Diabetic Musculoskeletal Complications and Their Imaging Mimics

Abstract

Diabetes mellitus is increasingly prevalent and results in various clinically important musculoskeletal disorders affecting the limbs, feet, and spine as well as in widely recognized end-organ complications such as neuropathy, nephropathy, and retinopathy. Diabetic muscle ischemia-a self-limited disorder-may be confused with infectious or inflammatory myositis, venous thrombosis, or compartment syndrome. The absence of fever and leukocytosis, combined with the presence of bilaterally distributed lesions in multiple and often noncontiguous muscles in the legs, including the thighs, is suggestive of ischemia; by contrast, the presence of well-defined intramuscular abscesses with rimlike enhancement favors a diagnosis of infectious pyomyositis. In the diabetic foot, an ulcer, sinus tract, or abscess with an adjacent region of abnormal signal intensity in bone marrow favors the diagnosis of pedal osteomyelitis over that of neuropathic arthropathy. Contrast material-enhanced magnetic resonance imaging is important when planning the treatment of foot infections in diabetic patients because it allows the differentiation of viable tissue from necrotic regions that require surgical débridement in addition to antibiotic therapy. Subtraction images are particularly useful for visualizing nonviable tissue. Dialysis-associated spondyloarthropathy characteristically occurs in diabetic patients with a long history of hemodialysis. Intervertebral disk space narrowing without T2 signal hyperintensity, extensive endplate erosions without endplate remodeling, and facet joint involvement are suggestive of spondyloarthropathy instead of infectious diskitis or degenerative disk disease. Although the clinical features of these conditions may overlap, knowledge of the patient's medical history, coupled with recognition of key imaging characteristics, allows the radiologist to make a prompt and correct diagnosis that leads to appropriate management.

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update)

“…MRI is widely available (in high income countries), with lower costs than some of the newer advanced imaging technologies, and gives an overview of the presence and anatomy of both soft tissue and bone infections in the foot. The presence of reactive bone marrow edema from non‐infectious pathologies, such as trauma, previous foot surgery or Charcot neuroarthropathy, lowers the specificity and positive predictive value . In selected patients with possible neuro‐osteoarthropathy, newer techniques such as MR angiography, dynamic contrast‐enhanced MRI or neurography may better distinguish Charcot from osteomyelitis .…”

“…The presence of reactive bone marrow edema from non-infectious pathologies, such as trauma, previous foot surgery or Charcot neuroarthropathy, lowers the specificity and positive predictive value. 81,82 In selected patients with possible neuro-osteoarthropathy, newer techniques such as MR angiography, dynamic contrast-enhanced MRI or neurography may better distinguish Charcot from osteomyelitis. [83][84][85][86] Newer advanced imaging tests, especially…”

Sentinel Lymph Node Biopsy for Gastrointestinal Cancers

“…Diyabetik hastalarda osteomiyelit, hemen her zaman, bir ülser ile devamlılığı olacak şekilde, komşuluk yoluyla ortaya çıkar (7,8,9). Osteomiyelit tanısında altın standart yöntem, kemik biyopsisidir (7).…”

“…Eğer bu, lokal ülserasyon ile ilişkili ise de, altta yatan bir osteomiyelite işaret eder (11). Ancak, belirsizliğin yüksek olması nedeniyle, laboratuvar ve görüntüleme yöntemlerine başvurulması gereklidir (7). Laboratuvar Tüm hastalarda; tam kan sayımı, beyaz küre sayısı ve kan glukoz seviyesi öncelikli olarak belirlenmelidir.…”

Arabinofuranose‐derived positron‐emission tomography radiotracers for detection of pathogenic microorganisms

“…In addition to traditional laboratory and sampling methods, diagnostic imaging tools are frequently used in the work‐up of infection and include computed tomography (CT), single photon emission CT (SPECT), magnetic resonance imaging (MRI), and hyperpolarized 13 C magnetic resonance (HP MR) spectroscopy. While essential, these methods frequently suffer from low diagnostic accuracy due to their inability to differentiate infection from inflammation, cancer, and rheumatologic disease and tedious data acquisition 2–5 . In light of these concerns, several groups including ours hope to develop faster, more accurate, and higher resolution positron emission tomography (PET) tools for imaging bacterial infection.…”