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Diabetic myonecrosis: likely an underrecognized entity.
[pyomyositis]
Diabetic
myonecrosis
is
a
rare
complication
of
long
-standing
diabetes
mellitus
that
presents
as
acute
onset
of
swelling
and
pain
of
the
affected
muscles
.
The
differential
diagnosis
includes
cellulitis
/
pyomyositis
,
necrotizing
fasciitis
,
neoplasm
,
and
deep
venous
thrombosis
(
DVT
)
.
Missed
diagnoses
can
lead
to
unnecessary
invasive
diagnostic
procedures
and
inappropriate
treatment
.
The
diagnosis
is
established
by
the
clinical
presentation
and
findings
on
magnetic
resonance
imaging
(
MRI
)
scan
.
A
30
-
year
-old
African-
American
man
presented
with
a
painful
mass
affecting
the
medial
aspect
of
the
right
thigh
for
several
months
.
Initial
laboratory
studies
showed
white
blood
cell
count
of
8800
cells
/
mm
(
3
)
,
D-
dimer
value
of
0
.
55
µg
/
mL
,
HgBA
1
c
level
of
15
.
1
%
,
glucose
level
of
352
mg
/
dL
,
erythrocyte
sedimentation
rate
of
22
mm
/
h
,
and
C-
reactive
protein
level
of
222
mg
/
L
.
An
MRI
scan
was
obtained
,
and
diabetic
myonecrosis
was
diagnosed
and
treated
.
One
year
later
,
the
patient
had
similar
symptoms
of
pain
in
the
contralateral
thigh
.
Repeat
workup
and
MRI
scan
were
obtained
.
The
MRI
abnormalities
originally
seen
in
the
right
thigh
1
year
earlier
were
present
in
the
left
thigh
,
with
complete
resolution
of
the
abnormalities
seen
in
the
right
thigh
.
Treatment
with
bed
rest
and
analgesics
resulted
in
symptom
resolution
.
Patients
with
diabetic
myonecrosis
typically
have
no
fever
,
normal
white
blood
cell
count
,
mildly
increased
erythrocyte
sedimentation
rate
,
and
elevated
C-
reactive
protein
level
in
50
%
of
cases
.
They
lack
the
radiologic
signs
of
fascial
enhancement
or
well-defined
,
rim-enhancing
collections
that
are
seen
in
necrotizing
fasciitis
and
pyomyositis
/
abscess
.
The
onset
of
severe
pain
and
the
lack
of
mass
effect
on
imaging
differentiate
diabetic
myonecrosis
from
tumor
-like
conditions
such
as
vascular
malformations
or
soft
tissue
tumors
.
Normal
D-
dimer
levels
and
ultrasound
Doppler
examination
of
the
extremity
help
to
rule
out
DVT
.
The
typical
MRI
scan
findings
and
clinical
presentation
can
lead
to
the
diagnosis
of
diabetic
myonecrosis
,
allowing
the
physician
to
avoid
invasive
tests
,
such
as
muscle
biopsy
,
and
to
reassure
patients
that
this
condition
is
self-limiting
with
appropriate
treatment
.
Diseases
Validation
Diseases presenting
"neoplasm"
symptom
adrenal incidentaloma
alexander disease
aromatase deficiency
carcinoma of the gallbladder
cholangiocarcinoma
cowden syndrome
cushing syndrome
cutaneous mastocytosis
dedifferentiated liposarcoma
dentin dysplasia
erdheim-chester disease
esophageal adenocarcinoma
esophageal carcinoma
familial hypocalciuric hypercalcemia
focal myositis
hodgkin lymphoma, classical
hydrocephalus with stenosis of the aqueduct of sylvius
junctional epidermolysis bullosa
kabuki syndrome
liposarcoma
lymphangioleiomyomatosis
pleomorphic liposarcoma
primary effusion lymphoma
proteus syndrome
pyomyositis
von hippel-lindau disease
waldenström macroglobulinemia
well-differentiated liposarcoma
werner syndrome
wolf-hirschhorn syndrome
This symptom has already been validated