A man with diabetes and a swollen leg

Abstract

Manish Sagar and colleagues (Jan 9, p 116)1Sagar M Bowerfind WM Wigley FM A man with diabetes and a swollen leg.Lancet. 1999; 353: 116Summary Full Text Full Text PDF PubMed Scopus (11) Google Scholar report a case of diabetic muscular infarction. They provide new information on a rare pathological condition that adds to a rather small pool of available data. In doing so, they emphasise leucocytosis and associated fever and conclude that this complication of diabetes mellitus may be of infectious or focal myoinflammatory origin. In addition, they report that creatine kinase concentration was 917 IU/L. We would like to contribute to the discussion. In all publications on this subject, the data are obtained after an interval between the event and the patient's presentation at the hospital. Retrospective analysis of the case histories and serum concentrations of creatine kinase revealed that in most cases no or only mild increases in this enzyme were reported.2Case records of the Massachusetts General HospitalWeekly clinicopathological exercises. Case 29-1997. A 54-year-old diabetic woman with pain and swelling of the leg.N EnglJ Med. 1997; 337: 839-845Crossref PubMed Scopus (5) Google Scholar In most cases, an interval of longer than 4 weeks was recorded. However, with the exception of one case, increases in creatine kinase were noted when the interval was less than 14 days. We report a patient we examined who developed diabetic muscle infarction when he was put on insulin for his diabetes mellitus. Thus, we had the unique opportunity to study the clinical course of this condition along with laboratory tests from an initial stage. 1 day after the onset of pain in the patient's left calf, serum concentrations of creatine kinase peaked (2238 IU/L, normal range 0–180 IU/L). 3 days after the event, the creatine kinase concentration had dropped to 1166 IU/L and after 6 days it was at 340 IU/L. 13 days after the event, serum creatine kinase fell to within the normal range. We were also able to record a mild increase in body temperature (from 36·1°C to 37·2°C, measured at 0600 h) which returned to normal within 12 days. However, leucocytosis (white blood cell count 6·3×109/L) was not present and out patient was not put on antibiotics. Ultrasound may be a valid tool in the diagnosis of diabetic muscular infarction. This investigation is easily available and provides firm information on the peripheral vascular status of the patient. Similar to another case report,3Chason DP Fleckenstein JL Burns DK Rojas G Diabetic muscle infarction: radiologic evaluation.Skeletal Radial. 1996; 25: 127-132Crossref PubMed Scopus (74) Google Scholar we observed a focal hypoechogenic mass located to the skeletal muscle that was consistent with oedema or bleeding. By doppler technique, and duplexsonography, we were able to exclude deep-vein thrombosis or embolisation. The rapid changes in creatine kinase concentrations and in body temperature may explain the contradictory findings reported for diabetic muscular infarction. We suggest that fever or increase in serum creatine kinase indicate a recent event of this condition. In addition, our case suggests that use of ultrasound as a first step may provide a hint to make the diagnosis. Magnetic resonance imaging may be required to rule out masses of other origin.