Recurrent diabetic myonecrosis -an under-diagnosed cause of acute painful swollen limb in long standing diabetics

Diabetic myonecrosis (DMN) is an under-diagnosed complication of long-standing poorly controlled diabetes mellitus. It presents as abrupt pain and swelling of the extremity, mostly lower limbs. Diagnosis is often delayed as it mimics a number of clinical entities such as deep vein thrombosis (DVT), cellulitis, necrotizing fasciitis and malignancy. Failure to properly identify this condition can result in increased morbidity through exposure to unnecessary tests and biopsy. A 56-year-old male with a history of complicated type 2 diabetes mellitus, hypertension presented to emergency with gradually worsening left calf pain for last 2 weeks. A lower-extremity venous Doppler was negative for DVT. Magnetic resonance imaging (MRI) was suggestive of muscle edema likely of inflammatory etiology. Muscle biopsy revealed myonecrosis with ischemic myopathy and was negative for vasculitis or inflammatory myopathy. He was managed conservatively and his symptoms resolved in 4 weeks. After 6 months he had recurrence in right thigh which was managed conservatively too. Given these findings, a diagnosis of recurrent diabetic myonecrosis was made. Myonecrosis is a less known microvascular complications of diabetes and should always be keep in mind when evaluating a diabetic patient with muscle pain. Diagnosis can be made on MRI in appropriate clinical settings. The clinical course is usually self-limiting and patients respond well to supportive medical therapy that involves bed rest, strict glycemic control along with analgesic.