A case of diabetic muscle infarction in Japan

Musculoskeletal manifestations of the antiphospholipid syndrome

The scope of clinical and laboratory manifestations of the antiphospholipid syndrome (APS) has increased dramatically since its discovery in 1983, where any organ system can be involved. Musculoskeletal complications are consistently reported in APS patients, not only causing morbidity and mortality, but also affecting their quality of life. We reviewed all English papers on APS involvement in the musculoskeletal system using Google Scholar and Pubmed; all reports are summarized in a table in this review. The spectrum of manifestations includes arthralgia/arthritis, avascular necrosis of bone, bone marrow necrosis, complex regional pain syndrome type-1, muscle infarction, non-traumatic fractures, and osteoporosis. Some of these manifestations were reported in good quality studies, some of which showed an association between aPL-positivity and the occurrence of these manifestations, while others were merely described in case reports.

Diabetic muscle infarction: a systematic review

CONTEXT

Diabetic muscle infarction (DMI) is a rare complication associated with poorly controlled diabetes mellitus. Less than 200 cases have been reported in the literature since it was first described over 45 years ago. There is no clear 'standard of care' for managing these patients.

EVIDENCE ACQUISITION

PubMed searches were conducted for 'diabetic muscle infarction' and 'diabetic myonecrosis' from database inception through July 2014. All articles identified by these searches were reviewed in detail if the article text was available in English.

EVIDENCE SYNTHESIS

The current literature exists as case reports or small case series, with no prospective or higher-order treatment studies available. Thus, an evidence-based approach to data synthesis was difficult. The available literature is presented objectively with an attempt to describe clinically relevant trends and findings in the diagnosis and management of DMI.

CONCLUSIONS

Early recognition of DMI is key, so appropriate treatment can be initiated. MRI is the radiological study of choice. A combination of bed rest, glycemic control, and non-steroidal anti-inflammatory drug therapy appears to yield the shortest time to symptom resolution and the lowest risk of recurrence.

Retrospective analysis of treatment modalities in diabetic muscle infarction

Background

Diabetic muscle infarction (DMI) is a spontaneous necrosis of skeletal muscle of unknown etiology. The major risk factor is longstanding uncontrolled diabetes mellitus (DM). Optimal treatment for DMI is not known. The purpose of this study was to analyze the outcome of surgical treatment, physiotherapy, and bed rest in DMI.

Methods

We searched Medline from its inception to April 2013. We selected cases that provided sufficient data on recovery duration, recurrences, and non-recurrences. Baseline characteristics, including age, sex, microvascular complications, lesion size estimated on magnetic resonance imaging, type of diabetes, and duration of diabetes were assessed. The primary outcome was mean time to recovery from initial treatment and secondary outcomes were mean time to recurrence and recurrence rate.

Results

Mean time to recovery was 149 (95% confidence interval [CI] 113–186), 71 (95% CI 47–96), and 43 (95% CI 30–57) days for surgery, physiotherapy and bed rest, respectively. These figures were statistically significant only for surgery versus physiotherapy and surgery versus bed rest (P<0.01). Mean time to recurrence was 30, 107, and 297 days for surgery, physiotherapy, and bed rest, respectively. The recurrence rate was 57%, 44%, and 24% for surgery, physiotherapy, and bed rest, respectively.

Conclusion

Our results show a similar outcome for physiotherapy as compared with bed rest. It also confirms nonsurgical treatment as a better therapeutic option compared with surgical treatment.

