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Kerola AM, Eklund KK, Valleala H, Tynninen O, Helve J, Haapamäki V, Eriksson M. Diabetic myonecrosis complicated by emphysematous pyomyositis and abscess caused by Escherichia coli: a case report. J Med Case Rep 2024; 18:300. [PMID: 38946001 PMCID: PMC11215818 DOI: 10.1186/s13256-024-04614-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 05/24/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND Necrotizing myopathies and muscle necrosis can be caused by immune-mediated mechanisms, drugs, ischemia, and infections, and differential diagnosis may be challenging. CASE PRESENTATION We describe a case of diabetic myonecrosis complicated by pyomyositis and abscess caused by Escherichia coli. A white woman in her late forties was admitted to the hospital with a 1.5 week history of bilateral swelling, weakness, and mild pain of the lower extremities and inability to walk. She had a history of type 1 diabetes complicated by diabetic retinopathy, neuropathy, nephropathy, and end-stage renal disease. C-reactive protein was 203 mg/l, while creatinine kinase was only mildly elevated to 700 IU/l. Magnetic resonance imaging of her lower limb muscles showed extensive edema, and muscle biopsy was suggestive of necrotizing myopathy with mild inflammation. No myositis-associated or myositis-specific antibodies were detected. Initially, she was suspected to have seronegative immune-mediated necrotizing myopathy, but later her condition was considered to be explained better by diabetic myonecrosis with multifocal involvement. Her symptoms alleviated without any immunosuppressive treatment. After a month, she developed new-onset and more severe symptoms in her right posterior thigh. She was diagnosed with emphysematous urinary tract infection and emphysematous myositis and abscess of the right hamstring muscle. Bacterial cultures of drained pus from abscess and urine were positive for Escherichia coli. In addition to abscess drainage, she received two 3-4-week courses of intravenous antibiotics. In the discussion, we compare the symptoms and findings typically found in pyomyositis, immune-mediated necrotizing myopathy, and diabetic myonecrosis (spontaneous ischemic necrosis of skeletal muscle among people with diabetes). All of these diseases may cause muscle weakness and pain, muscle edema in imaging, and muscle necrosis. However, many differences exist in their clinical presentation, imaging, histology, and extramuscular symptoms, which can be useful in determining diagnosis. As pyomyositis often occurs in muscles with pre-existing pathologies, the ischemic muscle has likely served as a favorable breeding ground for the E. coli in our case. CONCLUSIONS Identifying the etiology of necrotizing myopathy is a diagnostic challenge and often requires a multidisciplinary assessment of internists, pathologists, and radiologists. Moreover, the presence of two rare conditions concomitantly is possible in cases with atypical features.
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Affiliation(s)
- Anne M Kerola
- Department of Rheumatology, Inflammation Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland.
| | - Kari K Eklund
- Department of Rheumatology, Inflammation Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Heikki Valleala
- Department of Rheumatology, Inflammation Center, Helsinki University Hospital and University of Helsinki, Haartmaninkatu 4, 00290, Helsinki, Finland
| | - Olli Tynninen
- Department of Pathology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Jaakko Helve
- Department of Nephrology, Abdominal Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Ville Haapamäki
- Radiology, HUS Diagnostic Center, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mari Eriksson
- Department of Infectious Diseases, Inflammation Center, Helsinki University Hospital, Helsinki, Finland
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Naredi M, Adhikari N, Bhardwaj GP, Saxena S, Bansal R, Sharma A. Diabetic myonecrosis in end-stage renal disease. THE NATIONAL MEDICAL JOURNAL OF INDIA 2021; 34:206-210. [PMID: 35112543 DOI: 10.25259/nmji_191_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
Diabetic myonecrosis or muscle infarction (DMI), a clinicoradiological entity is an underdiagnosed complication of diabetes mellitus. It refers to spontaneous aseptic necrosis of skeletal muscles commonly of the lower limb without evidence of any large vessel disease. It presents as painful swollen limb without any external insult in patients with long-standing diabetes mellitus with other microvascular complications especially nephropathy. We present four instances of DMI in our patients who had end-stage renal disease with a varied course.
