Diagnosis Of Diabetic Muscle Infarction Research Articles

Diabetic muscle infarction with pelvic vein thrombosis: An uncommon presentation to the emergency department

Diabetic muscle infarction (DMI) occurs as a rare complication associated with long-standing, poorly controlled diabetes mellitus (DM) and typically presents as acute painful muscle swelling in the absence of trauma. It resolves spontaneously over a few weeks to months in most patients and generally has a good prognosis. However, the coexistence of deep vein thrombosis (DVT) with DMI may have an additional risk of complications such as pulmonary embolism, recurrent DVT, and post-thrombotic syndrome (PTS). Although the treatment for DMI is mainly analgesia, rest, and control of diabetes, the coexistence of extensive DVT and diabetic ketoacidosis (DKA) may demand anticoagulation and a multidisciplinary team approach. Its management may also involve the endocrinologist, hematologist, and occasionally an interventional radiologist or vascular surgeon. We report two cases of patients with DMI with extensive DVT that presented to our emergency department (ED) as acute non-traumatic swelling of the lower limb. The diagnosis of DMI in both the cases was based on the presence of characteristic clinical features and typical magnetic resonance imaging (MRI) findings. The patients were treated with anticoagulation therapy in addition to the management of DKA, and discharged with good recovery.

English

Diabetic muscle infarction is rare complications of diabetes that occurs in patients with type 1 diabetes (70% of total cases) or in patients with poorly controlled type 2 diabetes. Here is a 55 year old male patient was admitted with diabetic ketoacidosis and coma. Two days later following recovery he gave history of pain in the right thigh since 10 days. There was no history of trauma, fever, weight loss. On examination vitals are stable, systemic examination: clinically normal. Examination of right thigh lower one third, showed a tender mass of about 3.4 x8.2 cms, FNAC of which showed muscle fibres with hemorrhagic back ground. MRI scan suggesting of myositis involving vastus group of muscles. This patient had normal renal functions and normal fundus. This patient responded to conservative management and antibiotics. CONCLUSION: A high index of suspicion is needed to make a timely diagnosis of diabetic muscle Infarction, and avoid the use of steroids or surgical intervention.

Diabetic muscle infarction with complications

Diabetic muscle infarction (DMI) is a rare complication of diabetes mellitus (DM) that is often misdiagnosed. We report a case of diabetic muscle infarction and discuss diagnostic testing and treatment modalities to avoid complications. Case Report: A 50-year-old male presented with spontaneous left thigh swelling for five days. He had several previous episodes in the contralateral side with recurrent admissions. His past medical history consisted of poorly controlled type 2 DM on insulin therapy, end stage renal diseases on hemodialysis and hypothyroidism. Physical examination revealed a tight, warm, erythematous and tender left thigh. Laboratory examination showed white blood cell count 1.23x10⁴/µL with neutrophilia; hemoglobin 10.7 g/L, hematocrit 32.3%, alkaline phosphatase 792 U/L, creatinine 5.94 mg/dL and glucose 455 mg/dL. Venous ultrasound of left lower extremity revealed deep vein thrombosis in the mid left femoral vein however, venogram was negative. Compartment syndrome was considered and fasciotomy with biopsy was performed. Subsequently the patient worsened which lead to multiple re-interventions. After reviewing medical records from both our hospital and from other facilities, a diagnosis of DMI was established. Muscle biopsy supported this, revealing active macrophage infiltration with areas of necrosis. Treatment is conservative with pain management, rest and proper glycemic control. Surgical intervention is not necessary as it increases morbidity. Conclusion: Although rare, DMI is a serious and potentially disabling complication of uncontrolled DM which continues to be under-diagnosed. Recognizing DMI more efficiently could prevent the patient from undergoing numerous, unnecessary diagnostic procedures, and medical or surgical interventions which in turn can result in more harm than good for the patient.

The Role of MRI in Diagnosis of Diabetic Muscle Infarction : an Underdiagnosed Entity

: Muscle infarction is an uncommon complication of long-standing diabetes mellitus. Here, we report the case of a 62-year-old diabetic male patient with acute pain and swelling of the right thigh with signs of mild inflammation but no evidence of infection or myopathy. Initial magnetic resonance imaging (MRI) revealed diffuse swelling and edema of quadriceps muscles with blurred margins. The clinical symptoms showed significant improvement after 1 month of symptomatic treatment. Follow-up MRI performed after 3 months showed remarkable improvement in inflammatory changes with mild residual swelling and edema of the vastus lateralis muscle. In the absence of any systemic signs of infection and laboratory diagnostic markers, the detection of typical features such as hyperintense signal on T2 weighted images or hypo- to isointense signals on T1 weighted images, without localized fluid collection, remains the most useful investigative tool for diagnosing diabetic muscle infarction and obviates the need for invasive procedures like muscle biopsy. Diabetic muscle infarction is a rare complication with distinct clinical presentation, laboratory findings, and MRI features, and can be resolved over a period only by administering adequate supportive treatment. Clinicians should be aware of this complication and always consider it in the differential diagnosis of diabetic patients presenting with acute onset of pain and swelling of the extremities. Implication for health policy/practice/research/medical education:No direct relation for health policy. Knowledge about the role of MRI in the management of this complication of diabetes will help the Physicians and unnecessary surgical interventions may be avoided. There is scope for research on drugs which can prevent and treat this complication. Please cite this paper as:Goswami P, Baruah MP. The Role of MRI in Diagnosis of Diabetic Muscle Infarction : an Underdiagnosed Entity. Int J Endocrinol Metab.2011;9(2):353-5. DOI: 5812/kowsar.1726913X.1886 Copyright© 2011 Kowsar M.P.Co. All rights reserved.

