Diabetic myonecrosis - Wikipedia, the free encyclopedia

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Diabetic myonecrosis
From Wikipedia, the free encyclopedia

Diabetic myonecrosis is a rare complication of diabetes. It is caused by infarcted muscle tissue, usually in the
thigh.

Contents
1 Epidemiology
2 Investigations and diagnosis
3 Treatment
4 Pathophysiology
5 Differential Diagnosis
6 References
7 Footnotes

Epidemiology
The mean age at presentation is thirty-seven years with a reported range of nineteen to sixty-four years. The
mean age of onset since diagnosis of diabetes is fifteen years. The female:male ratio is 1.3:1. Other diabetic
complications such as nephropathy, neuropathy, retinopathy and hypertension are usually present. Its major
symptom is the acute onset muscle pain, usually in the thigh, in the absence of trauma. Signs include exquisite
muscle tenderness and swelling.

Investigations and diagnosis

Tissue biopsy is the gold standard. Macroscopically this reveals pale muscle tissue. Microscopically infarcted
patches of myocytes. Necrotic muscle fibers are swollen and eosinophilic and lack striations and nuclei. Smallvessel walls are thickened and hyalinized, with luminal narrowing or complete occlusion. Biopsy cultures for
bacteria, fungi, acid-fast bacilli and stains are negative in simple myonecrosis.
Creatine kinase may be normal or increased probably depending upon the stage of the condition when sampling
is undertaken. ESR is elevated. Planar X-ray reveals soft tissue swelling and may potentially show gas within
necrotic muscle, Bone scan may show non specific uptake later in the course. CT shows muscle oedema with
preserved tissue planes (non-contrast enhancing). MRI is the exam of choice and shows increased signal on T2
weighted images within areas of muscle oedema. Contrast enhancement is helpful but must be weighed against
the risk of Nephrogenic Systemic Fibrosis as many diabetics have underlying renal insufficiency. Arteriography
reveals large and medium vessel arteriosclerosis occasionally with dye within the area of tissue infarction .
Electromyography shows non specific focal changes.

Treatment
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Treatment includes supportive care with analgesics and anti-inflammatory agents. Exercise should be limited as
it increases pain and extends the area of infarction. Symptoms usually resolve in weeks to months, but fifty
percent of sufferers will experience relapse in either leg. The majority
diagnosed with diabetic myonecrosis die within 5 years due to other
diabetes complications.[1]

Coronal fat suppressed STIR image

demonstrating enlargement and
increased signal in the left adductor
muscle group with associated
subcutaneous edema in a patient with
diabetic myonecrosis.

Axial fat suppressed T2 weighted

MRI image showing hyperintense
signal and enlargement of the left
thigh adductor muscle group in
diabetic myonecrosis.

(http://www.metrohealth.org/documents/patient%20services/MedPeds/DiabeticMyonecrosis.pdf)

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Pathophysiology
The pathogenesis of this disease is unclear. Arteriosclerosis obliterans
has been postulated as the cause, along with errors of the clotting and
fibrinolytic pathways such as antiphospholipid syndrome.[1]

Differential Diagnosis
A large number of conditions may cause symptoms and signs similar to
diabetic myonecrosis and include: deep vein thrombosis,
thrombophlebitis, cellulitis, fasciitis, abscess, haematoma, myositis,
pseudothrombophlebitis (ruptured synovial cyst), pyomyositis, parasitic
myositis, osteomyelitis, calcific myonecrosis, myositis ossificans,
diabetic myotrophy, muscle strain or rupture, bursitis, vasculitis, arterial
occlusion, haemangioma, lymphoedema, sarcoidosis, tuberculosis, catscratch disease, amyloidosis, as well as tumours of lipoma, chondroma,
fibroma, leiomyoma and sarcoma.

References

Axial fat suppressed post gadolinium

contrast enhancement MRI image
showing absent enhancement in the
left thigh adductor muscles centrally
indicating necrosis in diabetic
myonecrosis.

Wintz R, Pimstone K, Nelson S (SepOct 2006). "Detection of

diabetic myonecrosis. Complication is often-missed sign of
underlying disease."
(http://www.postgradmed.com/issues/2002/01_02/wintz.htm). Postgrad Med 119 (3): 669.
PMID 17128647 (https://www.ncbi.nlm.nih.gov/pubmed/17128647). - Case report
Mousa A, Hussein S, Daggett P & Coates P (79 November 2005). "Spontaneous non-traumatic muscle
pain in diabetes." (http://www.endocrine-abstracts.org/ea/0010/ea0010dp12.htm) (ABSTRACT PAGE).
Endocrine Abstracts 10: DP12. - Poster Presentation, 196th Meeting of the Society for Endocrinology,
London, UK
Subbiah V, Raina R, Kaelber D, Chung-Park M, Halle D, Mansour D & Perzy H (2004). "Diabetic
Myonecrosis (Rare And Ominous Complication Of A Common Disease)"
(http://www.metrohealth.org/documents/patient%20services/MedPeds/DiabeticMyonecrosis.pdf) (PDF).
American Medical Association Research Symposium. - Poster presentation

Footnotes
1. Reyes-Balaguer J, Solaz-Moreno E, Morata-Aldea C, Elorza-Montesinos P (April 2005). "Spontaneous diabetic
myonecrosis." (http://care.diabetesjournals.org/cgi/content/full/28/4/980-a). Diabetes Care 28 (4): 9801.
doi:10.2337/diacare.28.4.980-a (https://dx.doi.org/10.2337%2Fdiacare.28.4.980-a). PMID 15793211
(https://www.ncbi.nlm.nih.gov/pubmed/15793211).

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Categories: Diabetes

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