CLINICAL VIGNETTE |
Symmetrical muscle involvement in necrobiosis lipoidica
Princess of Wales Hospital, Rheumatology, Bridgend, United Kingdom
Correspondence to: D. Sreerangaiah. E-mail: dee.sreerangaiah{at}gmail.com
A 31-yr-old factory manager presented with a 6-month history of painless swellings over the extensor aspect of both forearms, associated with marked weakness, but no overlying skin changes. Plain X-rays were normal but MRI identified symmetrical signal change throughout the extensor muscle groups, with overlying subcutaneous oedema. Muscle enzymes, inflammatory markers and urinalysis were normal; muscle biopsy was inconclusive. The presentation was thought to be of a focal myositis.
The swellings improved over 12 months, leaving atrophied areas. Skin biopsy showed degenerate collagen, granulomatous inflammation and a vasculopathy affecting the small- and medium-sized vessels. These features were consistent with necrobiosis lipoidica.
Eighteen months later, the patient developed polyuria and polydipsia. His fasting plasma glucose was 15.8 mmol/l, and he was commenced on hypoglycaemic agents.
Necrobiosis lipoidica occurs in 0.3% of diabetic patients and approximately two-thirds of patients with necrobiosis lipoidica have diabetes at presentation. A further 15% will develop diabetes after the onset of the skin lesions.
This case is unusual in that the initial presentation was of swellings involving the extensor muscle compartment of both forearms. Only later did he develop the cutaneous features of necrobiosis lipoidica. No other cases of necrobiosis lipoidica presenting with clinical and radiological features of symmetrical muscle involvement have been reported.
The authors have declared no conflicts of interest.
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