A Latent Autoimmune Diabetes in Adults Patient Manifesting Severe Musculoskeletal Complications

Patients with diabetes have many different kinds of complications involving multiple organs, but those involving the musculoskeletal system are relatively uncommon. Diabetic muscle infarction (DMI) is a rare, painful, and potentially serious condition in patients with poorly controlled diabetes mellitus. A 35-year-old man diagnosed with type 2 diabetes eight years ago, visited with severe muscle pain in the right anteromedial thigh without any event of trauma. He had been treated with metformin, but his glycemic control was very poor with a glycated hemoglobin of 14.5%. Evaluation of his painful thigh lesion did not reveal any evidence of infection or vasculitis, but the magnetic resonance imaging and bone scan showed findings of DMI at vastus medialis muscle and an insufficiency fracture at the right medial tibial condyle. He was diagnosed with retinopathy, neuropathy and microalbuminuria but not macrovascular complications. We also diagnosed his diabetes as latent autoimmune diabetes in adults (LADA) based on his low C-peptide level, positive anti-glutamic acid decarboxylase (GAD) antibody and early onset diabetes. Instead of antibiotics, bed rest, analgesics and strict blood glucose control with multiple daily insulin injections led to symptom improvement. This is an unusual case of a young man with LADA experiencing severe musculoskeletal complication of DMI and insufficiency fracture. If a poorly controlled diabetic patient appears to have unaccounted soft tissue pain, musculoskeletal complications such as DMI associated with hyperglycemia should be considered.

Case of Recurrent Diabetic Muscle Infarction Related to Strict Blood Glucose Control / 대한내과학회지

Diabetic muscle infarction (DMI) is an uncommon complication in patients with diabetes and it tends to be underdiagnosed, or misdiagnosed, clinically. Recently, we experienced a case of recurrent diabetic muscle infarction that was unusual in that the patient was younger than other patients. The patient was a 21-year-old woman with a 9-year history of maturity-onset diabetes of the young (MODY) who was referred to our department complaining of pain and edema in her right thigh. Magnetic resonance imaging (MRI) showed an increased T2-weighted signal and edema in the affected muscle. The final diagnosis was DMI. However, when the patient had partially recovered and was receiving supportive care, she had a second attack on the other side of the same leg during her hospitalization, in spite of her blood glucose level being strictly controlled. We report the clinical characteristics and imaging findings of this patient with recurrent DMI.

Recurrent diabetic myonecrosis: A rare complication of a common disease.

Spontaneous aseptic diabetic muscle infarction (DMI) is one of the rare complications of diabetes. We report a case of type 2 diabetes mellitus with advanced microvascular complications presenting with severe muscular pain. She was diagnosed as DMI on the basis of clinical presentation, radiological and histopathological investigations. She was managed conservatively. During 18 months of follow up, she had good improvement but subsequently other muscle groups were involved suggesting recurrent DMI.

Evidenced-based diagnosis for diabetic muscle infarction / 中国实用内科杂志

Objective To obtain the most effective diagnosis method for diabetic muscle infarction by using the evidence based medicine.Methods In March 2006 we attempted to find the guideline,systematic review,random controlled trials,clinical controlled trials and case reports for the diagnosis of diabetic muscle infarction by searching Cochrane Library(Issue 4,2005),Embase(1974—2005),Medline(1966—2005)and CNKI database(1949—2005),then critically appraised the quality of available evidences.Results According to the present evidence,when the the patient was suspected to have diabetic muscle infarction,we should choose the sonography to exclude some common diseases at first;the CT examination of all the patients showed no obvious manifestations;the normal MRI examination of 67 patients showed obvious manifestations;the patients who did the muscle biopsy or needle biopsy did not develop any complications.Conclusion The diagnosis of diabetic muscle infarction should be based on the clinical presentations and MRI outcome,but when the diagnosis is uncertain,we should use the needle biopsy to confirm the diagnosis at an early time.

Recurrent Muscle Infarction in a Diabetic Hemodialysis Patient / 대한신장학회잡지

Diabetic muscle infarction (DMI) is a rare complication of long-standing diabetes mellitus. The typical feature of DMI is abrupt onset of thigh pain, tenderness, and swelling and then spontaneous resolution over several months and frequent recurrence. Until 2004, a case of DMI has been reported among end-stage renal disease patients on dialysis in korea. Under-recognition or misdiagnosis (cellulitis, myositis, abscess, hemorrhage, and tumor) by physicians may contribute to the relative rarity of the diagnosis. We report a case of recurrent diabetic muscle infarction in a hemodialysis patient.

