Diabetes-Associated Focal Myonecrosis: A Case Report and Literature Review.

Diabetes-associated focal myonecrosis is a rare complication seen in individuals with long-standing uncontrolled diabetes, characterized by inflammation and necrosis of a single or group of muscles. The exact cause of this condition is not well understood, but it is believed to be due to focal muscle infarction secondary to arteriosclerosis and diabetic microangiopathy. Diagnosis is challenging and often requires clinical examination, lab investigations, imaging, and EMG. Treatment is mainly supportive with pain control and tight glycemic control, and surgical intervention is rarely needed. The clinical presentation includes a sudden onset of localized pain and swelling in the affected muscle, which may be accompanied by fever, malaise, and weight loss. Diabetic myonecrosis exhibits a slightly higher prevalence in females and commonly manifests at an early stage. While the short-term prognosis is good, the recurrence rate is high, often affecting the opposite limb within six months. Our case describes a 35-year-old young male with uncontrolled diabetes mellitus, diagnosed one year ago, who presented with medial thigh pain and tenderness for the last two days. Due to his early disease, focal myonecrosis was not our first differential diagnosis. A CT scan with contrast revealed findings consistent with either focal myositis or infarction. We ruled out other causes, including infections, autoimmune disease, trauma, and medications, and in combination with the patient's uncontrolled diabetes mellites, a diagnosis of diabetes-associated focal myonecrosis was made. The patient improved with blood sugar control and supportive care, including nonsteroidal anti-inflammatory drugs and muscle relaxants.

Papillary Muscle Infarction by Cardiac MRI in Patients With Mitral Regurgitation.

BACKGROUND: Papillary muscle (PM) infarction (PMI) detected by cardiac magnetic resonance imaging (CMR) is associated with poor outcomes. Whether PM parameters provide more value for mitral regurgitation (MR) management currently remains unclear. Therefore, we examined the prognostic value of PMI using CMR in patients with MR. METHODS: Between March 2018 and July 2023, we retrospectively enrolled 397 patients with MR undergoing CMR. CMR was used to detect PMI qualitatively and quantitively. We also collected baseline clinical, echocardiography, and follow-up data. RESULTS: Of the 397 patients with MR (52.4 ± 13.9 years), 117 (29.5%) were assigned to the PMI group, with 280 (70.5%) in the non-PMI group. PMI was demonstrated more in the posteromedial PM (PM-PM, 98/117) than in the anterolateral PM (AL-PM, 45/117). Compared with patients without PMI, patients with PMI had a decreased AL-PM (41.5 ± 5.4 vs. 45.6 ± 5.3)/PM-PM diastolic length (35.0 ± 5.2 vs. 37.9 ± 4.0), PM-longitudinal strain (LS, 20.4 ± 6.1 vs. 24.9 ± 4.6), AL-PM-LS (19.7 ± 6.8 vs. 24.7 ± 5.6)/PM-PM-LS (21.2 ± 7.9 vs. 25.2 ± 6.0), and increased inter-PM distance (25.7 ± 8.0 vs. 22.7 ± 6.2, all p < 0.001). Multiple logistic regression analyses identified male sex (odds ratio [OR] = 3.65, 95% confidence interval = 1.881-7.081, p < 0.001) diabetes mellitus (OR/95% CI/p = 2.534/1.13-5.68/0.024), AL-PM diastolic length (OR/95% CI/p = 0.841/0.77-0.92/< 0.001), PM-PM diastolic length (OR/95% CI/p = 0.873/0.79-0.964/0.007), inter-PM distance (OR/95% CI/p = 1.087/1.028-1.15/0.003), AL-PM-LS (OR/95% CI/p = 0.892/0.843-0.94/< 0.001), and PM-PM-LS (OR/95% CI/p = 0.95/0.9-0.992/0.021) as independently associated with PMI. Over a 769 ± 367-day follow-up, 100 (25.2%) patients had arrhythmia. Cox regression analyses indicated that PMI (hazard ratio [HR]/95% CI/p = 1.644/1.062-2.547/0.026), AL-PM-LS (HR/95% CI/p = 0.937/0.903-0.973/0.001), and PM-PM-LS (HR/95% CI/p = 0.933/0.902-0.965/< 0.001) remained independently associated with MR. CONCLUSIONS: The CMR-derived PMI and LS parameters improve the evaluation of PM dysfunction, indicating a high risk for arrhythmia, and provide additive risk stratification for patients with MR.

