A Case Report of Inflammatory Myositis in a Patient with Uncontrolled Type 2 Diabetes and Hypertension

Case Report

Abstract

Inflammatory myositis presents a significant clinical challenge when occurring alongside metabolic disorders. We report a case of a 48-year-old male who presented with acute onset proximal muscle weakness, calf swelling, and intermittent fever. The patient had a history of uncontrolled Type 2 Diabetes Mellitus (T2DM) with an HbA1c of 10.1% and hypertension (HTN). Laboratory investigations revealed elevated CPK-NAC and LDH levels, while nerve conduction studies demonstrated motor axonal and demyelinating neuropathy affecting bilateral peroneal, tibial, and median motor nerves. Histopathological examination confirmed the diagnosis of myositis. The patient also developed cellulitis, necessitating broad-spectrum antibiotic therapy. Treatment protocol included glycemic control with insulin (both regular and long-acting) and oral hypoglycemics, antihypertensive medication, corticosteroids, and hydroxychloroquine. The case revealed notable interactions between chronic metabolic disorders and inflammatory muscle disease, where persistent hyperglycemia potentially contributed to immune dysregulation and microvascular damage. The patient showed improvement with the implemented therapeutic regimen, though a muscle biopsy was recommended for further diagnostic clarity.