Diabetic myonecrosis: challenges in diagnosis and management

Case presentation A 29-year-old female presented with acute onset right thigh pain and swelling 24 hours after peritoneal dialysis catheter insertion. She had a background of type 1 diabetes mellitus diagnosed over 20 years prior to presentation. Her glycaemic control had been suboptimal, with multiple episodes of diabetic ketoacidosis and complications including diabetic retinopathy, gastroparesis, autonomic neuropathy and end stage renal disease secondary to diabetic nephropathy, requiring peritoneal dialysis. She was discharged after completing a course of intravenous antibiotics for presumed infection but re-presented one week later to her renal team with worsening right thigh pain and swelling. There was no history of trauma or symptoms to suggest an infective aetiology. On examination she was in severe pain. She was tachycardic with a pulse rate of 110 bpm, blood pressure was elevated at 158/90 mmHg, she was afebrile and had normal oxygen saturation levels. The peritoneal catheter site appeared clean and her abdomen was soft with no ascites. The right thigh was markedly enlarged, circumference 45 cm compared with 25 cm on the left (Figure 1), very tender and warm to touch and movement limited due to pain. There was no erythema or inguinal lymphadenopathy and peripheral pulses were easily palpable.