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Punith Kempegowda Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Eka Melson Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Gerald Langman University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Fady Khattar University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Muhammad Karamat University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Quratul-Ain Altaf University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

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Summary

Diabetic myonecrosis, also known as diabetic muscle infarction is a rare complication of diabetes mellitus usually associated with longstanding suboptimal glycaemic control. Although theories of atherosclerosis, diabetic microangiopathy, vasculitis, ischaemia-reperfusion injury and hypercoagulable state have been proposed to explain the pathophysiology, none of these have been able to individually explain the pathophysiology in entirety. Diabetic renal disease is the most common risk factor for developing DMN and its recurrence. The diagnosis is often missed due to lack of awareness and the presentation mimicking other conditions associated with DM. The routine laboratory investigations are often non-specific and do not provide much value in the diagnosis as well. Muscle biopsy can provide a definite diagnosis but is not currently recommended due to its invasiveness and association with prolonged time to symptoms resolution. Magnetic resonance imaging, in combination with classic history and risk factors can clinch the diagnosis. Treatment is generally analgesia and rest, although the former’s use may be limited in the presence of renal disease.

Learning points:

  • Diabetic myonecrosis is a rare complication of diabetes mellitus associated with longstanding suboptimal glycaemic control.

  • Diabetic renal disease is a known risk factor, although the evidence is merely observational.

  • Although muscle biopsy could provide a definite diagnosis, it is not recommended as it can prolong the disease process and should be reserved only for cases not responding to conventional treatment.

  • Typical MRI findings in combination with classic symptoms and risk factors can clinch the diagnosis

  • Current treatment recommendations include NSAIDs and/or aspirin (if not contraindicated) alongside bed rest. Physiotherapy is not recommended in the acute phase but should be started as soon as patient is discharged from hospital.

  • Optimal glycaemic control is key to prevent recurrence.

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Soham Mukherjee Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Anuradha Aggarwal Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Ashu Rastogi Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Anil Bhansali Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Mahesh Prakash Department of Radiology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Kim Vaiphei Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Pinaki Dutta Department of Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh, 160012, India

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Summary

Spontaneous diabetic muscle infarction (DMI) is a rare and under diagnosed complication of diabetes mellitus. Clinically it presents with acute to subacute onset swelling, pain and tenderness of muscle(s) without systemic manifestations. MRI is helpful in diagnosis, exclusion of other causes and for localization of affected muscle for biopsy in atypical cases. Muscles of the thighs are commonly affected in diabetic myonecrosis (DMN). Here we present the summary of four cases seen in the last 3 years in a tertiary care centre with simultaneous or sequential involvement of multiple groups of muscles or involvement of uncommon sites. All these patients had advanced duration of diabetes with microvascular complications and poor glycemic control. Conservative management including rest and analgesics is the treatment of choice. Short-term prognosis is good but there may be recurrence.

Learning points

  • A high index of suspicion is required for the diagnosis of DMN which can avoid inadvertent use of antibiotics.

  • Acute–subacute onset severe focal muscle pain in the absence of systemic symptoms in a female patient with long-standing diabetes with microvascular complications suggests DMI.

  • MRI is the most sensitive test for diagnosis.

  • Muscle biopsy should be reserved for atypical cases.

  • Conservative management including rest and analgesics has good outcome.

  • Improvement usually occurs within 6–8 weeks, but there may be recurrence.

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