Introduction

Diabetic myonecrosis, also known as diabetic muscle infarction, is a rare complication of poorly controlled diabetes mellitus (DM). It is a severe complication of long-standing, poorly controlled diabetes characterized by acute, painful ischemic necrosis of skeletal muscle, usually in the thigh or calf.

Case description 

We present the case of a 24-year-old woman with a history of poorly controlled type 2 DM who presented with an acute onset of right hip pain rated 10/10 that had persisted for five days. She was found to be in DKA and was admitted to the intensive care unit for insulin infusion therapy. Initial MRI of the hip showed diffuse subcutaneous edema suspicious for cellulitis, edema, and mild enhancement of the musculature around the right hip, suspicious for myositis, infectious or inflammatory process, and greater trochanteric bursitis. Broad-spectrum antibiotic therapy was continued, and the patient continued to experience severe thigh pain and persistent leukocytosis. Repeat MRI of the right hip after 10 days demonstrated diffuse subcutaneous edema and abnormal T2 signal throughout the proximal thigh musculature, more pronounced on the right, consistent with muscle infarction vs myositis. Given the patient’s severe localized pain, markedly uncontrolled diabetes (HbA1c 14.8%), and characteristic MRI findings, the diagnosis was most consistent with diabetic myonecrosis. Antibiotics were discontinued, and management focused on bed rest, pain control, aspirin, and optimized glycemic control.

Discussion

This case highlights the importance of considering diabetic myonecrosis in patients with poorly controlled diabetes presenting with acute, severe limb pain. Diagnosis is a diagnosis of exclusion and is mainly based on clinical presentation with severe pain in the setting of poorly controlled diabetes and characteristic MRI findings. Early recognition is important to prevent unnecessary invasive testing and prolonged antibiotic exposure.