Multifocal Diabetic Muscle Infarction: A Rare Complication of Poorly Controlled Diabetes Mellitus

Abstract

Diabetic muscle infarction (DMI) is a rare complication of long-standing poorly controlled diabetes mellitus. We herein describe the case of a 56-year-old man with a 10-year history of poorly controlled type 2 diabetes mellitus with multiple microvascular and macrovascular complications who presented with the sudden onset of left thigh pain and swelling. MRI suggested muscle infarction. A muscle biopsy demonstrated coagulation necrosis in the skeletal muscle with inflammation and infarction in the walls of small blood vessels. Physicians should consider DMI in the differential diagnosis of patients with diabetes who present with painful, swollen muscles without systemic signs of infection.

Diabetic Muscle Infarction: A Rare End-Organ Vascular Complication of Diabetes

“…The findings suggestive of DMI in this patient begin with her spontaneous acute muscular pain, markedly in her thighs, with no history of trauma or indication of infection. 1,2,5,7,[9][10][11]15,18 The severe pain, even at rest, was exacerbated by movement, which limited her mobility. 8,11,12,14,17,19,20 DMI usually presents unilaterally 4,10,18 in the proximal lower extremity (81-83%) with rare reports of distal leg involvement.…”

“…8,11,12,14,17,19,20 DMI usually presents unilaterally 4,10,18 in the proximal lower extremity (81-83%) with rare reports of distal leg involvement. 2,5,8,11,14,19,20 Muscles commonly affected include quadriceps (60%), 4,10,16,18 hip adductors (13%), 4,10,11,14,16 hamstrings (8%) 4,10,16,18 and hip flexors (2%). 4,10,16 Patients are typically afebrile, without skin discoloration, 9,11,20 and usually present with accompanying local swelling (90%-99%), 1,2,4,5,7-13,16-20 tenderness, 1,2,[4][5][6][7][8][9][10]12,13,[15][16]…”

“…2,5,8,11,14,19,20 Muscles commonly affected include quadriceps (60%), 4,10,16,18 hip adductors (13%), 4,10,11,14,16 hamstrings (8%) 4,10,16,18 and hip flexors (2%). 4,10,16 Patients are typically afebrile, without skin discoloration, 9,11,20 and usually present with accompanying local swelling (90%-99%), 1,2,4,5,7-13,16-20 tenderness, 1,2,[4][5][6][7][8][9][10]12,13,[15][16][17][18][19] and painful, palpable mass (44%). 2,6,7,9,[11][12][13][14]…”

“…Diabetic muscle infarction (DMI) is a rare microvascular complication consisting of spontaneous ischemic necrosis of skeletal muscle in patients with poorly controlled diabetes. Though its characteristics have been defined, fewer than 200 cases 1,2 have been reported since it was first described in 1965 by Angervall and Stener. 3 Originally, it was termed "tumoriform focal muscular degeneration," owing to the initial cases' resemblance to tumors, which in that case were completely excised.…”

“…DMI can occur in patients with either type 1 or 2 diabetes, with type 1 representing around 70% of cases. [7][8][9][10] Affected patients have a history of long-standing (>15 years) and poorly controlled diabetes (average Hgb a1c of 9.4% with a range of 5.0% to 12.4%), 2,4,5,[9][10][11][12][13][14][15][16] with a mean age of 43 years old at diagnosis 1,[5][6][7]9,13,16,17 and mean duration between diagnosis of diabetes and DMI around 14.4 years. 5,7,10,13,17 There seems to be a slight predilection towards females.…”