRI of the left thigh revealed an area of diabetic myonecrosis, measuring 11cm. He was treated with continuous insulin infusion. On hospital day 3, after resolution of the anion gap metabolic acidosis, transition was made to basal-bolus insulin. On hospital day 5, recurrent euglycemic DKA was diagnosed with bicarbonate 15mmol/L, anion gap 18mmol/L, beta-hydroxybutyrate 49.6mg/dl (<=3mg/dl), glucose 185mg/dl, glucosuria (4+) and ketonuria (4+). Continuous insulin infusion was restarted. On hospital day 8, transition was made to subcutaneous insulin. Diabetic myonecrosis was initially managed conservatively with analgesics, aspirin, and physical therapy. Due to worsening leukocytosis on hospital day 13, Ceftriaxone was started and surgical debridement was performed, revealing a loculated abscess within necrotic muscle. Empagliflozin was discontinued at discharge. Discussion: The risk of euglycemic DKA with SGLT2i use is increased in patients with T1DM and decreased oral intake, and insults like trauma or surgery as seen in this patient. Although the half-life of empagliflozin is 12 to 14 hours, there have been case reports of persistent or recurrent euglycemic DKA for 7-12 days from the time of last dose. The continued glucosuria and ketonuria in this patient with serum glucose levels below the renal threshold confirmed the recurrence. Diabetic myonecrosis usually affects the muscles of the proximal lower extremities and is seen in patients with poorly controlled diabetes with microvascular complications, between one and two decades after diagnosis, as in this patient. Conclusion: A high index of suspicion for recurrent euglycemic DKA must be maintained in patients who have new or persistent high anion gap metabolic acidosis until 2 weeks from last dose of SGLT2 inhibitor. Diabetic myonecrosis, especially if complicated by abscess formation, may require surgical intervention. Presentation: 6/1/2024

A Rare Complication of Diabetes Mellitus: Bruns-Garland Syndrome (Diabetic Amyotrophy)

A Rare Complication of Diabetes Mellitus: Bruns-Garland Syndrome (Diabetic Amyotrophy)

FEATURES OF THE COURSE OF DIABETIC NEUROSTEOARTHROPATHY IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

Diabetic neuroosteoarthropathy (DNOA, Charcot foot) is a relatively rare complication of diabetes mellitus (DM), which can lead not only to impaired support function of the lower limb in such patients, but also to high amputation. DNOAP is characterized by persistent aseptic inflammation of the bone structures of the foot, which creates significant difficulties in planning treatment measures[1,2,3,4]. In the medical literature, there is data demonstrating the role of individual cytokines and neurohumoral factors in the prolongation of the inflammatory process in diabetes, however, studies identifying significant markers Aseptic inflammation with DNOAP is currently extremely rare[5,6,7].

Diagnosis and Management of Two Cases of Diabetic Muscle Ischemia

Diabetic muscle ischemia (DMI) is a rare complication of diabetes mellitus that presents as excruciating leg pain. Owing to its rare occurrence, DMI is seldom recognized. Here, we present two cases of DMI with a view to promote prompt diagnosis, thereby avoiding the need for patients to undergo unnecessary examinations.

Nonketotic Hyperglycemic Hemichorea in an Elderly Male: A Case Report

BackgroundNonketotic hyperglycemic hemichorea is a rare complication of diabetes mellitus seen in the emergency department. It is most commonly reported in elderly women, predominantly of Asian race, with poorly controlled diabetes mellitus. Patients present with a triad of nonketotic hyperglycemia, hemichorea, and contralateral basal ganglia abnormality on imaging. Its exact pathophysiology is still not known. However, it has a very good prognosis with early diagnosis and treatment. Case ReportWe report a case of hemichorea involving the right upper and lower limbs due to nonketotic hyperglycemia. The patient's symptoms resolved after normalization of blood glucose. Why Should an Emergency Physician Be Aware of This?Nonketotic hyperglycemic hemichorea should be included in the differential of a patient presenting with chorea and high blood glucose levels. It has an excellent prognosis with both symptoms and imaging abnormalities typically resolving completely with restoration of normoglycemia.

Glycogenic Hepatopathy in a Teenage Girl with Diabetes Mellitus Type 1

Glycogenic hepatopathy (GH) refers to a relatively rare complication of diabetes mellitus (DM) type 1 which constitutes of reversible accumulation of excess hepatic glycogen, usually manifesting in the form of liver enzyme elevation along with hepatomegaly. The occurrence of the disorder is most commonly related to inadequate control of blood sugars. Herein, we report upon a case of an 18-year-old girl presenting with severe transaminase elevations owing to poor metabolic control, as well as the progression of her enzymes and general condition during and after her hospitalization.

