Diabetic myonecrosis
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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. Small-vessel 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 is found to be normal. ESR is elevated. Planar X-ray reveals
soft tissue swelling and bone scan shows non specific uptake. CT shows muscle
oedema with preserved tissue planes (non-contrast enhancing). MRI shows
increased signal on T2 weighted images within areas of muscle oedema.
Arteriography reveals large and medium vessel arteriosclerosis occasionally with
dye within the area of tissue infarction . Electromyography shows non specific
focal changes.
Treatment
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.[citation needed]
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, cat-scratch disease, amyloidosis, as well as tumours of lipoma,
chondroma, fibroma, leiomyoma and sarcoma.
References
Wintz R, Pimstone K, Nelson S (Sep-Oct 2006). "Detection of diabetic myonecrosis.
Complication is often-missed sign of underlying disease.". Postgrad Med 119 (3):
66–9. PMID 17128647. http://www.postgradmed.com/issues/2002/01_02/wintz.htm. -
Case report
Mousa A, Hussein S, Daggett P & Coates P (7–9 November 2005). "Spontaneous
non-traumatic muscle pain in diabetes." (abstract page). Endocrine Abstracts 10:
DP12. http://www.endocrine-abstracts.org/ea/0010/ea0010dp12.htm. - 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)" (PDF). American Medical Association Research Symposium. - Poster
presentation
Footnotes
^ Reyes-Balaguer J, Solaz-Moreno E, Morata-Aldea C, Elorza-Montesinos P (April
2005). "Spontaneous diabetic myonecrosis.". Diabetes Care 28 (4): 980–1.
doi:10.2337/diacare.28.4.980-a. PMID 15793211. http://care.diabetesjournals.org/cgi/content/full/28/4/980-a.
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