Steroids for Diabetic Myonecrosis in ESRD: Unconventional Treatment with Unexpected Success

Introduction: Myonecrosis is a rare but serious complication of diabetes, particularly in patients with end-stage renal disease (ESRD), characterized by ischemic necrosis of skeletal muscles. Its diagnosis is often delayed due to overlapping presentations with cellulitis or deep vein thrombosis, and treatment is traditionally limited to supportive measures, including rest and pain control. The role of corticosteroids remains controversial in this condition as its effectiveness and utility is not widely understood. This case highlights the unconventional use of corticosteroids in managing refractory diabetic myonecrosis, emphasizing their potential in mitigating inflammation and promoting recovery. Case Description: We present a 31-year-old woman with ESRD on hemodialysis and a history of type 1 diabetes, who presented with recurrent, debilitating pain and swelling in the right lower extremity. Despite a comprehensive workup, including MRI and a muscle biopsy confirming myonecrosis, the patient’s symptoms persisted despite conventional supportive care. Following a multidisciplinary discussion, corticosteroid therapy was initiated, resulting in dramatic symptom resolution within 48 hours. The patient experienced significant pain reduction, improved mobility, and decreased swelling, allowing for discharge on a tapering steroid regimen. Notably, a subsequent recurrence of myonecrosis in a different muscle group also responded favorably to corticosteroid treatment, further underscoring its therapeutic potential in managing patients with this condition. Discussion: This case underscores the importance of considering corticosteroids as an adjunctive therapy in refractory diabetic myonecrosis, particularly in patients who fail to respond to standard supportive care. A detailed workup, a high degree of suspicion, distinct clinical findings, and imaging such as MRI along with muscle biopsy, can accurately diagnose this condition. While corticosteroids are not routinely used due to potential risks, their dramatic antiinflammatory effects in this patient highlight the need for further research to better understand their role and refine treatment strategies. By expanding the therapeutic approach to diabetic myonecrosis, this case provides valuable insights for improving outcomes in this rare and challenging condition.