37YEAR OLD FEBRILE MAN WITH SEVERE PAIN IN RIGHT THIGH WITH H/O DIABETES

A 37 years Old male who studied upto intermediate and auto driver by occupation came with Complaints of 

Pain in Right Thigh Since 3 Months

Swelling of Right Thigh Since 3 Months

Daily routine : 

Patient was absolutely alright 15 years back, his routine lifestyle used to be waking up at 6 am later he cleans his vehicle and freshen up and will start duty around 8 am. After one hour he usually have his breakfast outside which consists of idly, vada, dosa, poori etc and later he will start again taking rides and will have lunch outside only which consists of Rice curries ,sambar and curd. And he will continue his duty till 8pm and comes to home. Sometimes due to peer pressure he used to consume alcohol of around 90ml and will come home which he eventually stopped later on. And sometimes he may have dinner or not which consists od chapathi/rice with curries. 

Family history: 

He is son of father and mother who works as daily wage labourers and he had an elder sister and younger sister. Of significant medical family history his younger sister found to be having gestational diabetes mellitus in 2015 at age of 26 years later which she was kept on insulin for her diabetes. 

Family tree: 

HOPI:

In 2008, patient got married and around 2010 his first daughter was born FTNVD .  At the Age of 27 years Patient c/o fever associated Weight Loss( approximately around 10-15 kgs in 1-2 years For which he went to Hospital then his GRBS Was found to be above 500 & Treated with INSULIN and IV fluids & Discharge with in 3 hours INSULIN MIXTARD 18U In the Morning & 15U in the Night & Noticed to Have Hypoglycemic Episodes & Decreased the Dose to 10U in the Morning & 8U in the Same Month and consulted regularly to doctor So Then he Was started on Tab GLIMI M2 po/BD later shifter to METFORMIN 1000mg+GLIMEPIRIDE 2mg in the Morning & METFORMIN 500mg+GLIMEPIRIDE 1mg in the Night for 2 years & Later Used Other Tablets ( Rs - 40/10tabs ) for 1 Year & Later He Developed Fever & Noticed to have severe burning type of pain in left ankle which he relaises after coming home from work such severe that someone has to massage his leg to go to sleep and his rbs was found to be around 200-250 So again Shifted to INSULIN MIXTARD 10U Morning - 10U Night & used Checked his Glucose Levels for better control. He was on regular follow up and used to check his GRBS once/twice in a month. 

In Oct 2022 While Shifting a Rice Bag a Stone Fell on his Left Foot for which he went to RMP & Took Some Medication and went to work in wet paddy field with his wound soaked it in But it did not Heal Completely & Within 15days He Developed Swelling of Left LL Upto Knee for which he went to Some Private Hospital in Miryalguda where He Underwent Fasciotomy But Within 5-6 days after Surgery Swelling Increased & He was Informed as wound was not healing and Creatinine & Sugars Were Increasing in trend & Informed to go to Higher Centre & They Went to Another Hospital Where He Was Put on Foleys in v/o Abdominal Discomfort(? Urinary retention) & Immediately 2 times urobag was emptied. And another addressing issue before surgery only his Hb was found to be around 7.2 and serum albumin was 4.0 and urea 28 and serum creatinine is 1.1 mg/dl.

Due to Affordability issues he came to Our Hospital ( Stayed For 1 week ) - Regular Dressing & PRBC Transfusion was done & was on Followup every 2 days for 1 Week.

But His left LL Swelling was Increasing Gradually So he was referred to Plastic Surgery in our Hospital & Was Planned for Surgery But Couldn't Be Done due to High BP recordings & Was Planned for Surgery Later But Patient Denied & Went on LAMA. Then He Went to Some Local Hospitals & Gradually Healed.

One fine day he suddenly developed pain in the right thigh 3 months back which is aggrevated on walking and noticed suddenly when he woke up from bed. 

And it makes him stop for a while and then resume his walk.

He then had a burn injury to his left lower limb 2 months ago and eschar was formed later 

2 days back again due to fever Of high grade they came to hospital for admission. 

PAST HISTORY:- 

He is having H/o ?Type 2 diabetes since 10 years and is on MIXTARD now and htn since 2 months and Nicardia 20mg BD and Telmisartan 40mg OD. 

No H/o CAD,epilepsy,TB, Asthma, CVA. 

PERSONAL HISTORY:-

Patient is moderately built and moderately nourished.

APPETITE:- normal

SLEEP:- disturbed due to leg pain

BOWEL AND BLADDER:- regular

ADDICTIONS :- 16 yr of alcohol history started 3 years before marriage consuming around >90 ml occasionally. 

