"Severe lower extremity pain in a patient with diabetes"

Diabetes mellitus (DM) is one of the most prominent comorbidities in the United States and other developed nations, affecting approximately 21 million Americans (Selvin et al., 2014 [1]). A significant portion of diabetic individuals struggle with glycemic control, leading to numerous associated medical complications. Emergency physicians (EPs) are well acquainted with many, but not all, of the acute and chronic complications of uncontrolled diabetes. Diabetic myonecrosis is a rare and likely underdiagnosed complication of uncontrolled diabetes that has been underreported in the emergency medicine (EM) literature.

A 41-year-old insulin-dependent diabetic male presented to the emergency department with a month of worsening left lower extremity pain, swelling and paresthesia's. He had undergone a negative workup for a deep vein thrombosis at an outside hospital and did not report any preceding trauma. He denied any systemic infectious symptoms and had stable vital signs. His exam was notable for isolated swelling of his left posterior leg without erythema or fluctuance. His laboratory analysis was notable for elevated inflammatory markers and glucose. A contrasted CT study was performed which was suggestive of diabetic myonecrosis, later confirmed by MRI. The pt. was admitted for glucose and pain control and discharged home four days later.

Diabetic myonecrosis is a rare and likely underdiagnosed complication of uncontrolled diabetes that has been underreported in the emergency medicine (EM) literature. Emergency physicians will be better able to recognize and correctly diagnose diabetic myonecrosis by having a higher index of suspicion for it and being more familiar with its typical presentation.