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Pain in legs and calf. Type 1 diabetes.

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Dear Doctor,

I am a 24 year old male, Type 1 Diabetic for the last 21 years old patientwho is having sharp sometimes severe pain in both legs. It all started about seven months ago when I lost more than 10 kg in a little over two months in order to get fit to play sports. Soon afterwards, I had swelling and pain in both knees and was operated on for partial ligament tear. However my pain has only been worse after that and one can significantly feel my calf muscles vanish and look very floppy. In addition to this, I have severe pain that starts on top of my knees and extends to my legs. I have visited more than 10 orthopaedic doctors who could see nothing wrong with my joints.
However, one doctor suspected something in my muscles and did the following tests:

CPK 422 (30-200)
Creatinine 88.5 (64-104)
Uric Acid 523 (210-450)

Urine Microalbumin and Creatinine are within normal reference ranges, as well as serum T4 and TSH.

I don't know where to get a diagnosis from after seeing so man doctors. Please let me know what do you think and how I should follow up from here. My pains are not getting any better. I should also add that my legs feel spasm/rigidity when I eat red meat of any kind. Thank you very much.

Category: Internal Medicine Specialist

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Category: HIV- AIDS Specialist
 26 Doctors Online

Thank you for your query at

I have read your question with diligence.
You have raised CPK and Serum Uric acid. These tests are marker of muscle dysfunction. When drawing a blood sample to test CPK levels, certain precautions should be taken. Otherwise, the values can be falsely raised. If the values are truly raised, then a diagnosis of Myositis (inflammation of muscles) etc. have to be considered and further evaluation needs to be done.
There are some other cause which can be responsible for his problem. Looking at your present details you should consult your physician and ask for a referral to a Rheumatologist. Till then you should keep yourself well hydrated and avoid excessive protein in your diet.

Hope this was helpful to you. Feel free to ask queries.
With best wishes.

Patient replied :

Thank you for your response. My CPK has been done twice while avoiding any form of exercise for a few days and both times the values have turned out to be high. You mention there could be other causes for this problem. Please elaborate as my query was not just regardig high CPK levels. What possible diagnosis comes to mind when you think of high CK along with high uric acid and diminished desnsity of calf muscles? Can Rhabdomyolysis be a possibility? Please advice.

Thank you for the follow up.
I understand your concern and i apologize for not being more elaborative in my last reply to you.
Let me give a detailed reply this time.
Firstly you have high CPK levels. To go into the causes it mostly indicates some kind of muscle weakness and disease such as polymyositis, or myositis, muscular dystrophy, or Rhabdomyolysis. In your case polymyositis may be a possibility, however there will be no muscle destruction, or shortening as in your case. Muscular dystrophy again mostly is manifested during childhood, however some cases can be delayed up to the 20s and it can be associated with other autoimmune conditions such as Type 1 DM in your case. This will need a thorough evaluation with a Rheumatologist, who can asses your muscle bulk and do some other tests to find out the extent of destruction.
Now coming to Rhabdomyolysis. It does not seem likely in your case, because most patients with Rhabdomyolysis present with progressive muscle weakness, also associated with a dark cola colored urine since there is increased destruction of muscle tissue and the excess myoglobin gets excreted in the urine. Suspecting that you were advised to keep yourself adequately hydrated, and avoid over exercising. Though it seems unlikely in absence of other factors, it is better to rule it out, since it can cause acute kidney injury, doe to toxic myoglobin. The Rheumatologist can order appropriate tests, but Serum Myoglobin is something that will make the picture clearer.
Regarding the uric acid levels, sometimes in patients with concurrent diabetes, uric acid levels can be high. It mostly points towards gout. This can be diagnosed if your uric acid levels are continuously high, and x ray of the knees, are suggestive of gouty arthritis. So i will suggest you also get a X Ray of both the knees and follow it up with your rheumatologist when you discuss about your case. I know you have been to several doctors and it can be very frustrating. In case you have already reviewed your x ray and there is nothing wrong with the joints, and there are no features of arthritis, then this uric acid level can be directly due to your diabetes. As i said it can be concurrent. In case you haven't then X Ray of the knees and the possibility of gout has to be discussed with the Rheumatologist.
I will suggest you get a Serum Myoglobin done and the X rays taken and then follow it up.
Hope this was helpful,

Dr. Jaydeep Tripathy
Category: HIV- AIDS Specialist
MBBS from Sri Ramachandra University in December 2011
M.Med (Family Medicine) - TNMGR University, Chennai
MBA-MPH in Public Health in March 2016, SRM University
Finished AFIH in March 2016, SRM University
MRCP ( UK ), Internal Medicine, Royal College of Physicians, June 2016
Fellowship in Diabetology from Martin Luther University in January 2017

Currently Resident Physician, in MD Radiodiagnosis - Kamakshi Memorial Hospital, Chennai
Dr. Jaydeep Tripathy and 4 other Medical Specialists are ready to help you

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