Diabetic Muscle Infarction: An Uncommon Diabetic Complication with a Lack of Standardized Treatment

Diabetic muscle infarction (DMI) is a rare yet serious complication that has been strongly associated with uncontrolled diabetes. We present a rare case of diabetic muscle infarction in an African American man with end-stage renal disease (ESRD). We discuss the challenges involved with the diagnosis and treatment of this rare condition.

Case Description:

A 42-year-old African American man with uncontrolled type 2 diabetes mellitus and ESRD, presented to the hospital for acute new-onset right lower extremity pain and swelling. Clinical findings were notable for right lower extremity induration, tenderness, and swelling of the anterior medial thigh, with pitting edema and warmth to touch along the whole length of the thigh but sparing the inguinal and perineal regions, as well as the knee. Labs revealed an HgA1C of 8.6% as well as elevated inflammatory markers. Duplex ultrasound of the RLE was performed, which was negative for DVT. Magnetic resonance imaging (MRI) of the RLE showed increased T2 signal compatible with extensive muscle edema in the right thigh, most prominently involving the rectus femoris muscle and adductor musculature with relative sparing of the hamstring muscles. There was extensive subcutaneous edema, as well as fascial fluid noted. Given the patient’s history of poorly controlled diabetes, as well as compatible presentation and MRI findings, the diagnosis of DMI was made on clinical grounds.

Discussion:

DMI is an uncommon complication of diabetes initially reported in 1965. The mean HbA1C value at the time of diagnosis is 9.34%. DMI is most often seen in advanced, poorly controlled diabetes. Studies have shown that 46.4% of patients with DMI had concurrent microvascular complications, retinopathy, nephropathy, or neuropathy. In 65% of patients with DMI at least two of these complications were present. MRI is currently the best imaging study when DMI is suspected because of its high specificity. Muscle biopsy can also be used to confirm the diagnosis. However, it is usually used when there is an atypical presentation, if other results have been inconclusive, or if treatment fails to elicit improvement and the clinical suspicion remains high. A biopsy is not the preferred diagnostic modality as it can cause a significantly longer recovery period. The short-term prognosis of diabetic myonecrosis is good and generally resolves spontaneously over a few weeks. Treatment with NSAIDs has shown faster recovery times, but their use can be limited in patients with renal disease. Tight glycemic control is recommended to reduce the risk of recurrence.