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A cumulative incidence of diabetic nephropathy of 25% to 40% has been documented after duration of diabetes of at least 25 years in both type 1 and type 2 diabetic patients.
All published work is licensed under a Creative Commons Attribution 4.0 International License. 1Department of Internal Medicine, Lincoln Medical and Mental Health Center, Bronx, New York, USA.
Diabetic muscle infarction (DMI) is a rare complication of diabetes mellitus (DM) that is often misdiagnosed. Although rare, DMI is a serious and potentially disabling complication of uncontrolled DM which continues to be under-diagnosed. A 50-year-old male presented to the emergency department complaining of left thigh pain, swelling and redness for last five days. Past medical history included uncontrolled type 2 DM, end stage renal diseases (ESRD) on hemodialysis, anemia of chronic disease, hypothyroidism and depression. Physical examination revealed moderately tender left anterior thigh, fullness and tightness of left lateral compartments with erythema and increased warmth in comparison to the right thigh. A vascular ultrasound of the left lower extremity (LLE) during admission demonstrated non-compressible echogenic focus most consistent with deep venous thromboembolism (DVT) in the mid left femoral vein. We retrieved his medical records from the previous hospital where he had multiple readmissions. Our patient had a long recovery period due to the recurrent spontaneous hematomas which required multiple visits to the operating room for muscle debridement, placement of wound-vac and evaluation by plastic surgery for possible skin graft.
Figure 1: Left lower extremity Doppler ultrasound, arrow on left images, pointing obstruction, possible thrombus.
Figure 4: Left lower extremity magnetic resonance imaging, Sagittal view, arrow showing points of hiperintensity in T2 weighted image. Diabetic muscle infarction or myonecrosis is a rare complication of long standing DM, most commonly affecting type 1 DM, but can be seen in type 2 DM as well. Similar to other cases described in literature, our patient had been a poorly controlled diabetic with microvascular complications and ESRD on hemodialysis. The presenting symptoms were similar to what has been described in other reports: acute onset of lower extremity painful swelling, no prior trauma, no fever. A year prior to this admission an MRI scan was done showing soft tissue fluid in relation to the extensor muscles of the proximal thigh particularly around the rectus femoris muscle in the right tensor fascia lata. To diagnose DMI the clinician must keep it high in the differential diagnosis, especially in poorly controlled DM patients with late complications such as nephropathy who present with lower extremity pain. The MRI scan is diagnostic test of choice since it can detect the characteristic changes with high sensitivity. In reviews, the majority of cases resolved spontaneously only requiring symptomatic treatment which includes non-steroidal anti-inflammatory drugs, rest, adequate glycemic control and physical therapy. Although rare, DMI is a serious and potentially disabling complication of uncontrolled diabetes mellitus which continues to be under diagnosed. Neither the service provider nor the domain owner maintain any relationship with the advertisers. Diabetic nephropathy has become the leading cause (25%-44%) of end-stage renal failure in Europe, the United States, and Japan.

