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Diabetic Muscle Infarction of the Tibialis Anterior and Extensor Hallucis Longus Muscles Mimicking the Malignant Soft-Tissue Tumor.

Mimata Y, Sato K, Tokunaga K, Tsukimura I, Tada H, Doita M - Case Rep Orthop (2015)

Bottom Line: A typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscles, but the patient did not complain of pain.MRI findings of DMI can be similar to that of a malignant soft-tissue tumor.So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedic Surgery, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan.

ABSTRACT
One of the most common causes of skeletal muscle infarction is diabetic muscle infarction (DMI), a rare complication associated with poorly controlled diabetes. We report an atypical case of DMI localized in the tibialis anterior (TA) and extensor hallucis longus (EHL) muscles of an elderly individual. A 64-year-old man with type 2 diabetes mellitus presented with a 6-month history of a palpable mass in his lower left leg. Magnetic resonance imaging (MRI) revealed that the mass exhibited heterogeneous signals on T1- and T2-weighted images and slight heterogeneous enhancement within the muscles on fat suppressed T1-weighted images. Because histopathological analysis revealed mostly necrotic muscle tissues but no neoplastic cells, we resected the affected muscles. A typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscles, but the patient did not complain of pain. Therefore, the diagnosis and treatment for DMI were delayed, and widespread irreversible muscle necrosis developed. MRI findings of DMI can be similar to that of a malignant soft-tissue tumor. So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI.

No MeSH data available.


Related in: MedlinePlus

Macroscopic findings. Macroscopic findings revealed diffuse necrosis of tibialis anterior and extensor hallucis longus muscles.
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fig3: Macroscopic findings. Macroscopic findings revealed diffuse necrosis of tibialis anterior and extensor hallucis longus muscles.

Mentions: A 64-year-old man was referred to our hospital with the diagnosis of a soft-tissue tumor in the lower left leg. He had a 10-year history of type 2 diabetes mellitus, and he was consuming oral hypoglycemic agents. However neither nephropathy nor retinopathy was pointed out by clinical examination such as blood test, urine test, and funduscopy before, and he did not complain of sensory disturbance. He also had a history of reconstruction of an acute aortic dissection. He was aware of a palpable mass in his lower left leg but had neglected it for 6 months because he did not feel pain at the site of the lesion. The mass gradually expanded and developed large blisters. Physical examination revealed swelling without tenderness on the anterior aspect of the lower left leg. Blood tests revealed the following: C-reactive protein level, 0.05 mg/L; white blood cell count, 4,580/mm3; CK level, 164 IU/L; and casual blood glucose level, 298 mg/dL. Radiography revealed no bony abnormalities and calcification of soft tissue, but there was evidence of moderate soft-tissue swelling. Computed tomography (CT) revealed a large mass (maximum diameter, 7.2 cm; length, 21.0 cm) with cystic lesions in the region of the TA and EHL muscles (Figure 1). Neither the calcification nor ossification was detected inside and around the mass. The mass and cystic lesions were not contrasted but the anterior tibialis artery was clearly observed by using enhanced CT. MRI revealed that the mass exhibited heterogeneous signals on T1- and T2-weighted images and the cystic lesions exhibited homogeneous signals on T1- and T2-weighted images; perifascial, intramuscular, and/or subcutaneous edema was not seen (Figure 2). Fat suppressed gadolinium-enhanced T1-weighted images revealed slight heterogeneous enhancement within the affected muscle with focal hypointense nonenhancing areas. The ankle brachial index (ABI) was normal. To distinguish muscle necrosis from a malignant soft-tissue tumor, a needle biopsy (Tru-Cut biopsy needle, 14-gauge, CareFusion, CA, USA) was performed. However, we did not collect full volume of the muscle tissue; therefore, open surgical muscle biopsy was performed. Histopathological analysis revealed mostly necrotic muscle tissues, but neoplastic cells were not observed in the soft tissue resected from the lesion. Because the lesion was a remnant of a previous muscle infarction with several large blisters producing discharge, we resected the affected muscles (Figure 3). Excisional specimens revealed large areas of muscles with coagulative necrosis, fibrosis, and hemorrhage (Figure 4). Two weeks after surgery, the wound healed, and the patient was discharged. There is no evidence of any diseases including local recurrence at 9 months after surgery.


Diabetic Muscle Infarction of the Tibialis Anterior and Extensor Hallucis Longus Muscles Mimicking the Malignant Soft-Tissue Tumor.