A Case of Diabetic Muscle Infarction in a Maintenance Hemodialysis Patient / 대한신장학회잡지

Diabetic muscle infarction (DMI) is a rare complication of diabetes. Its clinical features are similar with infectious diseases. We report DMI in a 44-yr-old woman with a 18 year history of type 2 diabetes and a 4 year history of end-stage renal disease on hemodialysis. She was admitted for a 2 day history of severe pain and swelling in the right thigh. It developed spontaneously without trauma. Physical examination revealed tenderness on the right thigh and body temperature was normal. Peripheral pulses of right leg were good at the tibialis posterior and dorsalis pedis. There was no deep vein thrombosis in the lower limb on Doppler ultrasound. MRI showed a diffuse swelling and increased signal of quadriceps muscle group in T2 weighted images. She was diagnosed as having DMI and improved following conservative therapy. There was no recurrence during the follow up. DMI could be investigated by clinical findings and MRI imaging in diabetic patients on maintenance hemodialysis.

A Case of Diabetic Muscle Infarction Affecting Upper and Lower Limbs / 대한류마티스학회지

Spontaneous diabetic muscle infarction (DMI) is a rare condition that usually occurs in those with longstanding microvascular complications of diabetes. Typical presentation is abrupt onset of painful swelling in the lower limbs, uncommonly in the upper limbs. We report a 49 year-old woman with DMI affecting not only both thighs but also left arm. She had already advanced diabetic complications of retinopathy, nephropathy, and neuropathy. Magnetic resonance imaging (MRI) showed findings of hyper-intense T2 weighted signals and rim enhancement after intravenously administered gadolinium at the sites of infarction. Excisional biopsy specimens of the thigh muscle contained aseptic necrotic muscle mixed with areas of muscle fiber atrophy and fibrosis. The diagnosis of DMI was considered most likely, and she was treated with muscle rest, analgesics, and physical therapy. The swelling and pain of the involved limbs improved gradually without complications. Since ten months after discharge, her symptoms resolved almost completely, and never relapsed. Hence, we report a rare case of DMI involving left arm and both thighs with review of literature.

Diabetic Muscle Infarction in a Patient with Continuous Ambulatory Peritoneal Dialysis / 대한신장학회잡지

Diabetic muscle infarction (DMI) is a rare condition occurring in subjects with long-standing complicated diabetes mellitus. We report DMI in a 65-year-old man with type 2 diabetes mellitus undergoing continous ambulatory peritoneal dialysis (CAPD) with review of this condition in the literature. He had been suffered from type 2 diabetes mellitus for 21 years. In 1997, he reached end-stage renal disease and had received on renal replacement therapy with CAPD since then. In June 2002, he presented with sudden and spontaneous onset of severe pain in the right thigh region. He was afebrile, and the right thigh was swollen and tender but not erythematous. Laboratory data on admission included white blood cell count of 15, 800/mm3, hemoglobin 9.0 g/dL, platelet count 264, 000/mm3, BUN 102.3 mg/dL, serum creatinine 9.9 mg/dL, fasting blood glucose 85 mg/dL, postprandial 2 hours blood glucose 162 mg/ dL, hemoglobin A1C 5.84%, ESR 125 mm/h (it was 52 mm/h one month earlier), CRP 18.9 mg/dL, and normal levels of creatinine kinase. Magnetic resonance imaging (MRI) showed asymmetry of the muscle in T1-weighted images and increased signal intensity involving the medial portion of right thigh (adductor longus, adductor magnus, vastus intermedius muscle, etc) in T2-weighted images with no contrast enhancement. Radioisotope venography of the ileo-femoral veins was normal, excluding deep venous thrombosis as a cause. The right thigh was explored surgically and a biopsy taken from the vastus intermedius muscle was consistent with chronically inflammed scar tissue with no evidence of malignancy. A biopsy taken from the vastus intermedius muscle showed hemorrhagic necrosis of skeletal muscle, with lymphcytic infiltration. Most of the blood vessels appeared normal. The swelling resolved spontaneously following a few weeks of bedrest and analgesia. To our knowledge, this is the first reported case of DMI in patients undergoing renal replacement therapy in Korea.