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Affiliation(s)
- Mohit Naredi
- Department of Nephrology, Pushpawati Singhania Research Institute, Press Enclave Road, Sheikh Sarai Phase 1, New Delhi 110017, India
| | - Navneet Adhikari
- Department of Orthopaedics, Pushpawati Singhania Research Institute, Press Enclave Road, Sheikh Sarai Phase 1, New Delhi 110017, India
| | - Gaurav Prakash Bhardwaj
- Department of Orthopaedics, Pushpawati Singhania Research Institute, Press Enclave Road, Sheikh Sarai Phase 1, New Delhi 110017, India
| | - Sanjeev Saxena
- Department of Nephrology, Pushpawati Singhania Research Institute, Press Enclave Road, Sheikh Sarai Phase 1, New Delhi 110017, India
| | - Ravi Bansal
- Department of Nephrology, Pushpawati Singhania Research Institute, Press Enclave Road, Sheikh Sarai Phase 1, New Delhi 110017, India
| | - Ankit Sharma
- Department of Nephrology, Pushpawati Singhania Research Institute, Press Enclave Road, Sheikh Sarai Phase 1, New Delhi 110017, India
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Patibandla S, Auron M, Olson AP, Chamberlain S, Pendharkar SS. A Painful Coincidence? J Hosp Med 2021; 16:371-375. [PMID: 34129490 DOI: 10.12788/jhm.3514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 08/04/2020] [Indexed: 11/20/2022]
Affiliation(s)
- Saikrishna Patibandla
- Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, New York
| | - Moises Auron
- Department of Hospital Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andrew Pj Olson
- Departments of Medicine and Pediatrics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Samantha Chamberlain
- Department of Emergency Medicine, Ascension St John's Hospital, Detroit, Michigan
| | - Sima S Pendharkar
- Department of Medicine, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, Brooklyn, New York
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Alipanahzadeh H, Ghulamreza R, Shokouhian M, Bagheri M, Maleknia M. Deep vein thrombosis: a less noticed complication in hematologic malignancies and immunologic disorders. J Thromb Thrombolysis 2019; 50:318-329. [PMID: 31808122 DOI: 10.1007/s11239-019-02005-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Deep vein thrombosis (DVT) is a common complication in hematologic malignancies and immunologic disorders that coagulation and inflammatory factors play a crucial role in its occurrence. The content used in this article has been obtained by PubMed database and Google Scholar search engine of English-language articles (1980-2019) using the "Deep vein thrombosis," "Hematologic malignancies," "Immunologic disorders" and "Treatment." Increased levels of coagulation factors, the presence of genetic disorders, or the use of thrombotic drugs that stimulate coagulation processes are risk factors for the development of DVT in patients with hematologic malignancies. Inflammatory and auto-anti-inflammatory factors, along with coagulant factors, play an essential role in the formation of venous thrombosis in patients with immunological disorders by increasing the recruitment of inflammatory cells and adhesion molecules. Therefore, anti-coagulants in hematologic malignancies and immunosuppressants in immune disorders can reduce the risk of developing DVT by reducing thrombotic and inflammatory activity. Considering the increased risk of DVT due to impaired coagulation and inflammation processes, analysis of coagulation and inflammatory factors have prognostic values in patients with immunologic deficiencies and hematologic malignancies. Evaluation of these factors as diagnostic and prognostic biomarkers in the prediction of thrombotic events could be beneficial in implementing effective treatment strategies for DVT.
