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Paper text:
diabetic myonecrosis is a rare complication of diabetes mellitus which usually present with sudden onset pain of the involved muscle .
it affects both type 1 and type 2 diabetic patients who have long duration of diabetes and frequently have other microvascular complications .
a 60-year - old male , with history of diabetes for 4 years , regularly on oral hypoglycemic agents , presented with insidious onset pain and swelling of right thigh for 3 months .
his body mass index ( bmi ) was 18.2 kg / m , blood pressure 150/90 mm hg , and there was pedal edema bilaterally .
right thigh was hot , swollen with induration of medial and posterior part which was tender .
his total leucocyte count was 4370/mm , hemoglobin 9.5 gm / dl , and erythrocyte sedimentation rate ( esr ) 60 mm at the end of first hour .
his hba1c was 8.1% , serum creatinine 0.5 mg / dl , and 24 hours urinary albumin 30.8 mg .
magnetic imaging resonance ( mri ) of the right thigh revealed altered signal intensity involving the muscles of medial and anterior compartment of the thigh .
there was predominant involvement of the adductor muscles showing heterogenous increased enhancement and multiple nonenhancing areas in the adductor magnus muscle suggesting myositis with myonecrosis [ figure 1 ] .
the patient was treated conservatively with insulin , analgesics , antibiotics , antihypertensives , and physiotherapy .
mri of the right thigh showing heterogenous increased enhancement and multiple nonenhancing areas in the adductor magnus muscle suggesting myositis with myonecrosis a 56-year - old male , with history of diabetes for 10 years who was on oral hypoglycemic agents irregularly , presented with pain and swelling of lower portion of left thigh since 3 months .
lower part of the left thigh was swollen , hot , tender , and firm with pitting edema [ figure 2 ] .
glycemic status was poor ( rbs on admission 460 mg / dl , hba1c 17% ) with elevated serum creatinine level ( 1.6 mg / dl ) .
mri of the left thigh revealed altered signal intensity and swelling of vastus medialis and lateralis muscles with increased heterogenous enhancement of the vastus medialis muscle suggesting muscle infarction [ figure 3 ] .
he was treated with insulin , broadspectrum antibiotics , and analgesics besides other supportive treatment .
swelling of lower part of left thigh mri of the left thigh showing increased heterogenous enhancement of the vastus medialis muscle suggesting muscle infarction a 45-year - old female presented with complaints of insidious onset pain over lower part of right thigh she gave history of diabetes for 4 years and was on oral hypoglycemics very irregularly .
she had hypertension ( bp 160/90 mm hg ) , distal symmetrical mixed sensorimotor polyneuropathy , and nonproliferative diabetic retinopathy .
there was a localized tender and firm oval - shaped lump ( 5  4 cm ) on the medial aspect of the right thigh .
glycemic status was poor ( rbs at admission 523 mg / dl , hba1c 12.6% ) , serum creatinine 1.4 mg / dl , and her 24 hrs urinary albumin was 734 mg . ultrasonography of the thigh showed ill - defined hypoechoeic areas involving vastus group of muscles and there was increased vascularity around the hypoechoeic areas [ figure 4 ] .
ultrasonography of the thigh showing ill - defined hypoechoeic areas with increased vascularity around the hypoechoeic areas a 40-year - old male presented with pain and swelling of the left thigh for 3 months .
he had history of diabetes for 5 years and was on oral hypoglycemic agents with good glycemic control ( hba1c 7.3% ) .
his bmi was 22.3 kg / m , blood pressure 130/80 mm hg , was afebrile , and had pallor .
total leucocytic count was 12530/mm with a left shift , hemoglobin 6.4 gm / dl , and esr 110 mm at the end of first hour .
cect of the left thigh revealed large ill - defined areas of decreased attenuation involving multiple adductor and flexor muscles .
the patient was treated with insulin , antibiotics , anti - inflammatory drugs , antihypertensives , and physiotherapy .
he responded well to the conservative management and was discharged after 1.5 month of hospital stay .
a 60-year - old male , with history of diabetes for 4 years , regularly on oral hypoglycemic agents , presented with insidious onset pain and swelling of right thigh for 3 months .
his body mass index ( bmi ) was 18.2 kg / m , blood pressure 150/90 mm hg , and there was pedal edema bilaterally .
right thigh was hot , swollen with induration of medial and posterior part which was tender .
his total leucocyte count was 4370/mm , hemoglobin 9.5 gm / dl , and erythrocyte sedimentation rate ( esr ) 60 mm at the end of first hour .
his hba1c was 8.1% , serum creatinine 0.5 mg / dl , and 24 hours urinary albumin 30.8 mg .
magnetic imaging resonance ( mri ) of the right thigh revealed altered signal intensity involving the muscles of medial and anterior compartment of the thigh .
there was predominant involvement of the adductor muscles showing heterogenous increased enhancement and multiple nonenhancing areas in the adductor magnus muscle suggesting myositis with myonecrosis [ figure 1 ] .
the patient was treated conservatively with insulin , analgesics , antibiotics , antihypertensives , and physiotherapy .
mri of the right thigh showing heterogenous increased enhancement and multiple nonenhancing areas in the adductor magnus muscle suggesting myositis with myonecrosis
a 56-year - old male , with history of diabetes for 10 years who was on oral hypoglycemic agents irregularly , presented with pain and swelling of lower portion of left thigh since 3 months .
lower part of the left thigh was swollen , hot , tender , and firm with pitting edema [ figure 2 ] .
