Diabetic Myonecrosis: Uncommon Complications in Common Diseases

We report a case of sudden thigh pain from spontaneous quadriceps necrosis, also known as diabetic myonecrosis, in a 28-year-old patient with poorly controlled diabetes mellitus. Diabetic muscle infarction is a rare end-organ complication seen in patients with poor glycemic control and advanced chronic microvascular complications. Proposed mechanisms involve atherosclerotic microvascular occlusion, ischemia-reperfusion related injury, vasculitis with microthrombi formation, and an acquired antiphospholipid syndrome. Diabetic myonecrosis most commonly presents as sudden thigh pain with swelling and should be considered in any patient who has poorly controlled diabetes mellitus. 1. Background Diabetic myonecrosis is a rare complication associated with poorly controlled diabetes and advanced microvascular disease. Diabetic muscle infarction is usually unilateral and affects the lower limbs. The most commonly affected muscles are quadriceps, hip adductors, and hamstrings [1]. Bilateral involvement has been reported in 8.4% cases [2]. There has been one case reported of bilateral upper limb involvement [3]. It presents clinically as sudden pain and swelling of the involved muscle without previous trauma or fever. The pain is usually present at rest. Although diabetes may be a common disease, diabetic myonecrosis is a rare complication. We report the presentation of diabetic myositis in a 28-year-old male patient. 2. Case Report A 28-year-old African American male with uncontrolled type II diabetes mellitus arrived at the emergency department with sudden pain in the right lower extremity and difficulty bearing weight. The patient described the pain as aching, 10 out of 10 during maximal intensity with no relation to movement and no alleviating factors. He denied any preceding trauma or similar episodes in the past. On admission, he was afebrile with a pulse rate of 124 and blood pressure of 113/78. Examination of the left inner thigh revealed erythema, warmth, and a nonhealing, circumferential wound with no evidence of discharge or induration. The right lower extremity was unremarkable. Laboratory values revealed an elevated leukocyte count of 14.82？cells/mcl, with neutrophils of 84%. Random glucose was 660？mg/dL, K+ 3.7 mmol/liter, and Na+ 129 mmol/liter with an anion gap of 20. Other laboratory findings included a serum lactate level of 4.7 with creatine kinase levels of 176/U/L. Hemoglobin A1c was 16%. Antinuclear antibody (Ab), jo-1 Ab, scl-70？Ab, proteinase 3a-Ab, and myeloperoxidase Ab were negative. Serology was negative for HIV and hepatitis A, B, and