Relationship Between Diabetic Chorea and Timing of MRI Findings: A Systematic Review with Case Reports.

Diabetic chorea is a rare complication of diabetes mellitus for which head MRI is the most common diagnostic imaging modality. Cases have been reported where CT and/or MRI findings are inconsistent or clinical symptoms and imaging findings do not appear simultaneously. We aimed to compile the cases in which imaging findings appeared on MRI retests and to examine in a systematic review whether temporal differences in the appearance of imaging findings correlate with clinical characteristics. An 80-year-old man with type 2 diabetes mellitus came to a hospital with abnormal movements of the left upper and lower extremities. Two days after the first visit, his symptoms flared up, and his head MRI showed an old cerebral infarction and no new lesion. On day 14, he retested T1-weighted imaging and showed a high signal in the right putamen, which was considered diabetic chorea. Blood glucose was controlled with insulin, and the involuntary movements disappeared. PubMed and ICHUSHI were searched to identify patients with diabetic chorea who had undergone MRI retests. Patients grouped by the temporal change in the presence/absence of imaging findings were compared on age, sex, duration of diabetes mellitus, blood glucose level, HbA1c level, side of involuntary movement, time to first MRI, and follow-up MRI. Of the 64 cases analyzed, 43 (67.2%) were female. The mean age was 69.0 years. 16 (25.0%) had worsening findings upon MRI retesting, 37 (57.8%) had improvement, and 10 (15.6%) had unchanged findings. There were no significant differences in age, sex, mean blood glucose level or HbA1c at onset among the groups. There was no association between the pattern of appearance of imaging findings over time and clinical characteristics, including glucose levels. If initial MRI findings are negative, MRI retesting after a certain time may help diagnose diabetic chorea.

The role of neurohumoral factors in the persistence of aseptic bone inflammation in patients with diabetic neuroosteoarthropathy

BACKGROUND: Diabetic neuroosteoarthropathy (DNOAP, Charcot foot) is a relatively rare complication of diabetes mellitus (DM), which can lead not only to impaired support function of the lower limb in such patients, but also to high amputation. DNOAP is characterized by persistent aseptic inflammation of the bone structures of the foot, which creates significant ­difficulties in planning therapeutic measures. In the medical literature, there are data demonstrating the role of individual ­cytokines and neurohumoral factors in the prolongation of the inflammatory process in diabetes, however, there are currently very few studies that determine reliable markers of aseptic inflammation in DNOAP.AIM: To study the effect of neurohumoral factors and advanced glycation end products on the activity of aseptic inflammation in the bone structures of the foot in patients with type 2 diabetes mellitus (DM2) and diabetic neuroosteoarthropathy.MATERIALS AND METHODS. The study included 88 patients with type 2 diabetes (45 men, 43 women). Group 1 consisted of patients with DM2 and inactive DNOAP (n= 43), group 2 (n= 45) consisted of patients with DM2 and distal diabetic neuropathy without osteoarticular pathology. The diagnosis of diabetic neuropathy was based on the analysis of the clinical picture and indicators of peripheral sensitivity. Diagnosis of DNOAP and determination of its stage was based on clinical data, the results of infrared thermometry and radiology tests of the foot bones. General clinical assessment was used, radiology tests (X-ray, MRI), evaluation of CRP, calprotectin, copeptin, glutathione peroxidase 1 (GP1).RESULTS. According to the results of examination and palpation of the feet, as well as the analysis of the temperature gradient of the skin of the affected and contralateral limb (infrared thermometry), DNOAP was detected and the stage of this complication was determined. The diagnosis of the chronic stage of DNOAP was confirmed by the results of MRI and the clinical picture (no difference in skin temperature on the symmetrical areas of the feet). According to the results of laboratory analysis, a statistically significant difference in copeptin values was revealed — in group 1 — 0.232 µg/ml [0.147; 0.342], in group 2 — 0.115 µg/ml [0.065; 0.203] (p>0.05) and CRP — in group 1 — 7.113 mg/l [2.453; 16.505], in group 2 — 2.187 mg/l [1.131; 5.567] (p>0.05), leukocyte levels in the groups did not differ significantly: group 1 — 7.86 [6.40; 9.00]*10^9, group 2 — 7.00 [6.00; 8.15] (p>0.05). There was a trend towards an increase in the level of calprotectin and glutathione peroxidase-1 in the DNOAP group, however, the differences were not significant. calprotectin — in group 1 — 1.948 [1.229; 2.969], in group 2 — 1.692 [1.16; 2.514] μg/ml and glutathione peroxidase-1 in group 1 — 24.72 [20.1; 31.82], in group 2 — 22.98 [18.94; 31.2] ng/ml.CONCLUSION. In the study, statistically significant differences were obtained in the levels of copeptin and C-reactive protein: in patients with DNOAP, their values were significantly higher, which indicates the persistence of the aseptic inflammatory process in the bone tissue of patients even in the chronic stage of DNOAP. These data may help in deciding whether to use one or another method of unloading the affected joints, which will affect the clinical prognosis. The study of neurohumoral markers of arthropathy in the blood serum of patients with DM2 is carried out for the first time, and therefore it is difficult to compare with the results of other authors. It can be assumed that copeptin and CRP are significant markers of persistent inflammation of the osteoarticular structures of the foot in DNOAP.

