RadiologicPathologic Conference of Wilford Hall Medical Center

Diabetic Muscle Infarction

Justin Q. Ly1, Edward K. Yi2, Douglas P. Beall 1
55-year-old man with diabetes initially presented with a 3-week history of a nonhealing wound at the anterolateral aspect of the distal left lower extremity. Over the course of 10 days before presentation, he had noticed progressive redness, pain, and swelling of his anterior left leg. Radiography of the distal left lower extremity showed nonspecic swelling of the anterolateral soft tissues (Fig. 1A). Two days after the patients initial presentation and admission, he acutely developed left foot drop. Further evaluation with MRI of the distal lower extremity showed edema involving the anterior compartment muscles and mild bulging of the fascial planes (Figs. 1B and 1C), which was compatible with anterior compartment syndrome. Arteriography revealed a lling defect within the popliteal artery consistent with an embolic phenomenon. Subsequent dbridement of the wound revealed histopathologic ndings consistent with necrotic muscle (Fig. 1D). The nal diagnosis was diabetic muscle infarction caused by microangiopathic disease with thromboembolic phenomena. Diabetic muscle infarction is a rare complication of diabetes and is often associated with nontraumatic swelling of the affected extremity and gradual or, less commonly, sudden onset of muscle pain. Biopsy of the affected muscle usually shows histopathologic ndings consistent with edematous and necrotic tissue. Poorly con-

trolled and long-standing diabetes and extensive end-organ disease caused by microvascular disease are characteristic of patients with this process. The disease can be bilateral in more than one third of cases [1]. The thigh and calf are the most commonly involved areas, and multiple muscle involvement is common. A proposed mechanism begins with a thromboembolic event, leading to compartment syndrome and resultant ischemic muscle injury. This process is followed by inammation, hyperemia, and reperfusion associated with reactive oxygen species that cause further damage both directly and through worsening of the compartment syndrome from edema [2]. In effect, a vicious cycle is initiated, with eventual muscle necrosis. Radiography may show diffuse swelling. MRI reveals edematous muscle, which is a nonspecic but characteristic nding. The differential diagnosis for diffuse muscle edema on MRI includes posttraumatic muscle contusions, strains, delayed onset muscle soreness, subacute denervation, radiation therapy, compartment syndrome, polymyositis, infectious myositis, compartment syndrome, and rhabdomyolysis [3]. Edema limited to the muscles of a specic compartment, with enlargement of that same compartment, is suggestive of compartment syndrome. Of note, the chronic form of compartment syndrome is indicated if these abnormal imaging changes fail to return to baseline after pos-

texertional (1525 min) MRI [1]. MRI after contrast administration revealing central areas of nonenhancement surrounded by enhancing muscle is indicative of muscle infarction of the nonenhancing areas [4]. In most cases, correlation of imaging ndings with clinical information is useful and often essential for delineating the exact cause of muscle edema. MRI is also useful in directing biopsy to the site with the highest diagnostic yield and for differentiating between acute and potentially more treatable disease versus chronic disease. Treatment consists of analgesics and non weight-bearing activity. Physical therapy and rehabilitation may be useful after the acute phase has passed. The recovery period is usually 46 weeks.
References
1. Nguyen B, Brandser E, Rubin DA. Pains, strains, and fasciculations: lower extremity muscle disorders. Magn Reson Imaging Clin N Am 2000;8:391408 2. Silberstein L, Britton KE, Marsch FP, Raftery MJ, DCruz D. An unexpected cause of muscle pain in diabetes. Ann Rheum Dis 2001;60:310312 3. May DA, Disler DG, Jones EA, Balkissoon AA, Manaster BJ. Abnormal signal intensity in skeletal muscle at MR imaging: patterns, pearls and pitfalls. RadioGraphics 2000;20:S295S315 4. Jelinek JS, Murphey MD, Aboulaa AJ, et al. Muscle infarction in patients with diabetes mellitus: MR imaging ndings. Radiology 1999;211:241247

Fig. 1.55-year-old man with diabetic infarction of distal lower extremity anterior compartment musculature. A, Radiograph of lateral distal lower extremity shows moderate anterior soft-tissue edema (arrows). B, Axial T1-weighted image shows subtle increased hypointensity of anterolateral compartment (arrowheads) relative to nearby musculature. C, Axial fat-suppressed T2-weighted image shows diffuse edema of tibialis anterior and extensor digitorum longus muscles. D, Photomicrograph of biopsy specimen reveals focal necrosis of skeletal muscle cells. (H and E, 200)
Received December 19, 2002; accepted after revision January 22, 2003. The opinions and assertions contained herein are those of the authors and should not be construed as ofcial or as representing the opinions of the Department of the Air Force or the Department of Defense.
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Department of Radiology, Wilford Hall Medical Center, Ste. 1, 2200 Bergquist Dr., Lackland AFB, TX 78236-5300. Address correspondence to J. Q. Ly. Hickam Primary Care Clinic, 755 Scott Cr., Hickam AFB, HI 96853.

AJR 2003;181:1216 0361803X/03/18151216 American Roentgen Ray Society

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AJR:181, November 2003