AACE Clinical Case Rep.

7 (2021) 383e384

Contents lists available at ScienceDirect

AACE Clinical Case Reports

journal homepage: www.aaceclinicalcasereports.com

Visual Vignette

A Case of Diabetic Myonecrosis

Kyrstin L. Lane, MD 1, *, Ari Weinreb, MD 2, Kira Chow, MD 3, Jane Weinreb, MD 1, 4
1
Division of Endocrinology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California
2
Division of Rheumatology, VA Greater Los Angeles Healthcare System, Los Angeles, California
3
Department of Radiology, VA Greater Los Angeles Healthcare System, Los Angeles, California
4
Division of Endocrinology, VA Greater Los Angeles Healthcare System, Los Angeles, California

a r t i c l e i n f o rate 46 mm/hour (normal 0-15). Initial noncontrast left femur

magnetic resonance imaging (MRI) (Fig. 1) demonstrated marked
Article history: signal increase (asterisks) within the gluteus maximus and
Received 4 February 2021 vastus lateralis, as well as the adductor magnus (not shown)
Received in revised form
with extensive subcutaneous edema (arrow). Subsequent fever
10 March 2021
Accepted 11 March 2021 and rising creatine phosphokinase (CPK) (458 U/L) prompted
Available online 26 March 2021 repeat MRI (hospital day 3; Fig. 2), which revealed multiple large
gluteus maximus (arrows), gluteus minimus, and vastus lateralis
abscesses.

Case Presentation What is the diagnosis?

A 35-year-old Caucasian man presented for 1 month of acute Answer

onset atraumatic left lateral thigh pain, swelling, and warmth. Diabetic myonecrosis. This is a rare diabetes complication
An outside physician gave a left trochanteric bursal steroid in- attributed to uncontrolled (mean A1C 9.3%, 79 mmol/mol)
jection approximately 2 weeks before admission, without diabetes with resultant diabetes complications, including
symptom relief. He presented to our hospital for persistent vascular disease.1,2 Diagnosis is based on clinical presentation,
symptoms. Medical history included 11 years of type 2 diabetes
(hemoglobin A1C 14.6%, 136 mmol/mol) complicated by non-
proliferative retinopathy and nephropathy (estimated glomer-
ular filtration rate 58; microalbuminuria). Medications included
glargine 25 units/day, prandial lispro 15 units, and metformin
with inconsistent medication adherence. Examination revealed
temperature 98.8
F, pulse 96/minute, respirations 15 breaths/
minute, blood pressure 94/49 mm Hg, oxygen saturation 100%,
body mass index 23.65 kg/m2, with left lateral thigh tenderness,
induration, edema, and increased warmth without erythema.
Left hip flexor, knee flexor, and knee extensor strength were
reduced due to pain; dorsalis pedis pulses 2þ. Laboratories
demonstrated white blood cell count 28 k/mL (normal 4.5-11),
creatinine kinase 295 U/L (normal 40-280), and sedimentation

Abbreviations: CPK, creatine phosphokinase; MRI, magnetic resonance imaging.

Editor’s Note: Submissions to “Visual Vignettes” are welcomed. Please submit
online via the Journal’s Editorial Manager site.
* Address correspondence and reprint requests to Dr Kyrstin L. Lane, Division of
Endocrinology, David Geffen School of Medicine, University of California Los
Angeles, Los Angeles, California
E-mail address: klane@mednet.ucla.edu (K.L. Lane). Fig. 1.

https://doi.org/10.1016/j.aace.2021.03.007
2376-0605/Published by Elsevier Inc. on behalf of the AACE. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/
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K.L. Lane, A. Weinreb, K. Chow et al. AACE Clinical Case Rep. 7 (2021) 383e384

including sudden onset atraumatic pain and swelling (typically

involving the thigh) and MRI demonstrating hyperintense
signal from involved muscles in the absence of other etiol-
ogies.1,2 Biopsy is reserved for atypical, worsening, or unclear
cases.1 Our patient’s initial presentation was consistent with
diabetic myonecrosis; treatment included analgesics, aspirin,
bed rest, and glycemic control.1,2 Subsequent fever, an un-
common feature of diabetic myonecrosis,1 and increasing CPK
prompted repeat left thigh MRI (Fig. 2) that demonstrated
superinfected diabetic myonecrosis with intramuscular
abscesses. In the setting of uncontrolled diabetes, the 1 to 3
week window for pyomyositis abscess formation3
suggested the trochanteric injection 19 days prior as the
infection source. He required abscess drainage and antibiotics,
resulting in clinical improvement. Abscess cultures were ster-
ile, potentially impacted by antibiotics. Our case is unique as
there was pyomyositis superimposed upon diabetic
myonecrosis, highlighting that these are not mutually exclu-
sive diagnoses and that new fever and/or increasing CPK
should prompt consideration of pyomyositis in a patient with
diabetes.

Disclosure

The authors have no multiplicity of interest to disclose.

References

1. Trujillo-Santos AJ. Diabetic muscle infarction: an underdiagnosed complication

of long-standing diabetes. Diabetes Care. 2003;26(1):211e215.
2. Horton WB, Taylor JS, Ragland TJ, Subauste AR. Diabetic muscle infarction: a
systematic review. BMJ Open Diabetes Res Care. 2015;3(1), e000082.
3. Chiedozi LC. Pyomyositis. Review of 205 cases in 112 patients. Am J Surg.
1979;137(2):255e259.

Fig. 2.

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