Painful swelling in the thigh: diabetic muscle infarction

Abstract

The case: A 52-year-old woman was admitted with painful swelling in her left thigh. She had a 12-year history of type 2 diabetes mellitus and hypertension, and she was a smoker (40 pack-year smoking history). At her last examination, her HbA 1C level was 7.7%, her serum total cholesterol level was 8.65 (normal < 5.17) mmol/L and her triglyceride level was 3.77 (normal < 2.26) mmol/L. She had diabetic retinopathy and microalbuminuria, and she had a myocardial infarction 12 years earlier. Two months before admission, the patient underwent a left femoropopliteal bypass for peripheral vascular disease. Her medications at the time of admission included acetylsalicylic acid, enalapril, metformin, glibenclamide and simvastatin.On admission, the patient complained of continuous severe pain in her anterior thigh that had developed gradually. The pain was not reduced by nonsteroidal antiinflammatory drugs taken orally. She reported that the pain was very intense, and that it was present at rest but became worse with movement. The pain had increased over the 4 weeks before presentation. She denied any trauma, fever or chills. The patient had lost 4 kg, and she was unable to walk because of the pain.A physical examination showed a firm swelling in the anterior part of her thigh. An area that measured 10 × 5 cm was hard and felt warm, and there was mild erythema and tenderness. The patient's muscle strength and motion were markedly limited by pain.Her acute phase reactants were elevated: her erythrocyte sedimentation rate was 153 (normal 0-30) mm/h, and her C-reactive protein level was 115 (normal 0.2-3.0) mg/L. She was anemic (hemoglobin 6.2 mmol/L) and had mild leukocytosis (11.2 [normal 3.8-9.8 . The results of liver function tests were normal. Doppler ultrasonography showed no abscess or deep vein thrombosis. Her femoropopliteal bypass graft and larger arteries were patent. Magnetic resonance imaging showed increased signal intensity on T 2 -weighted images of her left quadricep, with diffuse subcutaneous and fat edema. There was extensive swelling of the quadriceps vastus medialis and rectus with intermuscular edema (Figure 1, Figure 2). Despite 3 weeks of bed rest, opiates, enoxaparin and clopidogrel, there was only a slight clinical improvement. However, her Creactive protein level gradually decreased. An open muscle biopsy was performed to rule out a tumour. Instead, diabetic muscle infarction was confirmed (Figure 3). One week after the biopsy, there was significant worsening of her pain and severe edema of

Painful foot drop; a presentation of diabetic muscle infarction

“…Our patient presented with two symptomatic foci of muscle infarction, which is rare [1]. Case reports suggest that diabetic muscle infarction affects predominantly patients with Type 1 diabetes, with only 28 cases reported in Type 2 DM from a total of nearly 120 cases in the literature [1,4–7]. There is a female preponderance, often with a history of suboptimal glycaemic control.…”

“…The common peroneal nerve travels through a tight tunnel formed by stiff tissue boundaries and is particularly susceptible to compression by increased pressure such as that from oedema [3]. Diabetic muscle infarction was first described in 1965 and typically presents with an acute painful swelling, most commonly involving the thigh [1,4–7].…”

“…There is a female preponderance, often with a history of suboptimal glycaemic control. Coexisting diabetic microvascular complications are invariably present [1,4–7].…”

“…Diagnosis of diabetic muscle infarction is based on clinical findings and characteristic magnetic resonance images. The differential diagnoses are numerous and may include inflammatory myopathies such as polymyositis, infective causes such as osteomyelitis or cellulitis, diabetic amyotrophy, soft tissue tumours, deep vein thrombosis, arterial thrombosis, rhabdomyolysis and compartment syndrome [5–7].…”

Diabetic muscular infarct: an unusual cause of extremity pain and dysfunction

“…DiVerential diagnosis of DMI includes infections (pyomyositis, necrotizing fasciitis, cellulites, abscess, osteomyelitis), trauma (hematoma, exertional rupture of muscle, myositis ossiWcans), vascular (deep vein thrombosis, acute compartment syndrome), tumors (primary muscle lymphoma, soft tissue sarcoma, benign muscle tumor), inXammatory (focal inXammatory myositis, polymyositis, dermatomyositis), diabetes-related condition (diabetic amyotrophy), ruptured Baker's cyst, adverse reaction of simvastatin, and arterial graft complication [20]. Muscle abscesses, focal myositis, nodular myositis, polymyositis, hemorrhage, or neoplasm is characterized by a mass lesion like DMI, while disruption of the normal muscle architecture on MRI is expected.…”