Mimata Y, Sato K, Tokunaga K, Tsukimura I, Tada H, Doita M - Case Rep Orthop (2015)

Macroscopic findings. Macroscopic findings revealed diffuse necrosis of tibialis anterior and extensor hallucis longus muscles.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4506815&req=5

fig3: Macroscopic findings. Macroscopic findings revealed diffuse necrosis of tibialis anterior and extensor hallucis longus muscles.
Mentions: A 64-year-old man was referred to our hospital with the diagnosis of a soft-tissue tumor in the lower left leg. He had a 10-year history of type 2 diabetes mellitus, and he was consuming oral hypoglycemic agents. However neither nephropathy nor retinopathy was pointed out by clinical examination such as blood test, urine test, and funduscopy before, and he did not complain of sensory disturbance. He also had a history of reconstruction of an acute aortic dissection. He was aware of a palpable mass in his lower left leg but had neglected it for 6 months because he did not feel pain at the site of the lesion. The mass gradually expanded and developed large blisters. Physical examination revealed swelling without tenderness on the anterior aspect of the lower left leg. Blood tests revealed the following: C-reactive protein level, 0.05 mg/L; white blood cell count, 4,580/mm3; CK level, 164 IU/L; and casual blood glucose level, 298 mg/dL. Radiography revealed no bony abnormalities and calcification of soft tissue, but there was evidence of moderate soft-tissue swelling. Computed tomography (CT) revealed a large mass (maximum diameter, 7.2 cm; length, 21.0 cm) with cystic lesions in the region of the TA and EHL muscles (Figure 1). Neither the calcification nor ossification was detected inside and around the mass. The mass and cystic lesions were not contrasted but the anterior tibialis artery was clearly observed by using enhanced CT. MRI revealed that the mass exhibited heterogeneous signals on T1- and T2-weighted images and the cystic lesions exhibited homogeneous signals on T1- and T2-weighted images; perifascial, intramuscular, and/or subcutaneous edema was not seen (Figure 2). Fat suppressed gadolinium-enhanced T1-weighted images revealed slight heterogeneous enhancement within the affected muscle with focal hypointense nonenhancing areas. The ankle brachial index (ABI) was normal. To distinguish muscle necrosis from a malignant soft-tissue tumor, a needle biopsy (Tru-Cut biopsy needle, 14-gauge, CareFusion, CA, USA) was performed. However, we did not collect full volume of the muscle tissue; therefore, open surgical muscle biopsy was performed. Histopathological analysis revealed mostly necrotic muscle tissues, but neoplastic cells were not observed in the soft tissue resected from the lesion. Because the lesion was a remnant of a previous muscle infarction with several large blisters producing discharge, we resected the affected muscles (Figure 3). Excisional specimens revealed large areas of muscles with coagulative necrosis, fibrosis, and hemorrhage (Figure 4). Two weeks after surgery, the wound healed, and the patient was discharged. There is no evidence of any diseases including local recurrence at 9 months after surgery.

Bottom Line: A typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscles, but the patient did not complain of pain.MRI findings of DMI can be similar to that of a malignant soft-tissue tumor.So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI.

View Article: PubMed Central - PubMed

Affiliation: Department of Orthopedic Surgery, School of Medicine, Iwate Medical University, Morioka 020-8505, Japan.

ABSTRACT
One of the most common causes of skeletal muscle infarction is diabetic muscle infarction (DMI), a rare complication associated with poorly controlled diabetes. We report an atypical case of DMI localized in the tibialis anterior (TA) and extensor hallucis longus (EHL) muscles of an elderly individual. A 64-year-old man with type 2 diabetes mellitus presented with a 6-month history of a palpable mass in his lower left leg. Magnetic resonance imaging (MRI) revealed that the mass exhibited heterogeneous signals on T1- and T2-weighted images and slight heterogeneous enhancement within the muscles on fat suppressed T1-weighted images. Because histopathological analysis revealed mostly necrotic muscle tissues but no neoplastic cells, we resected the affected muscles. A typical symptom of DMI is severe abrupt-onset pain in the region of the affected muscles, but the patient did not complain of pain. Therefore, the diagnosis and treatment for DMI were delayed, and widespread irreversible muscle necrosis developed. MRI findings of DMI can be similar to that of a malignant soft-tissue tumor. So, it is necessary to consider the malignant soft-tissue tumor as one of the differential diagnoses of DMI.

No MeSH data available.


Related in: MedlinePlus