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, although other risk factors are unclear. DMI is an uncommon complication of diabetes with a lack of structured guidelines for evaluation or management. End-stage renal disease (ESRD) could have further implications in patients with DMI in terms of management given that nonsteroidal anti-inflammatory drugs (NSAIDs), which have been shown to reduce the recovery times and recurrence of DMI, could be contraindicated. We present a rare case of DMI in an African American man with ESRD who presented for new-onset right lower-extremity pain and swelling. We discuss the challenges involved with the diagnosis and treatment of this rare condition. This case adds to the knowledge of DMI, which is limited because of the low incidence of this condition, and it helps us understand how this condition affects the African American population and patients with ESRD.

Diabetic muscle infarction: A case report.

Diabetes muscle infarction (DMI) is a rare complication of diabetes in which patients who present with DMI more commonly have some form of kidney disease in addition to diabetes mellitus. DMI typically presents with muscle pain and swelling. Diagnosis typically requires imaging (MRI with gadolinium contrast is the gold standard) and a variety of laboratory studies may aid in the diagnosis. Treatment of DMI varies depending on the severity of the case. In general patients recover quickly, though there is a risk of recurrence. This particular case report is a 36 year old female who presented with right lower extremity pain and chronic kidney disease. Case reports like this are important to highlight DMI as it is likely to become more common as diabetes continues to become more prevalent.

A Hidden Complication of Poorly Managed Diabetic Control: A Case of Diabetic Myonecrosis.

Diabetic myonecrosis is an infrequently encountered complication of poorly managed type 2 diabetes. Despite its relative rarity, early detection and appropriate management can yield favorable outcomes. This case report details the presentation, diagnosis, and management of a 53-year-old male patient with a history of type 2 diabetes who presented with acute-onset pain, swelling of the muscles, and weakness. Following a battery of laboratory investigations, radiological imaging, and a muscle biopsy, the patient was diagnosed with diabetic myonecrosis. The patient was treated conservatively with analgesics, physiotherapy, and optimization of glycemic control, significantly improving muscle strength and function. This case highlights the necessity of considering diabetic myonecrosis as a potential differential diagnosis in diabetic patients who present with sudden muscle weakness and discomfort.

Recurrent diabetic myonecrosis in an African American woman with long-standing uncontrolled type 2 diabetes: a case report.

BACKGROUND: Diabetic myonecrosis, also called diabetic muscle infarction, is an uncommon complication of uncontrolled diabetes mellitus and is frequently underdiagnosed. The objective of this case report is to highlight the challenges in the early diagnosis and treatment of this disease. CASE PRESENTATION: A 51-year-old African American woman with a long history of uncontrolled diabetes mellitus presented to her primary care physician with right thigh pain. A diagnosis of diabetes myonecrosis was made on the basis of magnetic resonance imaging, biopsy, and negative autoimmune panel. After failing conservative treatment, the patient was treated with prednisone with gradual improvement of her symptoms. However, she had a recurrence of myonecrosis almost one year after her original presentation, which was also treated with prednisone. The recurrence had a shorter course and the patient recovered well. Challenges to the treatment in this patient were her debilitating pain and her underlying chronic kidney disease. CONCLUSIONS: A high index of suspicion for diabetic myonecrosis is necessary when a patient with diabetes presents with unilateral focal leg pain and swelling. Magnetic resonance imaging and biopsy can help confirm the diagnosis. Prednisone may be considered in patients who lack spontaneous regression with just rest. Educating healthcare professionals about this uncommon condition is of utmost importance in avoiding unnecessary testing and inappropriate treatment.

