6852 A Delayed Diagnosis of Diabetic Myonecrosis: Case Report
Authors: Taleb M , Stephan J , Vo T , Estrada K 
Published: October 2024

Abstract
Disclosure: M. Taleb: None. J. Stephan: None. T. Vo: None. K. Estrada: None.
Background: Diabetic myonecrosis, also termed diabetic muscle infarction, is a rare microvascular complication of diabetes mellitus (DM). Although it can manifest in patients with all types of DM, it is more common in type 1 DM. It presents with pain and swelling localized in a muscle group and is associated with significant morbidity. The most commonly affected area is the anterior thigh, followed by the posterior thigh or calf. Clinical Case: A 34-year-old woman presented with two months of left thigh pain and swelling. She had a history of long-standing type 1 DM complicated by end-stage kidney disease for which she had been initiated on peritoneal dialysis (PD) six months prior to presentation. Her localized symptoms started after a fall and persisted since then. Our patient’s initial workup showed an elevated CPK level of 1340 IU/L (normal &lt;178 IU/L), and limb radiographs were negative for fracture or dislocation. Her symptoms were attributed to musculoskeletal pain. She subsequently presented to the emergency departments multiple times with the same symptoms. On one presentation, she was diagnosed with nontraumatic rhabdomyolysis in the setting of hematuria and persistent left thigh pain. On another presentation, CT of the left femur was done and showed skin thickening, subcutaneous fat stranding, and edema without osseous abnormalities; she was diagnosed with complex regional pain syndrome (CRPS) and discharged home on gabapentin, which did not improve her symptoms. Ultimately, she was admitted to the hospital with the inability to ambulate due to her persistent and severe symptoms. MRI of the left hip and femur showed signs of diffuse myositis and areas of myonecrosis consistent with diabetic myonecrosis. Prior to initiation of PD, our patient’s HbA1c had been well controlled at the target of &lt;7%. Due to the high dextrose content in dialysate, she had an increase in her HbA1c to 9.0% within a span of three months despite no changes in her medications or diet. Once the diagnosis was established, aspirin was initiated and insulin regimen was adjusted for tighter glucose control. Two weeks after treatment our patient had resolution of her symptoms. Conclusion: We highlight a case of diabetic myonecrosis, a complication of DM, that can be missed due to its rarity and nonspecific presentation. Index of suspicion should be high in patients with persistent unexplained musculoskeletal symptoms. Despite MRI being the diagnostic modality of choice, obtaining it was delayed due to multiple factors including initial radiologic findings negative for acute fractures and previous misdiagnosis of rhabdomyolysis and CRPS. Management of diabetic myonecrosis is centered around tight glycemic control. This highlights the importance of close monitoring of glycemic control when initiating a patient with diabetes mellitus on PD, given the constituents of the dialysate used, to prevent complications of diabetes.
Presentation: 6/1/2024