Diabetic Myonecrosis: An Atypical Presentation

Diabetic myonecrosis is a frequently unrecognized complication of longstanding and poorly controlled diabetes mellitus. The clinical presentation is swelling, pain, and tenderness of the involved muscle, most commonly the thigh muscles. Management consists of conservative measures including analgesia and rest. Short-term prognosis is good, but long-term prognosis is poor with most patients dying within 5 years. Failure to properly identify this condition will expose the patient to aggressive measures that could result in increased morbidity. To our knowledge this is the first case reported in which there was involvement of multiple muscle groups including upper and lower limbs. 1. Introduction Diabetic muscle infarction (DMI), also named diabetic myonecrosis, is a rare and commonly underdiagnosed complication of longstanding diabetes mellitus. It refers to spontaneous ischemic necrosis of skeletal muscles not related to atheroembolism or occlusion of major arteries and is one of many micro- and macrovascular complications of diabetes. The usual presentation is sudden onset of pain at the involved muscles associated with swelling and tenderness [1]. The thigh muscles (usually the vastus group) are most commonly affected, but calf muscles might be involved as well. One case of upper limb involvement is also reported. Bilateral involvement has been described in 8.4% of cases [2]. We report a case of diabetic myonecrosis involving bilateral upper extremities that progressed to involve the lower extremities. 2. Case Report This is a case of a 49-year-old male patient, with 12 years history of poorly controlled diabetes mellitus type 2, on insulin therapy. Diabetic neuropathy, nephropathy, previous right toe amputation due to peripheral arterial disease, hypertension, and dyslipidemia were clinically evident. He arrived to our urgency room with the chief complaint of bilateral proximal upper extremities and upper back pain, weakness and stiffness of three days of evolution. Pain was initially of moderate intensity and during the course of one week became excruciating in nature associated with shoulder movement restriction and swelling. Patient was known to be a noncompliant type 2 diabetic on insulin therapy with no history of direct or indirect trauma, abnormal exercise, arthralgia, fever, nausea, vomiting, or skin breakdown, denied injecting insulin in his thighs or arms, use of tobacco or illicit drugs, but admitted a history of excessive alcohol consumption for a period of 2 years. Currently he is unemployed due to diabetes mellitus complications but was