glycemic status was poor ( rbs on admission 460 mg / dl , hba1c 17% ) with elevated serum creatinine level ( 1.6 mg / dl ) .
mri of the left thigh revealed altered signal intensity and swelling of vastus medialis and lateralis muscles with increased heterogenous enhancement of the vastus medialis muscle suggesting muscle infarction [ figure 3 ] .
he was treated with insulin , broadspectrum antibiotics , and analgesics besides other supportive treatment .
swelling of lower part of left thigh mri of the left thigh showing increased heterogenous enhancement of the vastus medialis muscle suggesting muscle infarction
a 45-year - old female presented with complaints of insidious onset pain over lower part of right thigh she gave history of diabetes for 4 years and was on oral hypoglycemics very irregularly .
she had hypertension ( bp 160/90 mm hg ) , distal symmetrical mixed sensorimotor polyneuropathy , and nonproliferative diabetic retinopathy .
there was a localized tender and firm oval - shaped lump ( 5  4 cm ) on the medial aspect of the right thigh .
glycemic status was poor ( rbs at admission 523 mg / dl , hba1c 12.6% ) , serum creatinine 1.4 mg / dl , and her 24 hrs urinary albumin was 734 mg . ultrasonography of the thigh showed ill - defined hypoechoeic areas involving vastus group of muscles and there was increased vascularity around the hypoechoeic areas [ figure 4 ] .
ultrasonography of the thigh showing ill - defined hypoechoeic areas with increased vascularity around the hypoechoeic areas
a 40-year - old male presented with pain and swelling of the left thigh for 3 months .
he had history of diabetes for 5 years and was on oral hypoglycemic agents with good glycemic control ( hba1c 7.3% ) .
his bmi was 22.3 kg / m , blood pressure 130/80 mm hg , was afebrile , and had pallor .
total leucocytic count was 12530/mm with a left shift , hemoglobin 6.4 gm / dl , and esr 110 mm at the end of first hour .
cect of the left thigh revealed large ill - defined areas of decreased attenuation involving multiple adductor and flexor muscles .
the patient was treated with insulin , antibiotics , anti - inflammatory drugs , antihypertensives , and physiotherapy .
he responded well to the conservative management and was discharged after 1.5 month of hospital stay .
diabetic myonecrosis or diabetic muscle infarction is an uncommon manifestation of long - standing and poorly controlled diabetes mellitus .
trujillo - santos , in a systemic review of all reported cases of diabetic myonecrosis , found that it was more common in women ( 61.5% of all cases ) , in type 1 diabetes ( 59% of all cases ) , and in long - standing diabetes ( mean duration of disease 14.3 years ) .
we are reporting four cases of diabetic myonecrosis admitted in a tertiary care hospital over a period of 2 years .
three of the cases are male and all are type 2 diabetes mellitus with a mean duration of diabetes of 5.75 years .
the exact pathogenesis is not known but may involve hypoxia - reperfusion injury , atherosclerotic occlusion , or vasculitis with thrombosis .
the thigh muscles ( usually the vastus group ) are most commonly affected but calf muscle can also be affected .
the affected area is swollen , tender , firm , and edematous with a feeling of a mass .
similar presentation may also be seen in pyomyositis , necrotizing fasciitis , deep vein thrombosis , soft tissue abscess , cellulitis , hematoma , and acute compartment syndrome .
most patients have long duration of diabetes ( mean duration 14.3 years ) and poor glycemic status .
but it has also been reported as the first manifestation of diabetes mellitus in some cases .
routine laboratory investigations are not helpful in diagnosis . total leucocyte count , creatine phosphokinase , and esr may be slightly elevated .
lack of correlation between muscle involvement and creatine phosphokinase level has lead to delay in medical advice by approximately 4 weeks .
the characteristic features of diabetic myonecrosis in mri is an increased signal from the affected muscle area in t2-weighted , inversion - recovery , and gadolinium - enhanced images and isointense or hypointense areas on t1-weighted images .
sonographic findings of diabetic muscle infarction include internal linear echogenic structures coursing through the lesion ; an absence of internal motion or swirling of fluid with transducer pressure ; and lack of predominantly anechoic areas .
computed tomography scan shows diffuse muscular enlargement with diminished attenuation of the affected muscle , increased attenuation of the subcutaneous fat , and thickening of the subcutaneous fascial planes and of the skin .
although biopsy has been done in many cases for diagnosis , currently it is not recommended because of potential complications and delayed recovery .
good glycemic control should be achieved and patients usually recover within few weeks with supportive treatment like bed rest and analgesics for pain .
kapur et al found that patients who underwent surgery had an average recovery period of 13 weeks compared to 5.5 weeks for those received conservative treatment only .
although the short - term prognosis of diabetic myonecrosis is good , the long - term prognosis is poor and most patients die within 5 years .
recurrence has been reported in 47.82% cases involving either the same or the other limb . in conclusion
, diabetic myonecrosis is an uncommon complication of long - standing poorly controlled diabetes presenting as sudden onset pain over the affected muscle .
short - term prognosis is good with most patients recovering within weeks with conservative treatment , but long - term prognosis is poor .
diabetic myonecrosis should be considered in the differential diagnosis for diabetic patients who present with painful swollen muscle .
diabetic myonecrosis is an underreported complication of long - standing , poorly controlled diabetes mellitus which is usually self - limiting and responds well to conservative management . 
 patients frequently have microvascular complications , and although short - term prognosis is good , the long - term prognosis is poor . 
 we report four cases of diabetic myonecrosis admitted in a tertiary care hospital .