A Rare and Unique Complication of Uncontrolled Type 2 Diabetes Mellitus: A Case Report and Literature Review of Spontaneous Diabetic Myonecrosis.

There are many microvascular and macrovascular complications regarding uncontrolled diabetes mellitus (DM). Among them, diabetes myonecrosis is one of the complications but rarely seen in the uncontrolled DM patient population. Here, we present a rare case of DM myonecrosis in a patient with elevated hemoglobin A1c (HbA1c) of 18.2% and discuss the literature review of diabetes myonecrosis. A 48-year-old male with hypertension and uncontrolled type 2 diabetes mellitus (T2DM) with hemoglobin A1c of 18.2% presented with progressive swelling and pain in the right thigh for two days. Physical examination demonstrated swollen and tense tender right thigh with a circumference five inches larger than the left. Computed tomography (CT) and magnetic resonance imaging (MRI) results revealed severe myositis of the right leg, likely myonecrosis, and associated fascial edema/fasciitis. The patient was also complicated with diffuse anasarca, which was corrected with albumin transfusion and furosemide. Aspirin and lisinopril were also started for antithrombotic and cardioprotective effects. The right thigh swelling improved, and the patient could ambulate with supportive measures and regular physical therapy (PT). He was discharged home after 45 days of hospitalization. Diabetic myonecrosis is a rare condition and hence is underdiagnosed. In patients with uncontrolled diabetes, especially with diabetic complications, physicians should have high clinical suspicion to diagnose diabetic myonecrosis when patients present with an acute unilateral painful swollen limb. Our case highlights the complicated course of diabetes myonecrosis with anasarca, improved with supportive measures.

Diabetic Muscle Infarction-A Rare Diabetic Complication: Literature Review and Case Report.

We present a case of a 31-year-old patient with type 1 diabetes diagnosed at the age of 6. Diabetes is complicated with neuropathy, retinopathy, and nephropathy. He has been admitted to the diabetes ward due to inadequate diabetes control. Gastroscopy and abdominal CT were performed, and gastroparesis was confirmed as an explanation for postprandial hypoglycemia. During hospitalization, the patient reported sudden pain localized on the lateral, distal part of his right thigh. The pain occurred at rest and was aggravated by movement. Diabetic muscle infarction (DMI) is a rare complication of long-lasting, uncontrolled diabetes mellitus. It usually occurs spontaneously, without any previous infection or trauma, and is often misdiagnosed clinically as an abscess, neoplasm, or myositis. DMI patients suffer from pain and swelling of the affected muscles. Radiological examinations, including MRI, CT, and USG, are most important for the diagnosis, assessing the extent of involvement and differentiating DMI from other conditions. However, sometimes a biopsy and histopathological examination are necessary. The optimal treatment has still not been determined. There is also a potential risk of DMI recurrence.

Diabetic myonecrosis, an uncommon presentation of diabetes mellitus in tropical area: A case report.

Diabetic myonecrosis is an uncommon complication related to long-standing poorly controlled diabetes. A 33-year-old Sudanese male patient with type one diabetes presented with progressive, severe bilateral thigh pain with low-grade fever. Laboratory results show hyperglycemia with ketonuria and elevated creatine kinase but normal white cell blood count. The patient was diagnosed initially with diabetic ketoacidosis with pyomyositis and received analgesic and insulin; the patient partially improved. After the second evaluation, bilateral thigh MRI was requested and shows diffuse edema involving the medial muscle group of the upper third of the right side with intramuscular facial edema, appearing as low signal in T1 and high signal in T2 and fat suppression images with no evidence of collection or abscess. Diagnosis of diabetic myonecrosis was made. The patient was managed conservatively and discharge on aspirin with full recovery.

Spontaneous Diabetic Myonecrosis Presenting as Acute Carpal Tunnel Syndrome.

