Endocrine Abstracts

Introduction: Diabetes can involve the musculoskeletal system causing frozen shoulder, Dupuytren’s contracture, diabetic sclerodactyly, trigger finger, muscle infarction, diabetic amyotrophy, idiopathic lumbosacral radiculoplexus neuropathy, necrotizing fasciitis and many other complications. A case is described, who despite having multiple acute and chronic sequelae of diabetes, was successfully managed and discharged.

Case Presentation: 54yrs old obese, Saudi gentleman with multiple co-morbids(Type 2 DM ≥10yrs, Hypertension, Chronic kidney disease(3B,A3), Proliferative DM retinopathy(awaiting intra-vitreal injections) & Grade I diastolic dysfunction), Chronic normochromic normocytic anemia(GI endoscopy-upper)-chronic inactive gastritis,(lower)-single rectal polyp(tubular adenoma on histopathology), was re-admitted under Medicine department on 15.01.2023 with left hip pain, radiating to the thigh, with restricted activity for 2 weeks prior to the presentation. Rest of the workup-normal. Past history of proximal lower-limb weakness, double incontinence(2yrs) & cataract surgery. No allergies or addictions. Unremarkable family history He was on regular ACE-inhibitor, Calcium channel blocker, thiazide, loop diuretic, Linagliptin, statin, iron, Metformin and Glargine-100. Systemic review-unremarkable. BP 185/85mmHg, Pulse 74/m, regular, T-36.8 C, RR 19/m, O<info>2</info>sat 94%(on 6ltrsO<info>2</info>). Weight 104 kgs. Pallor+ Bilateral pitting pedal edema++, JVP raised. M. skeletal (Left hip) Upper medial thigh tender, but without warmth or erythema. Reduced passive and active movements of hip. Other joints unremarkable. CVS-S1, S2 audible+ ejection systolic murmur + Neurology-symmetrical wasting of hands & quadriceps+ absent deep tendon reflexes in lower limbs, along with bilaterally reduced vibration & pin-prick sensations. Rest-normal. The patient was diagnosed to have MRI proven extensive myositis of left pelvis & proximal thigh with focal myonecrosis and infective iliopsoas bursitis. Besides there was suspicion of early osteomyelitis of left ischio-pubic ramus & milder right sided myositis(CRP413.9 mg/l. He also developed acute on chronic kidney injury [S.Creatinine 307umol/l(59-104), and acute myocardial demand ischemia(serial ECGs-mild ST-T changes, TroponinT1040 ng/l(≥100 clinically significant), CPK438u/l(39-308), Echo[new RWMA(inferior wall) +mild LV systolic dysfunction(EF45%)], Myocardial perfusion scan-myocardial infarction of distal inferior wall. Other significant labs. Hb% 6.9g/dl, MCV89.8fl, TLC 17.8 x10⁹/l,88% PMNs, HbA1c7.7%, S.albumin24.3g/l. CT chest-bilateral lower lobe opacities+ mild pleural effusion. No pulmonary embolism. NCV/EMG-sensorimotor axonal polyneuropathy. The patient was treated with Frusemide, packed RBCs, Albumin, Insulin, Oxygen & broad spectrum antibiotics. An US guided aspiration & C/S from left iliopsoas bursa revealed MRSA organism and was treated for both bursitis & Osteomyelitis. He improved with the given treatment and was discharged home on 09.02.23\.

Conclusion: Our patient exemplifies the presence of four co-existing musculoskeletal problems in close neighbourhood i.e. myonecrosis, myositis, infected ilopsoas bursitis and osteomyelitis. Diabetes was the common denominator amongst them.