Diabetic Muscle Infarction: A Rare Complication of Long-Standing and Poorly Controlled Diabetes Mellitus

Objective. To report a case of diabetic muscle infarction (DMI), a rare complication of long-standing poorly controlled diabetes mellitus. Methods. We describe a case of a 45-year-old male with an approximately 8-year history of poorly controlled type 2 diabetes mellitus with multiple microvascular complications who presented with the sudden onset of left thigh pain and swelling. He had a swollen left thigh and a CK of 1670 U/L. He was initially treated with intravenous antibiotics for a presumptive diagnosis of pyomyositis or necrotizing fasciitis with no improvement. A diagnosis of diabetic muscle infarction was considered. Results. An MRI of the thigh demonstrated diffuse edema in the anterior compartment. A muscle biopsy demonstrated coagulation necrosis in skeletal muscle and inflammation and infarction in the walls of small blood vessels. These studies confirmed the final diagnosis of DMI. He was treated with supportive care and gradually improved. Conclusion. DMI is a rare complication of diabetes that is often mistaken for infections such as pyomyositis and necrotizing fasciitis or thrombophlebitis. Treatment is supportive. Although the short-term prognosis is good in these patients, the long-term prognosis is poor.

Recurrent diabetic muscle infarction in a female with diabetes secondary to congenital generalised lipodystrophy

AbstractCongenital generalised Berardinelli‐seip lipodystrophy is a rare, autosomal recessive disorder characterised by selective absence of adipose tissue. Affected individuals are predisposed to severe insulin resistance and its attendant complications, including diabetes mellitus, hypertriglyceridaemia, acute pancreatitis and hepatic steatosis. The management of diabetes in these people can be challenging due to severe insulin resistance.A 25‐year‐old female patient, with diabetes secondary to congenital generalised lipodystrophy, presented to the emergency department with a two‐week history of sudden onset, spontaneous left leg pain associated with swelling over the medial aspect of her left thigh. Her diabetes control prior to presentation was unsatisfactory with HbA1c >12%, despite receiving maximum doses of metformin, pioglitazone and 200 units of subcutaneous insulin daily.Based on the clinical presentation, background medical history, examination and MRI findings, a diagnosis of diabetic muscle infarction was made. The patient's symptoms resolved over the next four to six weeks with rest and analgesia. Eleven months later, she represented with diabetic muscle infarction affecting her left quadriceps and, after a further 19 months, she had a third admission to hospital with diabetic muscle infarction but this time affecting her right quadriceps.We describe a rare case of recurrent diabetic muscle infarction. This complication has been previously reported in patients with type 1 diabetes of prolonged duration; however, we are not aware of any report of diabetic muscle infarction occurring in patients with diabetes secondary to congenital generalised lipodystrophy. In the current report, we discuss the pathogenesis, clinical course and management of diabetic muscle infarction. Copyright © 2010 John Wiley & Sons.

Painful swollen legs in a diabetic patient

A 52-year-old man presented with a 6-week history of bilateral painful thighs and reduced mobility. Glycaemic control of his type 2 diabetes of 25 years' duration was poor and he had recently commenced on insulin. His disease was complicated by retinopathy, peripheral neuropathy and nephropathy. He denied trauma to the legs. The thighs were swollen with pitting oedema extending from the ankles. There was no erythema or temperature disparity. The thighs were exquisitely tender on palpation of the anterior muscle compartment. Both calves were also tender to palpate. No mass was identified. The peripheral pulses were intact and the upper limbs were entirely normal. Haematological investigations revealed erythrocyte sedimentation rate 136 mm/hr, C reactive protein 13 mg/dl, normal white cell indices and normal coagulation profile. On biochemical analysis urea and creatinine were elevated; creatine kinase was increased at 250 U/litre. Glycosylated haemoglobin was 14%. All immunological and vasculitic profiles were normal. Urinary protein excretion was 12 000 mg/24 hours. This man was admitted for investigations, rest and rigorous control of his diabetes. He underwent ultrasound Doppler of his legs ruling out deep venous thrombosis or insufficiency of the large arteries. A computed tomography scan of the thighs revealed diffuse inflammation of the right thigh musculature. Nuclear bone scan confirmed increased uptake in the muscles but no bony abnormality. Magnetic resonance imaging was the definitive investigation showing diffuse enhancement on T2 weighted images of the anterior muscle compartment of the right thigh (vastus intermedius and vastus lateralis) with lesser changes noted in the left thigh and both calves (soleus) (Figure 1). A focal area of nonenhancement in the right rectus femoris following administration of gadolinium was consistent with an area of infarction (Figure 2). An open biopsy specimen showed non-specific inflammation and regenerating muscle fibres. Occasional necrotic muscle fibres were remarked upon. No haemorrhage was noted and the intramuscular blood vessels were normal. The diagnosis of diabetic muscle infarction was made. After 1 month of rest, analgesia and good glycaemic control the swelling and pain had completely resolved. A similar episode affecting the left thigh some months previously was reported. He is the only recorded patient to have had involvement of both thighs and calves bilaterally in the same episode.