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Affiliation(s)
- Hassan Alipanahzadeh
- Department of Anatomy, Faculty of Medicine, Kabul University Medical Science, Kabul, Afghanistan
| | - Reza Ghulamreza
- Department of Abdominal Surgery, Faculty of Medicine, Kabul University Medical Science, Kabul, Afghanistan
| | - Mohammad Shokouhian
- Department of Hematology and Blood Transfusion, School of Allied Medical Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Marziye Bagheri
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Mohsen Maleknia
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran. .,Student Research Committee, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Yong TY, Khow KSF. Diabetic muscle infarction in end-stage renal disease: A scoping review on epidemiology, diagnosis and treatment. World J Nephrol 2018; 7:58-64. [PMID: 29527509 PMCID: PMC5838415 DOI: 10.5527/wjn.v7.i2.58] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 12/25/2017] [Accepted: 01/24/2018] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Tuck Yean Yong
- Internal Medicine, Flinders Private Hospital, Bedford Park, SA 5042, Australia
| | - Kareeann Sok Fun Khow
- Geriatric Training Research and Aged Care Centre, The University of Adelaide, Paradise, SA 5075, Australia
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Diabetic Muscle Infarction Masquerading as Necrotizing Fasciitis. Case Rep Nephrol 2017; 2017:7240156. [PMID: 28529812 PMCID: PMC5424164 DOI: 10.1155/2017/7240156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 04/11/2017] [Indexed: 12/23/2022] Open
Abstract
A 43-year-old male patient with past medical history of diabetes mellitus (DM), end stage renal disease (ESRD) on hemodialysis (HD), congestive heart failure (CHF), obstructive sleep apnea (OSA), and chronic anemia presented with complaints of left thigh pain. A computerized tomogram (CT) of the thigh revealed evidence of edema with no evidence of a focal collection or gas formation noted. The patient's clinical symptoms persisted and he underwent magnetic resonance imaging (MRI) of his thigh which was reported to show small areas of muscle necrosis with fluid collection. These findings in the acute setting concerned necrotizing fasciitis. After careful discussion following a multidisciplinary approach, a decision was made to perform a fasciotomy with tissue debridement. The patient was treated with IV antibiotics and discharged with a vacuum assisted wound drain. The surgical pathology revealed evidence of muscle edema with necrosis. Seven weeks later the patient presented with similar complaints on the other thigh (right thigh). MRI of the thighs revealed worsening edema with features suggestive of myositis and possible muscle infarction. A CT guided biopsy of the right quadriceps muscle revealed fibrotic interstitial connective tissue and no evidence of necrosis. This favored a diagnosis of diabetic muscle infarction. The disease was managed with pain control, strict diabetes management, and aggressive dialysis.
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Khanna HK, Stevens AC. Diabetic Myonecrosis: A Rare Complication of Diabetes Mellitus Mimicking Deep Vein Thrombosis. AMERICAN JOURNAL OF CASE REPORTS 2017; 18:38-41. [PMID: 28074044 PMCID: PMC5242197 DOI: 10.12659/ajcr.900903] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 10/14/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Diabetic myonecrosis is an uncommon complication of long-standing poorly controlled diabetes mellitus. It presents as acute non-traumatic swelling and pain of the lower extremity, which can mimic deep vein thrombosis (DVT). The clinical course is usually self-limiting and patients respond well to supportive medical therapy. CASE REPORT A 54-year-old male with past medical history of poorly controlled diabetes mellitus type II, hyperlipidemia, gastroesophageal reflux disease (GERD), and remote history of DVT presented to our emergency department with 2-week history of progressively worsening left calf pain and swelling. On physical examination, the patient had increased warmth, edema, erythema, and tenderness in the left calf, with positive Homan's sign. A lower-extremity venous Doppler was negative for DVT. His creatinine phosphokinase (CPK) level was normal, but hemoglobin A1C was 11.0%, reflective of poor glycemic control. Magnetic resonance imaging (MRI) of the left calf revealed a focus of non-enhancement in the gastrocnemius muscle along with increased enhancement of the rest of the muscle, suggestive of diabetic myonecrosis. CONCLUSIONS Diabetic myonecrosis is a rare complication of long-standing diabetes mellitus that can often mimic DVT. Diagnosis can be made on an MRI, and treatment involves strict glycemic control along with antiplatelet therapy and non-steroidal anti-inflammatories (NSAIDs).
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