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Diabetic muscular infarction (DMI) is a rare manifestation which can be seen in patients with long-standing diabetes mellitus. We present a patient with uncontrolled diabetes type 2 presented with pain, swelling, and a palpable tender mass in one leg along with new skin lesions. BackgroundDiabetic muscular infarction (DMI) is a rare condition which has been seen in patients with long-standing diabetes who usually have other complications of poor glycemic control.
Case presentationA 57 year old woman, with uncontrolled diabetes type 2 and hypertension, referred to a university hospital clinic with a complaint of right leg swelling and tenderness since 40 days prior to admission. MRI shows a heterogenous enhancement in right tibialis anterior muscle in T2-weighted images. ConclusionsDMI is an uncommon complication of long-standing uncontrolled diabetes of both type 1 and 2 [2].
ConsentWritten informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interestThe authors declare that they have no competing interest.Authorsa€™ contributionsAA carried out data gathering and review of literature, participated in the sequence alignment and drafted the manuscript. A 67-year-old man with a history of non-melanoma skin cancer presented for a total body skin check. Nissan – used auto parts in houston, trucks, cars, savage, Partes usadas para carro, vehiculo, automovil, automobil, auto, carros, vehiculos, automoviles, automobiles, camionetas, trocas, camiones, camion, camioneta, troca.
In the 13 years that Hernandez worked for Walgreens after being diagnosed with diabetes, Walgreens allowed Hernandez to keep candy nearby in case of low blood sugar, keep her insulin in the break room refrigerator and take additional breaks to test her blood sugar or eat because of her diabetes. In that 13-year time period, there was only one time when Hernandez asked to take an additional break to eat food because of low blood sugar. After 10 minutes, when she started feeling better, Hernandez said, she went to pay for the chips at the cosmetic counter (where she had been instructed to pay for store items) but no one was there.
After meeting with store management,  Hernandez was suspended and then terminated for violating the store’s “anti-grazing” policy.
According to court testimony, Walgreens officials said the company incurs significant losses from employee theft, estimated at exceeding $350 million per year. The store manager testified he was “absolutely certain” about terminating Hernandez because she took the chips in violation of company policy, and that he believed there was no “gray area” or “discretion” under Walgreens’ policy.

Hernandez claimed her supposed violation of the anti-grazing rule was caused by her disability — low blood sugar — and should have been considered an accommodation. Walgreens argued that it can never be a reasonable accommodation to require an employer to accommodate employee theft, and asked that the case be dismissed.
After some legal wrangling between the corporation and the EEOC, the company agreed to the settlement, which was approved by Judge Orrick. According to the consent decree settling the suit, Walgreens agreed to pay Hernandez $180,000 and to post its revised policy regarding accommodation of disabled employees on its employee intranet site.  The company will also provide anti-discrimination training, make periodic reports to the EEOC, and post a notice regarding the decree for three years. HR Morning, part of the Catalyst Media Network, provides the latest HR and employment law news for HR professionals in the trenches of small-to-medium-sized businesses.
Biopsy of the skin lesion and T2-weighted MRI of the leg helped differentiate DMI and dermopathy. It has been reported as aseptic myonecrosis, ischemic myonecrosis, and tumoriform focal muscular degeneration.DMI was first described by Angervall and Stener in 1965 [1].
SS also carried out review of literature, participated in the sequence alignment and drafted the manuscript. About five years into her tenure, she was diagnosed with Type II diabetes, a condition she reported to her employer. Hernandez put the potato chips under the counter at her cash register and returned to restocking items. In order to combat the problem, Walgreens has a strict policy against employee theft in the form of “grazing” — eating food merchandise without paying for it first — that applies to all employees. The EEOC investigated and brought suit against Walgreens, arguing that Hernandez was terminated in violation of the Americans with Disabilities Act. First, there was the question of whether Hernandez’s actions came about as a result of her disability, the judge said.
Rather than simply regurgitating the day’s headlines, HR Morning delivers actionable insights, helping HR execs understand what HR trends mean to their business. She had received analgesics (ibuprofen 400 mg bid and diclofenac 50 mg bid) and cephalexin without any improvement.The patient had uncontrolled diabetes type 2 for over 10 years despite being on a maximum dose of oral hypoglycemic agents. The most likely hypothesis is vascular diseases like arteriosclerosis and diabetic microangiopathy [3]. Thigh muscles are the most commonly affected and reports of lower leg involvement are very rare [4].

Even though DMI has been reported for over 45 years, still, less than 200 cases have been reported [1].We are presenting a rare manifestation of uncontrolled diabetes type 2 in a patient who came with pain, swelling, and a palpable tender mass in one leg along with new skin lesions.
On physical examination she had swelling in her right shin with severe tenderness, 1+ pitting edema and a 0.5 cm size difference compared with her left leg. After 2 weeks the patient had a moderate improvement in pain and was able to walk with a walker. Upper extremity involvement has also been reported [5].Clinical features usually consist of local swelling, limitation and pain on motion, tenderness, and a palpable painful mass, usually without fever and severe induration. The pain was so severe that she could not walk and any weight-baring activities caused extreme pain.
Muscle enzymes are usually not elevated and an elevated ESR was seen in about 50%.Diagnosis can be made combining clinical presentation and radiologic imaging.
There were 2-3 round-oval hyperpigmented macules on her right lower extremity about 2 cm in diameter that appeared recently during her problem course without any itching, for which skin biopsy documented diabetic dermopathy. Biopsy confirms the diagnosis in over 90% of cases [7], but since it has potential complications, it should be reserved for atypical cases were diagnosis is hard to make.
Soft tissue sonography revealed moderate swelling and inflammation with no sign of cellulitis or abscess. MRI showed a heterogenous enhancement in right tibialis anterior muscle in T2-weighted images (FiguresA 2 and 3).
As the rate of diabetes mellitus is rising, we might be seeing these patients more often and we should be concerned about them. Treatment is controversial, but trials of anti-platelets, anticoagulation, analgesics, off-loading, rehabilitation methods, and anti-depressants have been used. We recommend more thorough clinical trials to see if these treatment regimens significantly improve the outcome.In conclusion DMI is an uncommon complication of long-standing uncontrolled diabetes presenting with swelling and severe pain usually in lower extremity and usually prompts an extensive diagnostic workup to find etiology of localized myositis which might be unnecessary if the physician has a high level of suspicion, and a T2-weighted MRI images can be a good diagnostic help. Complete blood count, renal and liver function, lipid profile, calcium, phosphorus and uric acid were also normal.

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