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Spontaneous diabetic myonecrosis: report of four cases from a tertiary care institute.

Mukherjee S, Aggarwal A, Rastogi A, Bhansali A, Prakash M, Vaiphei K, Dutta P - Endocrinol Diabetes Metab Case Rep (2015)

Bottom Line: Here we present the summary of four cases seen in the last 3 years in a tertiary care centre with simultaneous or sequential involvement of multiple groups of muscles or involvement of uncommon sites.Conservative management including rest and analgesics is the treatment of choice.Short-term prognosis is good but there may be recurrence.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology , Post Graduate Institute of Medical Education and Research , Chandigarh, 160012 , India.

ABSTRACT

Unlabelled: Spontaneous diabetic muscle infarction (DMI) is a rare and under diagnosed complication of diabetes mellitus. Clinically it presents with acute to subacute onset swelling, pain and tenderness of muscle(s) without systemic manifestations. MRI is helpful in diagnosis, exclusion of other causes and for localization of affected muscle for biopsy in atypical cases. Muscles of the thighs are commonly affected in diabetic myonecrosis (DMN). Here we present the summary of four cases seen in the last 3 years in a tertiary care centre with simultaneous or sequential involvement of multiple groups of muscles or involvement of uncommon sites. All these patients had advanced duration of diabetes with microvascular complications and poor glycemic control. Conservative management including rest and analgesics is the treatment of choice. Short-term prognosis is good but there may be recurrence.

Learning points: A high index of suspicion is required for the diagnosis of DMN which can avoid inadvertent use of antibiotics.Acute-subacute onset severe focal muscle pain in the absence of systemic symptoms in a female patient with long-standing diabetes with microvascular complications suggests DMI.MRI is the most sensitive test for diagnosis.Muscle biopsy should be reserved for atypical cases.Conservative management including rest and analgesics has good outcome.Improvement usually occurs within 6-8 weeks, but there may be recurrence.

No MeSH data available.


Related in: MedlinePlus

(a) Swelling of right thigh. (b) T2W fat-saturated MRI (coronal section) both thigh with hyperintensity in vastus medialis muscle of right thigh. (c) T1W MRI (axial section) of right thigh demonstrating post contrast enhancement of vastus medialis muscle with small areas of non-enhancement; features consistent with diabetic myonecrosis.
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fig3: (a) Swelling of right thigh. (b) T2W fat-saturated MRI (coronal section) both thigh with hyperintensity in vastus medialis muscle of right thigh. (c) T1W MRI (axial section) of right thigh demonstrating post contrast enhancement of vastus medialis muscle with small areas of non-enhancement; features consistent with diabetic myonecrosis.

Mentions: A 51-year-old female patient presented with complaint of pain and swelling in her right thigh for the last 2 weeks (Fig. 3a). She had fever and there was no history of trauma or i.m. injection. She is a known case of T2DM for the last 12 years, hypertensive for the last 1 year and hypothyroid on levothyroxine replacement for last 3 years. She had similar history with involvement of the left thigh and left calf muscle 4 and 8 months back respectively. On examination, right thigh was swollen, tender and indurated. She had neuropathy, nephropathy and proliferative retinopathy. Investigation revealed hemoglobin 10.9 g/dl, TLC 11 200/mm3, platelets 245×103/mm3, peripheral blood film suggestive of microcytic hypochromic red blood cell, urea 28 mg/dl, creatinine 1.0 mg/dl, HbA1c 11.2%, TSH 9.59 μIU/ml, T4 7.98 μg/dl, T3 1.02 ng/ml and CK 1281 U/l. Rheumatologic work-up was negative and coagulation profile was normal. 24 h urinary protein excretion was 642 mg/day. DVT was excluded by compression USG. USG right thigh showed generalized hypoechogenecity in the quadriceps muscles without any evidence of collection. MRI bilateral thigh revealed diffuse ill-defined intramuscular (right more than left) heterogeneous, intermediate to increased T2WI-IR (inversion recovery) and reduced T1 intensity, and significant contrast enhancement to suggest inflammatory etiology (Fig. 3b and c). There was involvement of the entire length of muscles of anteromedial compartment of the right thigh with dispersed areas of low intensity post contrast – suggestive of necrosis along with overlying subcutaneous fat edema – infiltration, while there was much limited involvement of muscles of medial compartment of the left thigh. The MRI features were consistent with the diagnosis of DMN. The patient was managed conservatively and doses of insulin and levothyroxine were optimized.


Spontaneous diabetic myonecrosis: report of four cases from a tertiary care institute.

