Endocrine Abstracts

Background: Diabetic myonecrosis is a rare complication associated particularly with prolonged dysregulation of blood glucose in diabetes. While the exact pathophysiology remains not fully understood, it is suggested that atherosclerosis, diabetic microangiopathy, vasculitis, ischemia-reperfusion injury and hypercoagulability might contribute to this condition. Diabetic nephropathy is the most blamed risk factor. Here, we present a case of diabetic myonecrosis followed up after renal transplantation due to diabetic nephropathy.

Case Presentation: A 40-year-old female patient with known type 1 diabetes, situs inversus and hypertension, who had a kidney transplant from a living donor due to diabetic nephropathy, was admitted to the internal medicine clinic due to progressive decrease in glomerular filtration rate (9 ml/dk). She had uncontrolled type 1 diabetes for 30 years with retinopathy, neuropathy, hypertension and nephropathy leading to ESRD. She had a diabetic foot arthroplasty in her history. HbA1c value was 11.7%. One week before the patient’s admission, she developed swelling, pain, and restricted mobility in the upper left thigh. The findings were significant in terms of infectious-inflammatory processes. WBC was 14.54×10³/μL (4.49-12.68×10³), sedimentation rate was 15 mm/hour (0-25), CRP was 17.9 mg/l (<0.5) creatine kinase total was 58 U/l (<145) in laboratory examination. A lower extremity Doppler ultrasound was performed and didn’t reveal any evidence of deep vein thrombosis (DVT). The skin ultrasound result showed edematous changes and thickening in the subcutaneous tissue of the symptomatic area with no significant drainable abscess or collection detected. In a contrast-free MRI imaging performed for differential diagnosis, myositis and fascial edema were observed in the vastus medialis and intermedius muscles on the left, along with a focal area suggesting necrosis within the vastus medialis. MRI findings indicated diabetic myonecrosis. During this period, blood glucose control was achieved with insulin glargine and insulin aspart. In the treatment of diabetic myonecrosis, bed rest and elevation of the extremity were applied. NSAIDs could not be given because her kidney functions were impaired. Oxycodone 10 mg/day was given for pain palliation. The patient’s complaints and symptoms regressed in 15 days.

Conclusions: Despite diabetes being a common disease, diabetic myonecrosis is an uncommon and challenging complication to diagnose. In the diabetic patients especially who have diabetic nephropathy, in situations of sudden onset pain and swelling in the lower extremities, diabetic myonecrosis, should be considered in the differential diagnosis and MRI should be performed.