Significance of the glycation process in the development and progression of diabetic osteoarthropathy (DOAP)

Diabetic osteoarthropathy (DOAP) is an extremely rare complication of diabetes mellitus, which is diagnosed in the subacute phase, when degenerative changes have already begun. Inadequate treatment due to an incorrect diagnosis leads to serious consequences for the patient. The complexity of diagnosing lies in the fact that a patient with this problem does not turn to a specialist in the «Diabetic Foot» office, but to various specialists: surgeons, orthopedists, physiotherapists. There is a problem in diagnosing this complication in the absence of uniform protocols and interpretation of specialists’ conclusions, technical means of modern diagnostics, and trained specialists. There is insufficient information about the effect of the glycation process on the DOAP development, although the glycation process causes neuropathy, which is a DOAP precursor. The complexity of diagnosing DOAP also lies in the fact that this pathology occurs not only in patients with diabetes mellitus, although statistically a higher percentage of diabetes patients have the disease. Therefore, DOAP is most often associated with diabetes mellitus. DOAP is a complex pathology that deprives the patient of the opportunity to lead a normal life, limits his/her freedom of movement, and leads to complete disability.

Diabetic Myonecrosis: A Case Study

Abstract Background: Diabetic myonecrosis is a rare complication of diabetes mellitus with less than 200 cases reported in the literature since initial description in 19651. Diabetic myonecrosis most commonly affects the thigh and usually presents with acute muscle pain, edema, and erythema in the absence of trauma or fever1. The pathogenesis has yet to be elucidated—atherosclerosis, microangiopathy, vasculitis, and ischemia-reperfusion injury have been theorized. Laboratory findings are relatively nonspecific—of the findings reported in a systematic review, CRP was elevated in 90%, ESR elevated in 83.3%, WBC elevated in 42.5%, and CK elevated in 31.6%1. Definitive diagnosis can be made by muscle biopsy which demonstrates muscle necrosis and edema; however, it is not routinely recommended due to procedural complications. MRI is the diagnostic modality of choice for diabetic myonecrosis which is both sensitive and specific for the diagnosis2. Clinical Case: 76-year-old male with T2DM presented to regional hospital with severe right lower leg pain in the absence of fever, tachycardia, hypotension, or recent trauma. Physical exam demonstrated discrete erythema of distal 2/3 of posterior right lower leg extending to the ankle distally. Labs demonstrated normal CK, elevated ESR, HgbA1c 8.2%, and negative blood cultures. MRI of the right lower extremity demonstrated abnormal prolongation of T2 relaxation time involving posterior muscle compartment including soleus and gastrocnemius with associated perifacial and subcutaneous edema. These findings were consistent with diabetic myonecrosis without evidence of osteomyelitis or abscess. Rest, optimal glycemic control, and aspirin were recommended and patient improved gradually with complete clinical resolution on outpatient follow-up. Conclusions: Diabetic myonecrosis is a rare complication of diabetes and should be considered in patients presenting with acute muscle pain. Among cases described in literature, 5.7% have affected the soleus and 5% have affected the gastrocnemius respectively1. The diagnostic modality of choice is contrast enhanced MRI with typical findings including hyperintense signal on T2 weighted images with associated muscular, perifascial, and/or subcutaneous edema3. The optimal treatment is yet unknown, but reasonable strategies based on case series include rest, glycemic control, and NSAID therapy1.