Multiple recurrences of diabetic muscle infarction: case report and literature review

This is the report a case of diabetic muscle infarction (DMI) associated with multiple recurrences and a review of the literature on DMI from the first description in 1965 to the present. Specifically the review of the clinical, laboratory, and muscle histopathologic features of 86 reported cases of DMI.Patients with DMI usually present with acute or subacute focal lower extremity muscle pain or swelling. Elevations in the white blood cell count and erythrocyte sedimentation rate are common laboratory findings. Magnetic resonance imaging, a highly sensitive diagnostic test in DMI, shows increased T2-weighted signal and edema in affected muscles. Typical muscle histopathology includes muscle fiber necrosis and endomysial inflammation. Slow symptomatic improvement usually occurs over a period of 1 to 6 months. Conservative therapy and analgesics seem appropriate for most patients. Although self-limiting, DMI is often associated with recurrent muscle infarctions and multisystem diabetes-related complications. Diabetes-induced arteriosclerosis and microangiopathy are the suggested causes of DMI.It is concluded that DMI is an uncommon but probably underrecognized disorder causing focal muscle pain and swelling, usually of thigh or calf muscles, in patients with diabetes mellitus complicated by poorly controlled hyperglycemia and multiorgan complications.

Diabetic myopathy: MRI patterns and current trends

OBJECTIVE

This study retrospectively evaluates diabetic myopathy in a large referral hospital population. It describes the MRI findings and the distribution of muscle involvement, including comparison with clinical parameters.

MATERIALS AND METHODS

MRI reports of the lower extremities from July 1999 through January 2006 were reviewed and compared with clinical parameters for patients with diabetic myopathy. Clinical parameters (e.g., type of diabetes, hemoglobin A(1C) level, creatine kinase level, and erythrocyte sedimentation rate [ESR]) and the presence of complications, including nephropathy, neuropathy, and retinopathy, were noted. The distribution of muscle involvement and imaging features were reviewed.

RESULTS

Over a 79-month period, 21 extremities (11 thighs and 10 calves) of 16 patients were imaged. Fourteen (88%) patients had type 2 diabetes, and two (12%) had type 1 diabetes. Four patients (25%) had disease in more than one location. In the thigh, the anterior compartment was involved in all patients. The posterior compartment was affected in nine (90%) of 10 calves. Muscle infarction and necrosis was seen in eight (38%) extremities. The creatine kinase level, ESR, and hemoglobin A(1C) level were elevated in the majority of cases. Coexisting nephropathy (50%), neuropathy (50%), and retinopathy (38%) were present in these patients.

CONCLUSION

Diabetic myopathy may occur more frequently in patients with type 2 diabetes than previously reported. In this population, T2-weighted and contrast-enhanced images have similar findings, and the increased coexistence of nephropathy makes administration of gadolinium-based contrast agents ill-advised. With a typical clinical presentation and MRI findings, a confident diagnosis can be made, and potentially harmful biopsy is avoided. Diabetic myopathy encompasses a spectrum of diseases, including muscle inflammation, ischemia, hemorrhage, infarction, necrosis, fibrosis, and fatty atrophy. It is usually seen with long-standing, poorly controlled diabetes.

Treatment and outcomes of diabetic muscle infarction

BACKGROUND

Diabetic patients can develop spontaneous infarctions of muscle. The optimal treatment of this diabetic muscle infarction (DMI) is unknown.

OBJECTIVE

This analysis was conducted to compare the outcomes of conservative, medical, and surgical treatments of DMI. The primary outcome is the time to recovery. Secondary outcomes include recurrence and mortality rates.

METHODS

A MEDLINE search from its inception to December 2002 was used to identify reported cases of DMI. We selected those cases that reported on specified baseline characteristics of the patients, including age, gender, duration of diabetes, type of diabetes, diabetic microvascular and macrovascular complications, and the magnetic resonance imaging or computed tomography findings, the type of therapy provided, the time to recovery of initial muscle infarction, recurrences, and deaths.

RESULTS

A total of 36 references meeting our inclusion criteria were retrieved, describing 49 patients. Thirty-four patients received conservative therapy (bedrest and analgesics), 8 received medical therapy (antiplatelet agents and/or steroids), and 7 had surgical excision of the infarcted muscle. There were no significant differences in baseline characteristics. The time to recovery from treatment onset was 8.1 weeks, 5.5 weeks, and 13 weeks in the conservative, medical, and surgical treatment groups, respectively. This was statistically significant only when comparing medical and surgical treatment. The respective recurrence rates were 35%, 29%, and 71%. The respective mortality rates within 2 years were 4%, 14%, and 29%.

