SUN-606 - When Infection Isn'T the Only Answer: A Case of Diabetic Myonecrosis

Introduction:

Diabetic myonecrosis (DMN) is a rare and under-recognized complication of poorly controlled diabetes mellitus (DM), that causes muscular ischemia and usually presents with acute pain and swelling. Its clinical presentation mimics conditions such as cellulitis or deep venous thrombosis (DVT), occasionally leading to a delayed diagnosis.

Case Report: A 51-year-old male with a history of poorly controlled type 2 DM, presented with progressive right medial thigh pain and difficulty ambulating for one week. He was noted to be febrile (103.1°F) and noted to have asymmetry with increased circumference of the right thigh compared to the left, with no changes noted on skin. The initial differential diagnosis included cellulitis and DVT. Ultrasound and duplex studies of the right lower extremity showed no evidence of abscess or thrombus. A CT scan revealed inflammatory changes suggestive of myositis, without a drainable collection, and incidentally identified multiple prostatic abscesses. Laboratory evaluation revealed leukocytosis (WBC 10.9 × 10³/µL; N=5.0–10.5), elevated C‑reactive protein (2.5 mg/dL; N=0–0.9), and markedly increased erythrocyte sedimentation rate (107 mm/hr; N=0–10), with a normal creatine kinase level (106 U/L; N=55–170). Both hemoglobin A1c (11.4%, N=0.0–6.0) and serum glucose (458 mg/dL, N=76–104) were elevated.
Broad-spectrum antibiotic therapy was initiated with cefepime and vancomycin.

MRI of the lower right extremity revealed multifocal muscle enhancement, edema, and perifascial fluid, features consistent with diabetic myonecrosis with superimposed infection. Blood cultures obtained on admission grew methicillin-sensitive Staphylococcus aureus (MSSA). Transthoracic echocardiogram was negative for endocarditis. Management of the prostatic abscesses was performed with transurethral resection of the prostate (TURP) with unroofing of the abscesses.

The patient reported a long-standing history of type 2 DM complicated by neuropathy and noted that financial constraints had limited his access to medical therapy. Management was conservative, focusing on analgesia with oxycodone, physical therapy, and rehabilitation. Strict glycemic control was achieved with an insulin regimen.

Discussion

The pathogenesis of DMN is not completely understood, but components of long-term, poorly controlled diabetes, such as atherosclerosis and microangiopathy, have been proposed. MRI and muscle biopsy are recommended for diagnosis; however, biopsy is mostly deferred due to its invasive nature. This case illustrates the diagnostic and therapeutic challenges of DMN, especially when complicated by underlying infection. The mainstay of diabetic myonecrosis management is supportive care with analgesia, physical rehabilitation, and optimization of glycemic control.

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