Diabetic Muscle Infarction of the Forearm in a Patient with Long-Standing Type 1 Diabetes

To describe a case of diabetic muscle infarction affecting an upper extremity in a patient with long-term poorly controlled diabetes. A case report of a patient with diabetes who presented with pain and swelling of his left arm is described, including clinical, laboratory, and radiologic findings. The results of pathologic examination are also illustrated. Moreover, we review the literature in a discussion of the evaluation, pathogenesis, and treatment of diabetic muscle infarction. A 41-year-old man with type 1 diabetes presented with a 1-week history of painful swelling of the left forearm. The leukocyte count and creatine kinase levels were normal. Magnetic resonance imaging of the left forearm revealed extensive deep tissue edema and an increase in T2 signal in the involved muscles. The patient was initially treated for cellulitis with intravenously administered antibiotics for 3 weeks without improvement. Muscle biopsy revealed skeletal muscle with prominent muscle fiber degeneration, myophagocytosis, and fibrosis, consistent with the diagnosis of diabetic muscle infarction. Once this diagnosis was made, antibiotic therapy was discontinued, and the condition was managed with narcotics and aggressive insulin therapy. Eight weeks after initial presentation, the patient reported complete resolution of symptoms. Diabetic muscle infarction is a rare but underrecognized complication of diabetes. To our knowledge, we present only the second such reported case of upper extremity involvement in the literature. The results of pathologic examination interpreted in the context of the patient's clinical history were consistent with the diagnosis.

Diabetic thigh muscle infarction in association with antiphospholipid antibodies

Background: Diabetic muscle infarction (DMI) is a rare complication of type 1 diabetes mellitus. DMI has a stereotyped clinical presentation and characteristic, though nonspecific, magnetic resonance imaging (MRI) and histologic findings. The etiology, however, remains controversial. Objectives: To present the first reported cases of DMI in association with positive antiphospholipid (aPL) antibody titers and to discuss the etiologic and pathogenic significance of the association between type 1 diabetes and aPL antibodies. Methods: Descriptive case reports of 2 patients with DMI and positive aPL antibodies and a review of the relevant literature. Results: Our 2 patients with DMI are female type-1 diabetics with end-organ microvascular complications who presented with an abrupt, painful swelling or mass of the thigh musculature. The diagnosis of DMI was based on the clinical picture and the findings on T2-weighted MRI and histologic evaluation. The first patient had a long history of known aPL antibodies in the setting of systemic lupus erythematosus. The second patient was only determined to be aPL positive after her recurrent episodes of DMI. The first patient was treated with anticoagulation and corticosteroids with relatively rapid resolution of symptoms. The second patient was treated with local débridement and supportive care with a resulting course of prolonged symptoms and recurrences. There are no controlled trials of the treatment of DMI. In the literature there is evidence for an increased prevalence of aPL antibodies in type 1 diabetic patients. The pathogenesis of DMI is poorly understood, but the hypercoagulable state often associated with aPL antibodies may play an important role. Conclusions/Relevance: aPL antibodies may be involved in the pathogenesis of diabetic muscle infarction and could serve as an important target of therapeutic intervention, namely with anticoagulation. Semin Arthritis Rheum 30:272-280. Copyright © 2001 by W.B. Saunders Company

Sonography of diabetic muscle infarction with MR imaging, CT, and pathologic correlation.

The purpose of this article is to describe the sonographic findings of muscle infarction in patients with diabetes with MR imaging, CT, and pathologic correlation. Sonographic findings of diabetic muscle infarction include internal linear echogenic structures coursing through the lesion; an absence of internal motion or swirling of fluid with transducer pressure; and a lack of a predominately anechoic area. We believe that these sonographic characteristics may help differentiate diabetic muscle infarction from abscess or necrotic tumor. Additional study involving direct sonographic comparison of these entities is needed to establish the role of sonography in diagnosis of diabetic muscle infarction.

Diabetic Muscle Infarction

Diabetic muscle infarction (DMI) is a rarely reported complication of diabetes mellitus and usually occurs in patients with poorly controlled diabetes and/or significant end-organ complications. It is not unusual for these patients to undergo extensive work-up and treatment for thrombophlebitis, myositis, or vasculitis when DMI is not initially considered. We report the use of magnetic resonance imaging (MRI) to diagnose DMI on three occasions in two patients. We believe MRI should be considered early in the evaluation of diabetic patients with unexplained localized complaints in an extremity. In compatible clinical situations, MRI may lead to a swift diagnosis of DMI while excluding conditions requiring specific therapy. In addition, when the presentation is atypical, MRI may help focus further evaluation, i.e., localize which muscle to biopsy.