RARE CASE REPORT OF DIABETIC MYONECROSIS

1. A Rare complication of Diabetes
- Diabetic Myonecrosis
Dr .Kavinkumar.R
DNB Resident
Dept of Medicine
MMHRC

2. CASE
• 39/F
• c/o swelling and pain in the anterior
aspect of right thigh with difficulty in
walking for 1 week
• H/o burning micturition
• N0 h/o trauma
• No h/o fever

3. • Patient is a known case of Type II DM for 10
years for which she was on insulin H.Actrapid
35U-25U-0 and H.Mixtard 0-0-35U(injection
site – thigh)
• H/O Ischemic Heart Disease (POST PTCA
2009)
• A known case of Systemic Hypertension for 10
years, on regular medication

4. On Examination
General examination-normal
Systemic examination:
• CVS – S1 S2 heard, No murmurs
• RS –B/L Air Entry (+), No crepitations or
wheeze
• BP 140/90mm Hg
• PR 72/min

5. Local Examination
• Diffuse indurated swelling over
anterior aspect of Right thigh
• Redness and local rise in
temperature - Present
• Tenderness - Present

6. Investigations
• Poor glycemic control (HbA1C 14.5 ) and RBS
276 mg/dl)
• Total count- 10300,
• S.urea-14 mg/dl
• S.creatinine- 0.8 mg/dl

7. • Urine Routine
albumin – Trace
sugar – nil
pus cells 10-15
epithelial cells 1-2
• S.electrolytes (Na – 136 mEq/L , K – 4.7 mEq/L
, HCO3 – 20 mEq/L , Cl – 95 mEq/L)
• CPK- Total 113 U/L
• Plasma ketone - negative

8. Fundus examination- Non proliferative
diabetic retinopathy

9. Echo-S/P PTCA
Dilated LV
Global hypokinesia of LV
Severe LV dysfunction
EF-30%
Trivial MR &TR
No PHT/PE /clot

10. • Doppler Right Lower Limb
1)intramuscular edema over ant aspect of
thigh
2) no Deep Vein Thrombosis
• X-ray right thigh
soft tissue swelling
no bony abnormalities

11. • USG Right thigh
focal enlargement of rectus femoris muscle
with altered echo texture (?Myonecrosis)

12. • MRI suggested features of Muscle ischemia
with Myonecrosis.

14. TREATMENT
• Conservative management
• Intravenous antibiotics
• Hot water bag and icepack application
• MgSo4 dressing
• Cardiac supportives and antihypertensives.
• Insulin
• NSAIDs
• And other supportive measures

15. • Patient improved with treatment
• Pain subsided and swelling reduced in size
• Patient started walking and discharged

16. DISSCUSSION
DIABETIC MYONECROSIS
• Chronic complication of Diabetes
• Mean age of onset since diagnosis of DM -15
years
• Incidence – 116 total reported cases
2nd case in MMHRC in last 5 years
Mc in Type 1 DM> Type 2 DM
Mean age of presentation 37 (19-64)
Female : Male – 1.3 : 1
• Mc site – Thigh ( Quadriceps ) 81-87%

17. • Associated with Diabetic Retinopathy,
Nephropathy , Neuropathy , Hypertension
• Symptoms
1)Acute onset muscle pain
2)difficulty in walking
• Signs : Exquisite muscle tenderness and
swelling

18. PATHOPHYSIOLOGY
• Unclear mechanism
• Postulated causes -1)Arteriosclerosis obliterans
2)Clotting and fibrinolytic
pathway errors
3) hypoxia-reperfusion
injury

21. DIFFERENTIAL DIAGNOSIS
 Deep vein thrombosis
 Thrombophlebitis
 Cellulitis
 Abscess
 Myositis ossificans
 Tumors
1)Lipoma
2)Fibroma
3)Leiomyoma
4)Sarcoma

22. INVESTIGATIONS
• Elevated Blood Sugar
• Elevated Total CPK
• Elevated ESR
• X-RAY : Soft tissue swelling
• EMG: non specific focal changes

23. • MRI – Investigation of Choice
Increased signal on T2WI with
area of muscle edema
Arteriography – Large and
medium vessel areteriosclerosis

24. • Tissue Biopsy –1) Gold standard
2) rarely needed and is
recommended only if symptoms are not improving.
• Macroscopically – pale muscle tissue
• Microscopy – 1)infarcted patches of myocyte
2) swollen and eosinophilic myocytes
with lack of striations and nuclei
3)small vessel walls are thickened
and hyalinised with luminal narrowing or
complete occlusion

25. NORMAL MUSCLE

27. TREATMENT
• SUPPORTIVE CARE
1) Analgesics and NSAIDS
2)Glycemic control
3)Rest
• Self-limiting disease that resolves within weeks to
months
• 50% chance of relapse in either lower limb
• Long-term outlook is poor due to underlying
arteriopathy
• Increased death from a major vascular event within
5 years

28. ROLE OF SURGERY ??
• Surgical management should be avoided
Average recovery period
13 weeks – who underwent Surgery
5.5 weeks - who received
conservative treatment
• Other complications associated with surgical
intervention
Seroma
Hematoma
Delayed wound healing
Infection

29. CONCLUSION
• Diabetic muscle infarction is an
uncommon complication of DM that is
probably under diagnosed…
• Surgical intervention is avoided in most
of the cases…

30. ACKNOWLEDGEMENT
 DEPT OF RADIOLOGY
 DEPT OF DIABETOLOGY