Venous ultrasound of left lower extremity revealed deep vein thrombosis in the mid left femoral vein however, venogram was negative. We report a case of diabetic muscle infarction and discuss diagnostic testing and treatment modalities to avoid complications. 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. DMI usually affects the muscles of the thighs and calves with rare reported cases in the upper extremities.
There was no history of trauma but similar episodes of leg pain had occurred since 2007 (twice in the right thigh and once in the left thigh), resulting in multiple admissions.
He had a 90 pack-year smoking history (quit seven months prior to last admission) and history of alcohol abuse. The patient was taken back to the operating room for wound exploration where multiple hematomas within viable muscle were found.
Results of the MRI scan and muscle biopsy from the right thigh performed six month prior to this admission were reviewed. However, in contrast, our case had multiple admissions to our hospital and other facilities with similar presentation, and was managed as a case of cellulites. A hyper-intense T2-weighted muscle signal, a reflection of increased tissue water, is the most common finding.
This is established as the standard of care, although pathology can definitely re-occur as seen in our patient. Hospitalists and primary care physicians should be educated extensively on this entity, keeping it among the differential diagnosis of the diabetic patient with non-traumatic leg pain and swelling.
Diabetic myonecrosis in a previously healthy woman and review of a 25-year Mayo Clinic experience. 2013; This article is distributed the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any means provided the original authors and original publisher are properly credited. In case of trademark issues please contact the domain owner directly (contact information can be found in whois).
Until the early 1980s, no renoprotective treatment was available for use in diabetic nephropathy. His past medical history consisted of poorly controlled type 2 DM on insulin therapy, end stage renal diseases on hemodialysis and hypothyroidism.
Vascular ultrasound did not produce any definitive diagnosis and it was assessed as cellulites. His medications included lisinopril, metoprolol, levothyroxyne, citalopram, and both fast and long acting insulin.
The patient required a third wound exploration due to recurrent blood clots and infarcted muscle was debrided until viable muscle with good perfusion was noted. Axial T1 and fat suppressed proton-density images MRI scan revealed collections within the right vastus lateralis muscle and within the abductor muscle group, with signal compatible with the presence of blood and hemosiderin, indicative of hemorrhage.
Conversion of the normal rich collateral circulation of muscle to an end-vessel circulatory pattern renders it particularly vulnerable to injury. On this admission, patient was thought to have DVT at first, which is one of the differential diagnoses of this pathology along with pyomyositis, myositis ossificans, traumatic muscle rupture, muscle hemorrhage, fasciitis, osteomyelitis, abscess and soft tissue neoplasm.

It has been reported in many cases that acute phase reactants tend to be elevated and creatine kinase (CPK) could be normal to mildly elevated.
Surgery and biopsy can delay recovery, as occurred with our case, leading to increase morbidity and decreased quality of life. Recognizing diabetic muscle infarction more efficiently could save the patient from undergoing unnecessary, diagnostic procedures, including medical or surgical interventions that could in turn result in more harm than good to the patient.
T2-weighed magnetic resonance imaging (MRI) is the diagnostic imaging of choice and while muscle biopsy provides a definitive diagnosis, surgical intervention is neither necessary nor recommended given the fact that it leads to more complications in these patients.
Histopathological changes in DMI vary with timing of biopsy acquisition from acute coagulative necrosis with inflammatory infiltrates to myofiber atrophy and fibrosis. Being able to correctly diagnose these patients and educating them on the nature of their condition may also aid in reducing medical costs. The two main treatment strategies for prevention of diabetic nephropathy are improved glycemic control and blood pressure lowering, particularly using drugs blocking the reninangiotensin system. After reviewing medical records from both our hospital and from other facilities, a diagnosis of DMI was established. Such complications include hemorrhages within the affected muscle, often requiring blood transfusions. Our patient presented with left thigh pain and swelling, with previous similar presentations in the contralateral side.
In a study by Trujillo-Santos et al., many mechanisms are proposed, including an alteration of the coagulation-fibrinolysis system and vascular disease. Our recommendation for diabetic patients with microvascular disease, presenting with leg swelling and pain, is that once deep venous thromboembolism is ruled out, magnetic resonance imaging should be done in order to diagnose this diabetic muscle infaction. Megatrials and meta-analyses have clearly demonstrated the beneficial effect of both the above-mentioned treatment modalities. Muscle biopsy supported this, revealing active macrophage infiltration with areas of necrosis.
Surgery was consulted and a diagnosis of compartment syndrome was made based on the clinical picture. Secondary prevention, that is, treatment modalities applied to diabetic patients at high risk for developing diabetic nephropathy (eg, those with microalbuminuria) has been documented, applying angiotensin converting enzyme inhibitors and angiotensin II receptor blockade. Emergency left thigh fasciotomy and assessment of fascia was performed, however, the muscle appeared pink and viable. Unfortunately, no prospective studies regarding the use of anticoagulation have been conducted [9] In our case, the patient had an elevation of factor VIII, which may contribute to the hypercoagulable state theory.
The renoprotective effects of these drugs are independent of their beneficial reduction in blood pressure. Conclusion: Although rare, DMI is a serious and potentially disabling complication of uncontrolled DM which continues to be under-diagnosed.

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