A 57-year-old man with diabetes mellitus presented with a 4-day history of left palm pain out of proportion, with swelling, erythema, and dense median and ulnar nerve distribution sensory changes. Magnetic resonance imaging with and without contrast revealed diffuse hand edema and myonecrosis. The patient was treated surgically because the examination was concerning for acute carpal tunnel syndrome and ulnar nerve compression. Spontaneous diabetic myonecrosis is a complication of diabetes mellitus that can be confused with several other conditions. It presents as acute-onset painful swelling in any muscle, and in the hand, may cause compressive neuropathies that necessitate surgical intervention.

Case report: Diabetic muscle infarction with diabetic ketoacidosis: A rare complication of diabetes.

Background: Diabetic muscle infarction (DMI), which is also referred to as diabetic myonecrosis, is a rare and long-term complication of poorly controlled diabetes mellitus, while we found that acute diabetes decompensation, such as diabetic ketoacidosis (DKA), could also stimulate the occurrence and development of DMI. Case presentation: A 23-year-old woman with type 1 diabetes presented with a 10-day history of nausea, vomiting, pain, and swelling of her left leg. Her urine ketone test was positive. The 3-beta-hydroxybutyrate and leukocyte counts and creatine kinase levels were elevated. Magnetic resonance imaging of the left thigh revealed extensive deep tissue oedema and an increase in the T2 signal in the involved muscles. Once the diagnosis of DMI was made, she was managed with rest, celecoxib, clopidogrel and aggressive insulin therapy. Three months after treatment, the patient reported complete resolution of symptoms. Conclusion: DMI is a rare DM complication with a high recurrence rate, commonly presenting with chronic complications, while our case report shows that acute diabetes decompensation, such as DKA, can stimulate the occurrence and development of DMI. Timely diagnosis and appropriate treatment could shorten the recovery time.

Spontaneous infarction of lumbar roots, vertebrae and paravertebral muscles.

Ischemic injury to the lumbosacral nerve roots and plexus is a rare condition resulting from thrombosis of one or several lumbar arteries. As the arterial supply of the spine presents great variations between subjects, the clinical presentation of lumbar thrombosis is highly variable depending on the relative involvement of nerve roots, bones or muscles. Diagnosis can be challenging, especially in the acute phase, as different structures can be simultaneously involved. The identification of an enlarged vessel centered in the area of tissue damage can help with the final diagnosis. We present the case of a 59-year-old woman who presented with spontaneous incomplete cauda equina syndrome due to diffuse lumbar nerve root infarction. On imaging, acute lumbar artery thrombosis was confirmed, and in addition to nerve roots, adjacent vertebral and paraspinal muscle infarctions were also present.

Diabetic myonecrosis: an unusual mimicker of idiopathic inflammatory myositis.

Diabetic myonecrosis or diabetic muscle infarction (DMI), is a very rare and under-recognised complication of poorly controlled long-standing diabetes mellitus. We report a case of a 59-year-old male, who had diabetes for ten years. He presented with bilateral thigh pain of insidious onset for three months and difficulty in walking, with a similar episode in his right thigh in 2015. Creatine phosphokinase (CPK) was one and half times the normal upper limit. Magnetic resonance imaging (MRI) of his thighs showed symmetrical bulky muscles with hyperintensities on T2-weighted and short tau inversion recovery (STIR) images, supporting a clinical diagnosis of idiopathic inflammatory myositis (IIM). However, a review of histopathology slides of a muscle biopsy from the right vastus lateralis performed in 2015 showed muscle fibre ischaemic necrosis suggestive of muscle infarction. Thus a diagnosis of recurrent diabetic myonecrosis was made and the patient was treated with bed rest, opioids and aspirin with gradual recovery.

Impact of posteromedial papillary muscle infarction on mitral regurgitation during ST-segment elevation myocardial infarction.