Testicular necrosis: a rare complication of poorly controlled diabetes mellitus

A case presented here depicting testicular necrosis in a 45 years old male patient with diabetes mellitus. Past history suggestive of diabetes with very irregular medication. Patient presented with gradually increasing right testicular enlargement for three weeks. Ultrasonography showed abscess formation with no vascularity in right testis. Right orchiectomy done. Histopathology report confirmed testicular necrosis. Testicular necrosis is a common complication after torsion which leads to orchiectomy. In those cases, patients present with acute onset pain in the scrotum, usually unilateral. On examination there is acutely tender testis with red and angry looking overlying skin. In diabetic patients, urinary tract infections are common occurrence as well as epididymo-orchitis. Patients present with testicular pain with fever, leucocytosis etc. But testicular necrosis is extremely rare. Long term complications specific to diabetes mellitus include retinopathy, nephropathy and neuropathy. Patients with all forms of diabetes of sufficient duration, including insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus, are vulnerable to these complications, which cause serious morbidity. Testicular necrosis is a very rare complication of diabetes mellitus. An internet search did not reveal any article of testicular necrosis as a complication of diabetes. A case of unilateral testicular necrosis as a complication of diabetes mellitus is presented here for the first time. Probably accelerated microangiopathy along with poor control of blood glucose led to this unique complication.

Diabetic Muscle Infarction in a Young Patient with Prader–Willi Syndrome and Type 2 Diabetes Mellitus

Diabetic muscle infarction (DMI), also known as diabetic myonecrosis, is a rare complication of diabetes mellitus (DM); hence, it is often underdiagnosed. Thus, timely diagnosis and treatment are essential for a better prognosis. We describe a 24-year-old woman with Prader-Willi syndrome and an 8-year history of uncontrolled type 2 DM, who presented with a sudden onset of fever and subacute painful swelling of her left thigh. She was finally diagnosed with DMI based on magnetic resonance imaging and muscle biopsy after excluding other infectious and inflammatory diseases of proximal muscles. The patient was treated with bed rest, strict glycemic control, and analgesics, and her symptoms gradually resolved. DMI should be considered in the differential diagnosis of patients with poorly controlled DM, who present with subacute pain and swelling of lower extremity muscles, without a history of trauma. Keywords: Diabetes complications; Infarction; Muscle; Prader-Willi syndrome

Nonketotic Hyperglycemic Chorea in a 10-Year-Old Asian Boy with Diabetes Mellitus

AbstractNonketotic hyperglycemic chorea-ballism (NKHCB), also known as diabetic striato-pathy (DS) by some, is a rare complication of diabetes mellitus and uncommon in children. We reported a case of a 10 11/12-year-old male child of Asian descent with uncontrolled type 1 diabetes mellitus (T1DM), Hashimoto's thyroiditis, and multiple food allergies presenting with bilateral chorea-ballism. His brain magnetic resonance imaging revealed developmental venous anomaly in right parietal lobe and right cerebellum, no focal lesions or abnormal enhancements. Choreiform movements resolved with correction of hyperglycemia. Children and adolescents with a movement disorder should be evaluated for diabetes mellitus, especially with increasing prevalence and insidious nature of T2DM associated with obesity.

Diabetic myonecrosis: an uncommon diabetic complication

SummaryDiabetic myonecrosis, also known as diabetic muscle infarction is a rare complication of diabetes mellitus usually associated with longstanding suboptimal glycaemic control. Although theories of atherosclerosis, diabetic microangiopathy, vasculitis, ischaemia-reperfusion injury and hypercoagulable state have been proposed to explain the pathophysiology, none of these have been able to individually explain the pathophysiology in entirety. Diabetic renal disease is the most common risk factor for developing DMN and its recurrence. The diagnosis is often missed due to lack of awareness and the presentation mimicking other conditions associated with DM. The routine laboratory investigations are often non-specific and do not provide much value in the diagnosis as well. Muscle biopsy can provide a definite diagnosis but is not currently recommended due to its invasiveness and association with prolonged time to symptoms resolution. Magnetic resonance imaging, in combination with classic history and risk factors can clinch the diagnosis. Treatment is generally analgesia and rest, although the former’s use may be limited in the presence of renal disease.Learning points:Diabetic myonecrosis is a rare complication of diabetes mellitus associated with longstanding suboptimal glycaemic control.Diabetic renal disease is a known risk factor, although the evidence is merely observational.Although muscle biopsy could provide a definite diagnosis, it is not recommended as it can prolong the disease process and should be reserved only for cases not responding to conventional treatment.Typical MRI findings in combination with classic symptoms and risk factors can clinch the diagnosisCurrent treatment recommendations include NSAIDs and/or aspirin (if not contraindicated) alongside bed rest. Physiotherapy is not recommended in the acute phase but should be started as soon as patient is discharged from hospital.Optimal glycaemic control is key to prevent recurrence.