CONCLUSION

This study supports the use of nonsurgical treatment in patients with DMI. It also demonstrates that DMI can be temporally associated with death.

[Diabetic muscle infarction-an orthopedic disease pattern?]

Diabetic muscle infarction (DMI) is a largely unfamiliar disease. It affects mainly patients around 40 years of age with long-standing diabetes and concomitant end-organ complications. The symptoms represent a classic pattern of a musculoskeletal disease with muscle pain without trauma, swelling, and functional impairment. Although its short-term prognosis is good, with improvement of the symptoms over weeks or months under analgesia and rest, a high recurrence rate of up to 60% can be observed. Additionaly, the long-term survival of patients after DMI is reduced mostly due to major vascular complications. Since many diabetic patients are in orthopedic care for musculoskeletal disorders, the orthopedic surgeon should be aware of this disease to avoid unnecessary invasive diagnostic procedures and initiate suitable therapy. Furthermore, a better knowledge of the disease could lead to definite conclusions regarding its real incidence and aid in establishing new therapeutic measures for prophylaxis and better long-term survival.

Diabetic muscle infarction: an underdiagnosed complication of long-standing diabetes

OBJECTIVE

To systematically review all the reported cases of diabetic muscle infarction (DMI) and its pathogenesis, clinical features, prognostic implications, and management.

RESEARCH DESIGN AND METHODS

We searched databases (MEDLINE and EMBASE) from their inception to August 2001 and reviewed bibliographies in reports retrieved. Data were extracted in a standardized form.

RESULTS

A total of 47 references were retrieved; 115 patients and 166 episodes were included. DMI was more frequent in women (61.5%, mean age at presentation 42.6 years). Of the cases, 59% had type 1 diabetes; the mean duration of disease was 14.3 years, and multiple diabetic end-organ complications were noted. DMI affects the lower limbs with abrupt onset of pain and local swelling. Diagnosis is made by biopsy, but the characteristic features in magnetic resonance imaging are very typical. Treatment includes bed rest and administration of analgesics, but recurrence is common.

CONCLUSIONS

DMI is a very uncommon complication of long-standing diabetes; presentation is well characterized and management is simple.

Diabetic muscle infarction after simultaneous pancreas-kidney transplant

Diabetic muscle infarction (DMI) is a rare entity that occurs in patients with long-standing type 1 insulin dependent diabetes mellitus (IDDM). We describe DMI occurring on an average of 5 months after SPK in four patients with IDDM and end stage renal disease (ESRD). These patients had evidence of other long-term diabetic complications including retinopathy and neuropathy, as well as microangiopathy and hypercoagulability, both of which are pre-disposing factors for DMI. The etiology of DMI is not well understood. Despite establishment of normoglycemia after kidney-pancreas transplantation, DMI may occur as a result of tissue damage/fragility secondary to the pre-existing long-term labile glycemic control and hypertension. This may be exacerbated by the pro-coagulant effects of the calcineurin-inhibitors and the use of steroids as part of the immunosuppressive regimen.

[Muscle infarction. An unknown complication of diabetes mellitus]

INTRODUCTION

Diabetic muscle infarction (MI) is a rare and little-known complication of diabetes mellitus.

CASE REPORT

We report a case of relapsing MI in which magnetic resonance imaging (MRI) suggested the diagnosis. A 53-year-old man with multi-complicated type II diabetes mellitus was admitted to our unit for illness and deep tumefaction of the right thigh. Because of unconclusive MRI, a muscular biopsy of the lesion was performed and MI confirmed. Three months after, a left relapse of MI occurred. Immediate treatment with immobilization and heparinotherapy permitted a rapid recovery.

CONCLUSION

About 70 previously reported cases are reviewed. The mean age at presentation was about 40 years. MI was usually seen in patients with long-standing diabetes with multiple end organ microvascular complications. Homo- or heterolateral recurrences are reported in almost half of the patients. MRI is the best imaging technique for suggesting the diagnosis.