The exact role of papillary muscle infarction (PMI) during the acute phase of acute ST-segment elevation myocardial infarction (STEMI) is not well understood, as existing data on the impact of PMI location is conflicting. We hypothesized that infarction of the posteromedial papillary muscle (PM-PMI) as determined by cardiac magnetic resonance imaging might be associated with an increased incidence of mitral valve regurgitation in the first week after STEMI. 242 patients with first STEMI underwent a late-enhancement (LGE-) cardiac magnetic resonance imaging within a median of 2 (IQR 2-5) days and echocardiography within 3 (IQR 2-5) days after primary angioplasty for the index event. PMI was scored based on short axis slices (AL-PMI: anterolateral PMI, PM-PMI, AL/PM-PMI: AL- and PM-PMI). Patients with PM-PMI had significantly higher odds (OR 2.62, p < 0.01) for the occurrence of mitral regurgitation than patients with no-PMI, AL-PMI or AL/PM-PMI. Furthermore, advanced age, non-anterior infarct location and longer pain-to-balloon time were identified as risk factors for the occurrence of mitral regurgitation. Binary logistic regression analysis revealed that PM-PMI is a predictor of mitral regurgitation independent of infarct location and age (OR 2.229, CI 1.078-4.903, p = 0.031). PM-PMI as determined by cardiac magnetic resonance imaging is an independent predictor of mitral regurgitation in the setting of acute STEMI. Our data might improve our understanding of the dynamic nature of functional mitral regurgitation.

Diabetic myonecrosis: A case series of two dialysis-dependent patients.

Diabetic myonecrosis (DMN) is a rare microangiopathic disorder that can present as an acutely painful and swollen limb in patients with established diabetes mellitus. The condition can be diagnosed noninvasively with magnetic resonance imaging and resolves with analgesia, bed rest, and glycemic control. Due to a relative lack of awareness regarding the condition, avoidable interventions such as muscle biopsies and even surgery are sometimes pursued, which have been associated with prolonged recovery times. The majority of patients with DMN have diabetic nephropathy, yet this condition is not widely recognized in the nephrology community, resulting in delayed diagnosis and patients undergoing unnecessary and potentially harmful investigations. There is therefore a need for increased awareness of the condition among renal physicians. Here, we report the cases of two patients on hemodialysis who were ultimately diagnosed with DMN, along with a review of the literature.

Diabetic Muscle Infarction: An Uncommon Cause for Acute Limb Pain in Dialysis Patients.

Diabetic muscle infarction (DMI) is one of the unusual complications of poorly controlled diabetes. It is usually seen in association with other microvascular complications. This condition is reported rarely, probably due to it's under recognition. It is also seen in patients with chronic kidney disease and should be considered in patients presenting with acute onset of limb pain. Here we present two cases of DMI in dialysis patients and discuss the available literature to highlight the clinical characteristics of the cases. We also present a diagnostic algorithm to discuss evaluation of dialysis patients presenting with limb pain.

Diabetic muscle infarction: often misdiagnosed and mismanaged.

A patient with type 2 diabetes, retinopathy, neuropathy, and nephropathy presented with severe right distal thigh pain, which awoke him from sleep. He was diagnosed with musculoskeletal pain and discharged home. Two days later, the severity of pain increased in his right thigh and, subsequently, he developed pain in the proximal lateral aspect of his left thigh, for which he returned to hospital. He had elevated creatine kinase and myoglobin levels. An ultrasound of the right thigh identified a loss of definition of the normal muscular striations and subcutaneous edema. On MRI, the axial STIR image demonstrated extensive T2 hyperintensity in the right vastus medialis and left vastus lateralis, consistent with the diagnosis of diabetic muscle infarction (DMI). This presentation emphasizes the need for a thorough patient history and physical examination, and the importance of directed imaging for the prompt diagnosis of DMI.

Diabetic muscle infarction in end-stage renal disease: A scoping review on epidemiology, diagnosis and treatment.