2319 A Case of Cryptogenic Liver Abscess in a Young Uncontrolled Diabetic

INTRODUCTION: Pyogenic liver abscess (PLA) is a rare complication of Diabetes Mellitus, usually seen in older adults who have had diabetes for many years. There is little information regarding the effects of glycemic control on the characteristics of PLA in diabetic patients. Actinomycosis is an infrequent invasive bacterial disease with indolent and non-specific presentation, therefore diagnosis is quite difficult to make for clinicians. Here, we report an uncontrolled diabetic patient who developed cryptogenic Actinomyces odontolyticus bacteremia and concurrent polymicrobial liver abscess. CASE DESCRIPTION/METHODS: A 41-year-old male with a history of uncontrolled Diabetes Mellitus Type 2, presented with severe, dull, epigastric pain. He was found to be in septic shock and diabetic ketoacidosis, requiring admission to the medical intensive care unit. Initial laboratory tests showed a white blood cell count of 16,800/mm3 (87% neutrophils), bicarbonate 14mmol/L, AST 147, ALT 126, alkaline phosphatase 193, beta hydroxybutyrate 5.04, and anion gap 17. HIV testing was negative. Hemoglobin A1c was 13%. A computed tomography (CT) image of his abdomen revealed a 7cm gas containing lesion in the left hepatic lobe concerning for hepatic abscess. He was started on empirica vancomycin and piperacillin/tazobactam and subsequently underwent CT-guided pigtail catheter insertion for drainage of the abscess. Microbiological examination of the drainage revealed polymicrobial pus including rare actinomyces. His blood cultures revealed actinomyces odontolyticus. He improved hemodynamically and repeat blood cultures were negative. He was discharged on IV Penicillin G and Metronidazole with duration dependent on resolution of abscess. Once infection is resolved, he will undergo colonoscopy and dental examination to identify possible source for infection. DISCUSSION: The incidence and morbidity of patients with PLA and diabetes has recently increased. Hyperglycemia can promote bacterial growth in tissues, and metabolic disorders impact the gastrointestinal tract. Diabetes can also promote infection through reduced immunity, neutrophil chemotaxis, mononuclear phagocyte activation, and opsonization. Actinomyces Odontolyticus is rare, especially in the absence of other pathology, and many conditions have been described as a possible initiating event including diverticulitis, appendicitis or peptic ulcer disease. A multi-team approach is always recommended when disseminated actinomycotic infection is observed.

Unilateral isolated hypoglossal nerve palsy: A rare complication of Diabetes Mellitus

We report a middle-aged male who presented with sudden onset slurring of speech with polyuria and polydipsia of three weeks duration. Evaluation suggested unilateral hypoglossal nerve palsy. The patient was detected to have uncontrolled hyperglycemia and exhaustive workup for possible alternative etiology including connective tissue disorders, retropharyngeal infection, hypothyroidism, thrombosis of median branches of vertebral artery, lacunar infarct over the hypoglossal nerve nucleus, multiple sclerosis, epilepsy, malignancy etc. was unrewarding. Unilateral isolated hypoglossal nerve palsy not only unmasked his diabetes, but also got corrected following glycemic control. The case report exemplifies a relatively infrequent clinical manifestation of diabetes, thereby reiterating that although unilateral isolated hypoglossal nerve palsy is rare, nevertheless warrants thorough evaluation before being labelled as “idiopathic” and diabetes remains one amongst various potentially reversible medical causes.