No h/o smoking

He has a wife and 2 daughter and a son. 

GENERAL PHYSICAL EXAMINATION

Patient is concious coherent and cooperative, well oriented to time place and person.

Pallor  +

Icterus -

Cyanosis -

Clubbing -

Lymphadepathy -

Edema +

Vitals 

Bp -140/100

RR - 24

HR - 96

SPO2- 100 on 2lt O2 

GRBS- 262 on on 19/4/23 around 6:45 pm

Temp- 99.7 F

SYSTEMIC EXAMINATION:-

CVS :- S1 and S2 are heard and no murmurs heard 

RS :- BAE+, NVBS  and inspiration right basal fine crepitations are noted. 

PER ABDOMEN :- soft and non tender 

CNS:- HMF Intact

          Cranial nerves are intact

         Tone:-            Right                                                                  Left 

                              UL            LL                                                       UL           LL 

                           Normal     couldn't be elicited due to pain             normal   normal

                       

         Power:-                 Right                                                                        Left            

                                UL             LL                                                                UL             LL 

                                4/5          unable to examine due to pain                       4/5             4/5

                      

       Reflexes:- 

Biceps:-          right - 2+                   left - 2+

Triceps:-        right- 2+                     left- 2+

Supinator:-   right- 2+                       left- 2+

Knee:-           right - not examined   left - 1+

Ankle:-         right - not examined     left - 1+

Plantar:-      right - mute                  left-  mute 

LOCAL EXAMINATION:-

On inspection , local raise of temperature and tenderness of right thigh at distal inferior region  is present . pain aggravating on flexing of right knee is more when compared with flexion at hip region. Pain is excruciating and unable to move his right lower limb. Edema of right lower limb is more compared to left lower limb. Unable to bear the weight on knee joint while trying to walk and to stand. He is complaining of severe claudication pain where he has to rest and later he is able to walk since 4 days. 

PALPATION: Localised tenderness of right thigh more in lateral aspect compared to medial aspect.

Joint mobility is restricted and patient is unbale to flex  his  knee due to severe pain.

No raynauds phenomenon is noted.

Distal pulses - dorsalis pedis, posterior tibial pulse, popliteal and femoral pulses are felt.

RIGHT THIGH DIAMETER 2CMS ABOVE FEMORAL CONDYLE - 43cms 

LEFT THIGH DIAMETER 2CMS ABOVE FEMORAL CONDYLE - 40cms 

PROVISIONAL DIAGNOSIS: RIGHT LOWER LIMB PAIN UNDER EVALUATION SECONDARY TO ?INFECTION ?cellulitis ?Claudication pain 

INVESTIGATIONS:- 

 Chest X Ray  PA view

2D ECHO 

ECG

on 01/10/2022

HEMOGLOBIN - 7.2 

FBS -72

PPS - 190

SERUM ALBUMIN - 4.0

UREA 28

SERUM CREATININE 1.1

LABS: 19/04/2023

Hemoglobin - 6.7 gm/dl

TLC - 6500 cells/cumm

N/L/E/M/B - 78/11/02/02/00

PCV - 21.6 VOL%

MCV - 88.9 FL

PLATELETS - 1.3 LAKHS 

IMPRESSION - NORMOCYTIC NORMOCHROMIC ANEMIA WITH MILD THROMBOCYTOPENIA.

HIV / HBSAG /HCV - NEGATIVE

PT - 18 sec 

INR - 1.33

APTT - 35 sec

CUE - Albumin - ++

sugar -  +

pus cells : 2-3 

RBC - nil

urine spot protein : 171.2

urine spot creatinine : 71

urine spot protein creatinine ratio : 2.49

Blood Urea - 154 mg/dl --> 162 --> 99 --> 157 --> 160

serum creatinine - 3.2 --> 3.6 --> 3.1 --> 3.4

Uric acid - 7.1 mg%

sodium - 132 mEq/L

potassium - 4.9 mEq/L

Chloride - 103 mEq/L

 Blood Lactate - 15 mg/dl

LFT - TB/DB - 0.4/0.13

AST - 8 IU/L

ALT - 8 IU/L

ALP - 127 IU/L

TOTAL PROTEINS - 5.5 gm/dl 

ALBUMIN - 2.59 gm/dl

 20/04/2023

Hemoglobin - 6.3 gm/dl

TLC - 10000 cells/cumm

N/L/E/M/B - 85/07/02/06/00

PCV - 20.8 VOL%

MCV - 91.6 FL

PLATELETS - 1.5 LAKHS 

IMPRESSION - NORMOCYTIC NORMOCHROMIC ANEMIA.

