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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
"and to reassure patients that this condition is self-limiting with appropriate treatment"
symptom
pyomyositis
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