Recurrent diabetic muscle infarction, a rare complication of diabetes: a case report

Diabetic muscle infarction is a rare complication of diabetes mellitus that presents as a localized, exquisitely painful swelling and limited range of motion of the involved extremity. The onset is usually acute, persists for several weeks and resolves spontaneously over several weeks to months without the need for intervention. However, as diabetes mellitus is an immunocompromised state and any painful swelling in the limbs is often taken as infectious in aetiology, the patient is inadvertently investigated with invasive procedures and is started on unnecessary antibiotics, adding to the burden of management. Keeping in view the low threshold for starting antibiotics in painful limb swelling in diabetes mellitus in our setting, we hereby describe a case of recurrent painful diabetic muscle infarction, first involving the right upper and later the right lower limb, managed with physical rest and analgesics. This case emphasizes that the treating physician keep this rare complication of diabetes mellitus in consideration in the respective clinical scenario and adopt a less aggressive (a noninvasive method like ultrasound) rather than a more aggressive (an invasive method like muscle biopsy) approach in diagnosis and take a similar approach towards management.

Diabetic striatopathy—Does it exist in non-Asian subjects?

BackgroundDiabetic striatopathy (DS) is a rare complication of diabetes mellitus (DM). The syndrome appears in patients with uncontrolled DM and is characterized by abrupt onset of movement disorder, mainly hemichorea and accompanied by specific findings on brain imaging. It is believed that DS is unique to the Asian population and affects mainly elderly women with uncontrolled DM. MethodsIn order to define existence and characterization of DS in Western population, we reviewed the medical records of all patients admitted to the Chaim Sheba Medical Center between 2004 and 2014 and identified those with documented elevated HbA1c (>10%). The charts and imaging studies of those with elevated HbA1c and undiagnosed neurological symptoms were reviewed to diagnose DS. ResultsOut of 697 patients with HbA1c>10%, 328 patients had unknown neurological diagnosis. Among them, we identified 4 patients (3 women, mean age 73 and mean HbA1c of 14.8%) with hemichorea or choreoathetosis and brain imaging findings compatible with the diagnosis of DS. Only one out of the 4 patients was diagnosed during hospitalization with DS. All patients were treated with insulin with improvement of their symptoms during hospitalization. However, there was a recurrence in 2 of them and 1 died during the second episode. ConclusionDiabetic striatopathy exists but underdiagnosed in the Western population. It is important to increase the awareness for this clinical syndrome in order to treat those patients properly.

Recurrent myonecrosis involving adductor muscle group bilaterally: a rare complication of diabetes mellitus.

Diabetic myonecrosis is a rare and underdiagnosed complication of long-standing, uncontrolled diabetes. It usually occurs in patients with long-standing diabetes in the presence of microvascular complications. Thigh muscles are more commonly affected and the usual presentation is thigh swelling with or without pain, systemic features being rare. Magnetic resonance imaging is the gold standard for diagnosis. Most patients recover spontaneously with bed rest, adequate analgesia and good glycemic control. We present a case of recurrent myonecrosis of adductor muscles of the thigh in a patient with long standing type 2 diabetes mellitus who recovered with conservative management.

Diabetic muscle infarction with complications

Diabetic muscle infarction (DMI) is a rare complication of diabetes mellitus (DM) that is often misdiagnosed. We report a case of diabetic muscle infarction and discuss diagnostic testing and treatment modalities to avoid complications. Case Report: A 50-year-old male presented with spontaneous left thigh swelling for five days. He had several previous episodes in the contralateral side with recurrent admissions. His past medical history consisted of poorly controlled type 2 DM on insulin therapy, end stage renal diseases on hemodialysis and hypothyroidism. Physical examination revealed a tight, warm, erythematous and tender left thigh. Laboratory examination showed white blood cell count 1.23x10⁴/µL with neutrophilia; hemoglobin 10.7 g/L, hematocrit 32.3%, alkaline phosphatase 792 U/L, creatinine 5.94 mg/dL and glucose 455 mg/dL. Venous ultrasound of left lower extremity revealed deep vein thrombosis in the mid left femoral vein however, venogram was negative. Compartment syndrome was considered and fasciotomy with biopsy was performed. Subsequently the patient worsened which lead to multiple re-interventions. After reviewing medical records from both our hospital and from other facilities, a diagnosis of DMI was established. Muscle biopsy supported this, revealing active macrophage infiltration with areas of necrosis. Treatment is conservative with pain management, rest and proper glycemic control. Surgical intervention is not necessary as it increases morbidity. Conclusion: Although rare, DMI is a serious and potentially disabling complication of uncontrolled DM which continues to be under-diagnosed. Recognizing DMI more efficiently could prevent the patient from undergoing numerous, unnecessary diagnostic procedures, and medical or surgical interventions which in turn can result in more harm than good for the patient.