IS Case 217: Diabetic muscle infarction

Brady Huang, MD

Imaging Sciences URMC 2008
Publication Date: 2009-05-22

History

Patient is a 36-year-old male with Type-2 diabetes mellitus presenting with increasing right calf swelling and pain over several months. The patient had no history of trauma and no associated constitutional symptoms and had a negative Doppler sonogram for deep vein thrombosis and negative EMG.

Findings

There is diffuse edema of the posterior compartment muscles which enhance with intravenous gadolinium. On ultrasound there is diminished echogenicity of the affected muscles.

Diagnosis

Diabetic muscle infarction

Discussion

Diabetic muscle infarction was first described in 1965 by Angervall and Stener [1] as tumoriform focal muscular degeneration. Like other long-term complications of diabetes, diabetic muscle infarction is believed to be secondary to microvascular pathology, eliciting inflammation, ischemia, and infarction of the affected muscles. Diabetic muscle infarction typically involves the muscles of the lower extremities particularly the thigh, followed by the calf. Patients with diabetic muscle infarction usually have other long-term manifestations of diabetes, such as peripheral vascular disease, nephropathy and cardiovascular disease. Pain and swelling of the affected extremity, with ambulatory difficulty is the usual presentation. Treatment is directed at symptomatic relief including adequate pain control, rest, and anti-inflammatory medications. Diabetic muscle infarction is generally self-limiting and symptoms usually resolve without sequelae, however the occurrence portends a poor disease prognosis due to macrovascular complications including myocardial infarction and stroke.

The imaging features for diabetic muscle ischemia include hyperintensity on fat-suppressed T2-weighted images and gadolinium-enhanced T1-weighted images, compared with unaffected skeletal muscle. Hyperintensity within a muscle on unenhanced T1-weighted images may represent hemorrhagic foci. Rim enhancement with low signal intensity centrally is considered to be representative of muscle infarction and necrosis. Sonography may show a well-defined intramuscular lesion with mixed echogenicity that is predominantly hypoechoic without any anechoic areas. CT shows asymmetric enlargement and decreased attenuation of the involved muscles, increased attenuation of the subcutaneous fat, and thickening of the skin and fascial planes. A low attenuation intramuscular lesion with ring-enhancement may be seen on contrast-enhanced CT.

References

  1. Angervall L, Stener B. Tumoriform focal muscular degeneration in two diabetic patients. Diabetelogia 1965; 1:39-42. [PDF]
  2. Kapur S, Brunet JA, McKendry RJ. Diabetic muscle infarction: case report and review. J Rheumatol. 2004 Jan;31(1):190-4. [PMID: 14705241]
  3. # Trujillo-Santos AJ. Diabetic muscle infarction: an underdiagnosed complication of long-standing diabetes. Diabetes Care. 2003 Jan;26(1):211-5. [PMID: 12502683]
  4. Jelinek JS, Murphey MD, Aboulafia AJ, Dussault RG, Kaplan PA, Snearly WN. Muscle infarction in patients with diabetes mellitus: MR imaging findings. Radiology. 1999 Apr;211(1):241-7. [PMID: 10189479]
  5. Delaney-Sathy LO, Fessell DP, Jacobson JA, Hayes CW. Sonography of diabetic muscle infarction with MR imaging, CT, and pathologic correlation. AJR Am J Roentgenol. 2000 Jan;174(1):165-9. [PMID: 10628474]
  6. # Sharma P, Mangwana S, Kapoor RK. Diabetic muscle infarction: atypical MR appearance. Skeletal Radiol. 2000 Aug;29(8):477-80. [PMID: 11026718]

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