Diabetic Muscle Infarction of the Forearm in a Patient with Long-Standing Type 1 Diabetes

doi:10.4158/EP.12.2.188

Endocrine Practice

Volume 12, Issue 2, March–April 2006, Pages 188-192

https://doi.org/10.4158/EP.12.2.188 Get rights and content

ABSTRACT

Objective

To describe a case of diabetic muscle infarction affecting an upper extremity in a patient with long-term poorly controlled diabetes.

Methods

A case report of a patient with diabetes who presented with pain and swelling of his left arm is described, including clinical, laboratory, and radiologic findings. The results of pathologic examination are also illustrated. Moreover, we review the literature in a discussion of the evaluation, pathogenesis, and treatment of diabetic muscle infarction.

Results

A 41-year-old man with type 1 diabetes presented with a 1-week history of painful swelling of the left forearm. The leukocyte count and creatine kinase levels were normal. Magnetic resonance imaging of the left forearm revealed extensive deep tissue edema and an increase in T2 signal in the involved muscles. The patient was initially treated for cellulitis with intravenously administered antibiotics for 3 weeks without improvement. Muscle biopsy revealed skeletal muscle with prominent muscle fiber degeneration, myophagocytosis, and fibrosis, consistent with the diagnosis of diabetic muscle infarction. Once this diagnosis was made, antibiotic therapy was discontinued, and the condition was managed with narcotics and aggressive insulin therapy. Eight weeks after initial presentation, the patient reported complete resolution of symptoms.

Conclusion

Diabetic muscle infarction is a rare but underrecognized complication of diabetes. To our knowledge, we present only the second such reported case of upper extremity involvement in the literature. The results of pathologic examination interpreted in the context of the patient’s clinical history were consistent with the diagnosis. (Endocr Pract. 2006;12:188-192)

Section snippets

INTRODUCTION

Diabetic muscle infarction (DMI) is a rare, and often underrecognized, complication of poorly controlled diabetes. It occurs in patients with end-organ complications, including neuropathy, nephropathy, and retinopathy. Patients classically present with acute pain and edema in the involved muscle. The lower extremities are typically affected. We describe a case of upper extremity muscle infarction in a patient with type 1 diabetes mellitus who had multiple end-organ complications. The diagnosis

CASE REPORT

A 41-year-old man with a history of type 1 diabetes mellitus initially presented with a 1-week history of painful swelling of the left forearm. Three weeks before the current presentation, he had had an episode of severe hypoglycemia necessitating emergent intravenous access. He described gradually worsening pain and swelling but had no systemic complaints including fever or chills. His symptoms did not diminish with a 5-day course of cephalexin.

The patient had a history of uncontrolled type 1

DISCUSSION

DMI is a rare and often underrecognized complication of diabetes. It was first described in 1965 by Angervall and Stener (2) as “tumoriform focal muscular degeneration.” Since then, more than 100 cases have been reported. DMI usually occurs in patients with poorly controlled diabetes complicated by microvascular disease, including nephropathy, neuropathy, and retinopathy (3). The condition is more commonly seen in women than in men (3,4). A recent systematic review of reported cases found that

CONCLUSION

DMI is an underrecognized complication of diabetes. It can have unusual initial manifestations, and clinicians should be aware of DMI as a diagnostic possibility in the assessment of patients with diabetes, extremity pain, and edema regardless of whether the upper or lower limbs are involved. It should especially be considered in those patients with end-organ complications of their disease. MRI is perhaps the most useful diagnostic procedure, although muscle biopsy may be necessary in atypical

REFERENCES (16)

G.E. Umpierrez et al.
Diabetic muscle infarction
Am J Med.
(1996)
E.K. Bjornskov et al.
Diabetic muscle infarction: a new perspective on pathogenesis and management
Neuromuscul Disord.
(1995)
G.W. Palmer et al.
Diabetic thigh muscle infarction in association with antiphospholipid antibodies
Semin Arthritis Rheum.
(2001)
J.L. Eady et al.
Diabetic muscle infarction
J South Orthop Assoc.
(1997)
L. Angervall et al.
Tumoriform focal muscular degeneration in two diabetic patients
Diabetologia.
(1965)
A.J. Trujillo-Santos
Diabetic muscle infarction: an under-diagnosed complication of long-standing diabetes
Diabetes Care.
(2003)
Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 29-1997. A 54-year-old diabetic woman with pain and swelling of the leg
N Engl J Med.
(1997)
J.A. Morcuende et al.
Diabetic muscle infarction
Iowa Orthop J.
(2000)

There are more references available in the full text version of this article.

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Case ReportDiabetic Muscle Infarction of the Forearm in a Patient with Long-Standing Type 1 Diabetes

ABSTRACT

Objective

Methods

Results

Conclusion

Section snippets

INTRODUCTION

CASE REPORT

DISCUSSION

CONCLUSION

Am J Med.

Neuromuscul Disord.

Semin Arthritis Rheum.

Diabetic muscle infarction

J South Orthop Assoc.

Tumoriform focal muscular degeneration in two diabetic patients

Diabetologia.

Diabetic muscle infarction: an under-diagnosed complication of long-standing diabetes

Diabetes Care.

Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 29-1997. A 54-year-old diabetic woman with pain and swelling of the leg

N Engl J Med.

Diabetic muscle infarction

Iowa Orthop J.

Case Report
Diabetic Muscle Infarction of the Forearm in a Patient with Long-Standing Type 1 Diabetes