Rehan Gul, Adnan Gul.
Diclofenac Sodium Induced Myositis -An Unusual Etiology.
J Coll Physicians Surg Pak Jan ;10(5):190-1.

We report a case of left lower limb myositis in a 28 year old man after he was administered intramuscular injection of diclofenac sodium. Interesting features found are highlighted.

CASE REPORT: A twenty-eight years old man, sprained his ankle 5 days back. For the pain, he received 75 mg intramuscular injection of diclofenac sodium in his left gluteal region. The next day patient noticed tightness in the lateral aspect of mid third of left thigh along with the pain in the left gluteal region mainly in the area of injection. Patient was started on oral diclofenac sodium 50 mg thrice daily by his family physician. The same evening, patient noticed generalized rash over the body. He consulted his family physician, who stopped the drug considering this due to hypersensitivity reaction. Next day the intensity of pain in the left gluteal region remained the same but the feeling of tightness and swelling in the left thigh increased. He developed high grade fever by the evening.After few days the swelling started subsiding. Physiotherapy and ambulation were started. Serial CPK decreased from 198 He was taken to another hospital where he received another intramascular injection of diclofenac sodium (75 mg) on the left gluteal region. Next day the patient was presented to the emergency department of our hospital. On examination, his left lower limb was found swollen and erythematous, starting from below the inguinal ligament infront and gluteal region behind, up to the calf. Tenderness was also present in the same area. Movement, both active and passive, were present but limited and painful. Investigations revealed nothing significant. A provisional diagnosis with septic arthritis of left hip joint was made. X-ray of left hip showed tear drop sign on the left side with erosion of the medial aspect of acetabulum and femoral head debridement was given but he refused. At two months follow diagnostic tap of left hip joint, only 1 cc of clear serous fluid was aspirated. Gram staining and the culture did not grow any organism. Ultrasound of the area revealed a mild soft tissue thickening in the left lateral gluteal region with the thickened gluteal muscles, showing fuzzy outline, consistent with the inflammation in this region. No definite collection seen. MRI showed increased signal intensity in left gluteal and thigh muscles suggestive of inflammation. After two days of admission, patient`s condition remained the same. Aspiration of a left hip was repeated again, with a thought that pus might have developed, but clear serous fluid was aspirated. A decision was made to do limited exploration and to take biopsy of left thigh muscles. At operation no pus or fluid collection was found. No necrosis of the muscles or fascia seen. Tissues were sent for culture and histopathology. Culture was negative for any organisms and histopathology revealed no evidence of active inflammation and degeneration. After 6 days of admission, there was still no clue about the etiology. Patient developed generalized edema (anasarca). Liver function tests showed a decrease in total proteins and albumin only. In the meantime, help of an infectious disease expert was also sought, who ruled out the possibility of autoimmune causes. But the feeling of tightness and swelling in the left thigh increased. He also developed high grade fever by the evening. After few days the swelling started subsiding. Physiotherapy and ambulation were started. Serial CPK decreased from 198 IU/L to 125 IU/L. Finally, patient was discharged from the hospital. At first week follow-up,discharging sinus was noticed from the site of incision which was compious, thick and yellow in colour, but patient was afebrile. Culture and gram stain of the discharge was negative and his daily dressings continued. On the second follow-up after second week, discharging sinus dried up and the patient started walking with support. There the affected side. Third follow-up was done in the third week on telephone as the patient was out of the city. Sinus had started draining again but patient was afebrile. Option of up the discharge stopped and wound healed. Patient remained afebrile, walking with full weight bearing without support but Department of Surgery, Cavan General Hospital, Ca van Ireland was unable to run or walk fast. Patient was then asked to attend follow-up clinics, if required, for any new problems.

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