Clinical Case Discussion

[ismailalamin]

A 42-year-old male immigrant from South America with poorly controlled DM type 2 (HbA1c 13%) and hypertension presented with a one-month history of progressively worsening pain in his left thigh and calf associated with secondary inability to walk. There was no history of trauma or intramuscular injections.

Medications

Insulin 70/30 bid, lisinopril 20 mg daily, ASA 81 mg daily and simvastatin 40 mg daily.

Physical examination


Afebrile, and there was no evidence of arthritis or effusion. There was swelling and tenderness in the left distal quadriceps area and calf with limited range of motion of the knee. Peripheral pulses and sensation were normal.

What is the most likely diagnosis?
What tests would you order?
What treatment would you start for this patient?

[Noor Ebrahim]

Alslam 3lykm
It is difficult to me to some extent but I will try to discuss it,, important information of this condition , 42 yrs old male ,from south Africa , poorly controlled diabetes and hypertension, chronic and progressive painful unilateral leg swelling.O/E afebrile ,tenderness,limitation of movement=inflammation.intact peripheral pulses.
first starting with the common causes :
DVT: but i think it is unlikely due to its long duration and no history of immobilization for long time .
Cellulitis or osteomylitis : no trauma or other risk factors.
his medications:simvastatin rarely can cause rhabdomyolysis,..
with his poorly controlled diabetes although it's rare diabetic myopathy should be put on mind.
investigation.
CBC, RFT for infection and general condition of the pt.
doppler U/S for DVT
CK for suspicion of rhabdomyolysis
then if we didn't reach the dignosis we can proceed for MRI for diabetic myopathy
Tretment according to the diagnosis and mean while conservative management ,like leg elevation and analgesia.

[hussam abdalgany]

I agree with Dr.Noor

We also need to exclude necrotizing fasciitis, infections like myositis and tick or insects bites (South American) -

we may also go far to add the rare DM complication: diabetes myonecrosis considering his poorly controlled sugar and the inability to walk without obvious joint problem (that points to a muscular issue)

Thanks Dr.Nawrany for the nice case .. waiting for the answer or more hints

[mohamed kambal]

Dear doctors : Alslam 3lykm
1\ most likely diagnosis: DM Amyotrophy... Although rare but in this case with a male having uncontrolled DM and asymmetrical pain and weakness of the lower limbs i find it more reasonable. o allah a3lm..
2\ investigations: NCS and EMG
3\RX: bed rest and physiotherapy and control of dm..with pain killer for the pain.

with my best rgards

[Hani]

Dear Dr.Kambal,

DM Amyotrophy is a neuropathy, we usually see muscular atrophy we depressed or absent reflexes of knee and ankle. in this case there is swelling of muscles and nothing was mentioned about neuro signs

[einas]

another DD is diabetic myonecrosis which is affect the long standing diabetics the most common site is the lower limbs and esp the quadriceps causing the tenderness swelling and restriction of joint movement as in this case with the knee joint .

thank u for the interesting case

[hussam abdalgany]

Alsalam alikom ,, thanx doctor alnawrany for the nice case ,, there is alot of logic DD mentioned by the nice doctors above and I agree with them waiting for your final judjment .