Diabetic muscle infarction (DMI) refers to spontaneous ischemic necrosis of skeletal muscle among people with diabetes mellitus, unrelated to arterial occlusion. People with DMI may have coexisting end-stage renal disease (ESRD) but little is known about its epidemiology and clinical outcomes in this setting. This scoping review seeks to investigate the characteristics, clinical features, diagnostic evaluation, management and outcomes of DMI among people with ESRD. Electronic database (PubMed/MEDLINE, CINAHL, SCOPUS and EMBASE) searches were conducted for ("diabetic muscle infarction" or "diabetic myonecrosis") and ("chronic kidney disease" or "renal impairment" or "dialysis" or "renal replacement therapy" or "kidney transplant") from January 1980 to June 2017. Relevant cases from reviewed bibliographies in reports retrieved were also included. Data were extracted in a standardized form. A total of 24 publications with 41 patients who have ESRD were included. The mean age at the time of presentation with DMI was 44.2 years. Type 2 diabetes was present in 53.7% of patients while type 1 in 41.5%. In this cohort, 60.1% were receiving hemodialysis, 21% on peritoneal dialysis and 12.2% had kidney transplantation. The proximal lower limb musculature was the most commonly affected site. Muscle pain and swelling were the most frequent manifestation on presentation. Magnetic resonance imaging (MRI) provided the most specific findings for DMI. Laboratory investigation findings are usually non-specific. Non-surgical therapy is usually used in the management of DMI. Short-term prognosis of DMI is good but recurrence occurred in 43.9%. DMI is an uncommon complication in patients with diabetes mellitus, including those affected by ESRD. In comparison with unselected patients with DMI, the characteristics and outcomes of those with ESRD are generally similar. DMI may also occur in kidney transplant recipients, including pancreas-kidney transplantation. MRI is the most useful diagnostic investigation. Non-surgical treatment involving analgesia, optimization of glycemic control and initial bed rest can help to improve recovery rate. However, recurrence of DMI is relatively frequent.

Chronic ischemic mitral regurgitation and papillary muscle infarction detected by late gadolinium-enhanced cardiac magnetic resonance imaging in patients with ST-segment elevation myocardial infarction.

BACKGROUND: Both papillary muscle infarction (PMI) and chronic ischemic mitral regurgitation (CIMR) are associated with reduced survival after myocardial infarction. The influence of PMI on CIMR and factors influencing both entities are incompletely understood. OBJECTIVES: We sought to determine the influence of PMI on CIMR after primary percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) and to define independent predictors of PMI and CIMR. METHODS: Between January 2011 and May 2013, 263 patients (mean age 57.8 ± 11.5 years) underwent late gadolinium-enhanced cardiac magnetic resonance imaging and transthoracic echocardiography 4 months after PCI for STEMI. Infarct size, PMI, and mitral valve and left ventricular geometric and functional parameters were assessed. Univariate and multivariate analyses were performed to identify predictors of PMI and CIMR (≥grade 2+). RESULTS: PMI was present in 61 patients (23 %) and CIMR was present in 86 patients (33 %). In patients with PMI, 52 % had CIMR, and in patients without PMI, 27 % had CIMR (P < 0.001). In multivariate analyses, infarct size [odds ratio (OR) 1.09 (95 % confidence interval 1.04-1.13), P < 0.001], inferior MI [OR 4.64 (1.04-20.62), P = 0.044], and circumflex infarct-related artery [OR 8.21 (3.80-17.74), P < 0.001] were independent predictors of PMI. Age [OR 1.08 (1.04-1.11), P < 0.001], infarct size [OR 1.09 (1.03-1.16), P = 0.003], tethering height [OR 19.30 (3.28-113.61), P = 0.001], and interpapillary muscle distance [OR 3.32 (1.31-8.42), P = 0.011] were independent predictors of CIMR. CONCLUSIONS: The risk of PMI is mainly associated with inferior infarction and infarction in the circumflex coronary artery. Although the prevalence of CIMR is almost doubled in the presence of PMI, PMI is not an independent predictor of CIMR. Tethering height and interpapillary muscle distance are the strongest independent predictors of CIMR.