RETICULOCYTE COUNT - 1.2

ESR - 140 

CREATINE KINASE - 124 IU/L 

FBS - 312 mg/dl

HbA1c - 7.0%

PPBS - 137 mg/dl

ABG - 20/04      23/04

PH - 7.27           7.19

PCO2 - 27.0       22.5

PO2 - 77.6         66.6

HCO3 - 12.1      8.2

St HCO3 - 13.4    10.5

O2 sat - 94.1      90.8

USG ABD

Arterial and venous doppler of B/L lower limbs

MRI Right thigh :- 

Outside MRI reporting : 

Renal biopsy:-

COURSE IN HOSPITAL:- 

19/4/23

On 19/4/23 night 9p.m. his grbs was 55 gm/dl for which 25 d was given then after this his grbs was 131 gm/dl. Since the admission his sugars were in control but 

He had a fever spike for which a neomol was given.

Blood and urine culture samples were sent. 

Surgery, orthopedics, ophthalmology opinions were taken.

Surgery opinion:- Rt lower limb cellulitis

 Advice :- arterial and venous doppler b/l lower limbs which turns out to be normal with some atherosclerotic changes. 

Orthopedics :- rt lower limb cellulitis

Ophthalmology:- no fundoscopic changes showing diabetic or hypertensive changes 

2D echo was done and it showed dilated chambers. 

21/4/23:-

MgSO4 dressing was done.

22/4/23

No organisms isolated in blood and urine culture.

Hemoglobin improved from 6.7 to 7.7

MgSO4 dressing was done.

DIAGNOSIS:-

? Pre renal/? Renal AKI on CKD secondary to ? PyoMyositis  ?inflammatory myopathy of Rt LL with mild knee joint effusion

HFPEF (64%)

K/C/O DM SINCE 10 YEARS 

             HTN SINCE 6 MONTHS

TREATMENT:- 

-IV FLUIDS URINE OUTPUT+ 30ml/hr

-INJ CLINDAMYCIN 600MG IV/TID

-INJ. LASIX 40 MG IV/TID

-INJ. TRAMADOL IN 100 ML NS IV/SoS

-INJ HAI SC/TID AND NPH SC/BD -->according to GRBS 

- TAB. PCM 650 MG PO/TID

-TAB. NICARDIA 10 MG PO/QID

-STRICT I/O CHARTING

Discussion:  

1) Michele Y.Y. Seah, Sadanand N. Anavekar, Judy A. Savige, Louise M. Burrell; Diabetic Pyomyositis: An uncommon cause of a painful leg. Diabetes Care 1 July 2004; 27 (7): 1743–1744. https://doi.org/10.2337/diacare.27.7.1743

similar case report of 63 year old male with history of diabetes and pain in left lower limb and unable to bear the weight and fever diagnosed with large heterogenous collection throughout left vastus intermedius muscle  confirmed on MRI , surgical exploration and repeated debridement was done where tissue growth showed MSSA and with appropriate treatment he was discharged.

2) Differential diagnosis work up 

Musculoskeletal

Arthritis
Fracture
Muscle cramps

Vascular
Arterial occlusion
Intermittent Claudication

Infection
Cellulitis
Tendinitis
Septic arthritis

Neuropathic
MonoNeuropathy (e.g., diabetic)
Meralgia paresthetica
Complex regional pain syndrome

Deficiency: Vitamin D deficiency
MicroTrauma
Soft tissue injury
Compartment syndrome
Rhabdomyolysis

3)American Journal of Roentgenology. 2009;192: 1708-1716. 10.2214/AJR.08.1764

MRI Findings in Inflammatory Muscle Diseases and Their Noninflammatory Mimics

crohn's - Granulomatous myositis must be differentiated from pyomyositis and muscular edema due to deep vein thrombosis because both of these latter complications also accompany the course of the disease. 

Muscle Infarction - Diabetic myonecrosis (infarction) is a rare complication of diabetes mellitus manifested by local pain and sometimes low-grade fever. On MRI, marked edema and enhancement around irregular regions of muscle necrosis are seen .

Staphylococcus aureus is the most common pathogen. On MRI, hyperintense focal lesions with massive perifocal edema, progressing usually to abscess, are seen. Muscle involvement can occur with a viral infection (e.g., influenza, dengue, Coxsackie B virus) or parasitic invasion (e.g., trichinellosis, cysti cercosis, or toxoplasmosis). In immunocompromised patients, musculoskeletal fungal infections (e.g., candidiasis, aspergillosis, or mucormycosis) can also occur. Acute rhabdomyolysis can be encountered with clostridial and streptococcal myositis.

4) 

Creatine kinase is done by CLEA - cross linked enzyme aggregates