Proximal upper and lower extremities severe pain, muscle weakness in a young diabetic male with multiple chronic complications. A rare and unusual clinical presentation
O. Torres, C. Palermo, M. Padilla, J. Martinez, K. Davila, M. Miranda, E. Gonzalez, M. Mangual, I. Laboy, R. Tirado, I. Chinea & M. Miranda
A 49 years old male patient with 12 years history of poorly controlled type 2 diabetes mellitus on insulin therapy, complicated with neuropathy, nephropathy, retinopathy, peripheral arterial disease (right toe amputation), hypertension and dyslipidemia. He presented with upper extremities proximal muscle and upper back moderate pain that progressed to excruciating pain with restriction of motion, weakness, and stiffness of 3 days of evolution. He denied trauma, abnormal exercise, arthralgia, fever, nausea or vomiting. Physical examination was remarkable for bilateral upper extremities edema, local tenderness and indurations without palpable crepitus. Laboratory results showed normocytic normochromic anemia, hyperkalemia, creatinine of 1.9 mg/dl, high anion gap metabolic acidosis, erythrocyte sedimentation rate of 76 mm/hr and increased creatine kinase of 225 U/L. Electrocardiogram demonstrated a sinus tachycardia and peaked T waves. Blood cultures were negative. Upper extremities Venous Doppler was negative for DVT. Echocardiogram revealed moderate LVH, non thrombus or vegetation. MRI of the left arm showed diffused soft tissue swelling and T2 hyper intensity of the deep biceps, brachialis, and brachioradialis muscles in the anterior muscle compartment with heterogeneous patchy contrast enhancement consistent with diabetic myonecrosis. Similar findings noted in latissimus dorsi muscle. After two week he started with the same symptomatology in both thighs, with gradual relief of upper extremities affection, but with residual muscle wasting. A muscle biopsy with electronic microscopy allowed us to rule out other conditions. Currently he has symptomatic improvement.
Diabetic muscle infarction is a rare complication of longstanding diabetes referring to spontaneous ischemic necrosis of skeletal muscle, unrelated to atheroembolism or occlusion of major arteries. This condition cause acute or subacute pain, swelling and tenderness, typically in the thigh or calf. Rarely, the upper limb may be involved and only one case has been reported. Diabetic myonecrosis is an indicator of poor prognosis, tends to resolve spontaneously but with frequent relapses. A review of the literature, identified at total of 116 patients.
Declaration of interest: The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project.
Funding: This research did not receive any specific grant from any funding agency in the public, commercial or not-for-profit sector.