Mukherjee S, Aggarwal A, Rastogi A, Bhansali A, Prakash M, Vaiphei K, Dutta P - Endocrinol Diabetes Metab Case Rep (2015)

(a) Swelling of right thigh. (b) T2W fat-saturated MRI (coronal section) both thigh with hyperintensity in vastus medialis muscle of right thigh. (c) T1W MRI (axial section) of right thigh demonstrating post contrast enhancement of vastus medialis muscle with small areas of non-enhancement; features consistent with diabetic myonecrosis.
© Copyright Policy - license
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4482157&req=5

fig3: (a) Swelling of right thigh. (b) T2W fat-saturated MRI (coronal section) both thigh with hyperintensity in vastus medialis muscle of right thigh. (c) T1W MRI (axial section) of right thigh demonstrating post contrast enhancement of vastus medialis muscle with small areas of non-enhancement; features consistent with diabetic myonecrosis.
Mentions: A 51-year-old female patient presented with complaint of pain and swelling in her right thigh for the last 2 weeks (Fig. 3a). She had fever and there was no history of trauma or i.m. injection. She is a known case of T2DM for the last 12 years, hypertensive for the last 1 year and hypothyroid on levothyroxine replacement for last 3 years. She had similar history with involvement of the left thigh and left calf muscle 4 and 8 months back respectively. On examination, right thigh was swollen, tender and indurated. She had neuropathy, nephropathy and proliferative retinopathy. Investigation revealed hemoglobin 10.9 g/dl, TLC 11 200/mm3, platelets 245×103/mm3, peripheral blood film suggestive of microcytic hypochromic red blood cell, urea 28 mg/dl, creatinine 1.0 mg/dl, HbA1c 11.2%, TSH 9.59 μIU/ml, T4 7.98 μg/dl, T3 1.02 ng/ml and CK 1281 U/l. Rheumatologic work-up was negative and coagulation profile was normal. 24 h urinary protein excretion was 642 mg/day. DVT was excluded by compression USG. USG right thigh showed generalized hypoechogenecity in the quadriceps muscles without any evidence of collection. MRI bilateral thigh revealed diffuse ill-defined intramuscular (right more than left) heterogeneous, intermediate to increased T2WI-IR (inversion recovery) and reduced T1 intensity, and significant contrast enhancement to suggest inflammatory etiology (Fig. 3b and c). There was involvement of the entire length of muscles of anteromedial compartment of the right thigh with dispersed areas of low intensity post contrast – suggestive of necrosis along with overlying subcutaneous fat edema – infiltration, while there was much limited involvement of muscles of medial compartment of the left thigh. The MRI features were consistent with the diagnosis of DMN. The patient was managed conservatively and doses of insulin and levothyroxine were optimized.

Bottom Line: Here we present the summary of four cases seen in the last 3 years in a tertiary care centre with simultaneous or sequential involvement of multiple groups of muscles or involvement of uncommon sites.Conservative management including rest and analgesics is the treatment of choice.Short-term prognosis is good but there may be recurrence.

View Article: PubMed Central - PubMed

Affiliation: Department of Endocrinology , Post Graduate Institute of Medical Education and Research , Chandigarh, 160012 , India.

ABSTRACT

Unlabelled: Spontaneous diabetic muscle infarction (DMI) is a rare and under diagnosed complication of diabetes mellitus. Clinically it presents with acute to subacute onset swelling, pain and tenderness of muscle(s) without systemic manifestations. MRI is helpful in diagnosis, exclusion of other causes and for localization of affected muscle for biopsy in atypical cases. Muscles of the thighs are commonly affected in diabetic myonecrosis (DMN). Here we present the summary of four cases seen in the last 3 years in a tertiary care centre with simultaneous or sequential involvement of multiple groups of muscles or involvement of uncommon sites. All these patients had advanced duration of diabetes with microvascular complications and poor glycemic control. Conservative management including rest and analgesics is the treatment of choice. Short-term prognosis is good but there may be recurrence.

Learning points: A high index of suspicion is required for the diagnosis of DMN which can avoid inadvertent use of antibiotics.Acute-subacute onset severe focal muscle pain in the absence of systemic symptoms in a female patient with long-standing diabetes with microvascular complications suggests DMI.MRI is the most sensitive test for diagnosis.Muscle biopsy should be reserved for atypical cases.Conservative management including rest and analgesics has good outcome.Improvement usually occurs within 6-8 weeks, but there may be recurrence.

No MeSH data available.


Related in: MedlinePlus