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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
CASE REPORT  
Year : 2021  |  Volume : 32  |  Issue : 5  |  Page : 1475-1478
Diabetic muscle infarction: An unusual cause of acute limb pain in patients on maintenance hemodialysis


1 Department of Nephrology, Jawaharlal Nehru Medical College, Wardha, Nagpur, Maharashtra, India, Nagpur
2 Department of Medicine, NKP Salve Institute of Medical Sciences, Nagpur, Maharashtra, India

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Date of Web Publication4-May-2022
 

   Abstract 


Diabetic muscle infarction is underdiagnosed complication occurring in dialysis patients with advanced diabetes mellitus. Atherosclerotic vascular disease and long-standing diabetes are risk factors for this painful condition. Most common presenting symptom is localized pain in the affected limb. We present here a case of muscle infarction occurring in a diabetic patient on maintenance hemodialysis (HD). Our patient had low-grade fever and pain in right thigh which restricted his movements for one month. His pain worsened during and post-HD. External examination of right lower limb was normal except for tenderness in the right thigh region. Laboratory examination showed leukocytosis with normal serum creatine phosphokinase levels. Magnetic resonance imaging of the thigh was suggestive of muscle infarction. Patient was treated with bed rest, analgesics, antiplatelets and blood transfusion. HD prescription was changed to sustained low-efficiency dialysis with reduced ultrafiltration. Gradually, in a week, his fever and pain subsided and he was able to walk on his own. Thus, it is important to identify this clinical condition early in the course of illness to further prevent its progression.

How to cite this article:
Balwani MR, Pasari AS, Bhawane AR, Tolani PR. Diabetic muscle infarction: An unusual cause of acute limb pain in patients on maintenance hemodialysis. Saudi J Kidney Dis Transpl 2021;32:1475-8

How to cite this URL:
Balwani MR, Pasari AS, Bhawane AR, Tolani PR. Diabetic muscle infarction: An unusual cause of acute limb pain in patients on maintenance hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2021 [cited 2022 May 25];32:1475-8. Available from: https://www.sjkdt.org/text.asp?2021/32/5/1475/344771



   Introduction Top


Diabetic muscle infarction (DMI) is an unusual complication in patients with advanced diabetes mellitus (DM). Diabetic nephropathy patients are prone to develop DMI and nearly one-fourth of such patients receive renal replacement therapy (RRT).[1]


   Case Report Top


A 60-year-old male diabetic nephropathy patient with a history of 15 years type 2 DM came for consultation with complain of low-grade fever and right thigh pain for the past 15 days. He was on RRT in the form of maintenance hemodialysis (HD) through right radiocephalic arteriovenous fistula twice per week, each session of 4 h duration. Fever was low grade, intermittent, not associated with chills, with no diurnal variation, use to subside with paracetamol. He noticed pain in right thigh during the session of HD two weeks prior. His pain started in the initial first half hour of HD and gradually worsened till the end of HD session. Pain decreased in the next 24 h but was present during interdialytic period. In the next two weeks of HD, his pain worsened during dialysis sessions and persisted during interdialytic period. The pain intensity was so severe that he was afraid of undergoing HD and decided to stop the RRT. Before hospitalization, he was treated symptomatically with opioid analgesics, antipyretics, amitriptyline, and multivitamin supplements. He was provisionally diagnosed to have neuropathic pain and was treated accordingly. He was hospitalized and clinical examination was performed. External examination of both lower limbs showed no swelling, redness, pustules, or hair loss. There was no sign of volume overload. Palpation of anterolateral aspect of right thigh revealed extreme tenderness and he did not allow us for deep palpation. Deep palpation of anterior aspect of left thigh revealed tenderness. Peripheral pulse of both lower limbs was equal and palpable. Initial provisional diagnosis of inflammatory myositis or abscess was kept. Biochemical examination was performed which revealed anemia (hemoglobin: 6.8 g/dL), mild neutrophilic leukocytosis (total leuckocyte count 12,400/mm3 and neutrophil 78%), normal electrolyte levels (Na, K, Ca, PO4, uric acid, magnesium), normal serum creatine phosphokinase (CPK) levels, and mildly raised lactate dehydrogenase (LDH) levels. Neurologist opinion was sought who kept initial diagnosis of inflammatory myositis and advised muscle biopsy. He was treated with bed rest, antipyretics, opioid analgesics, and HD was withheld. His dry weight was 55 kg and he had residual urine output of approximately 1 L/day. On careful clinical examination, bruit over abdominal aorta was audible in supra and infraumbilical region. Doppler abdominal aorta revealed moderate aortic narrowing while Doppler both lower limb arterial and venous vessels was normal. In view of normal vascular structure, diagnosis was limited to muscular compartment and ultrasonography ruled out any abscess or growth in the anterolateral aspect of both thighs. Magnetic resonance imaging (MRI) of both thigh was performed in view of rare possibility of DMI. It showed extensive patchy as well as confluent areas of altered signal intensity involving bilateral thigh muscles (predominantly the anterior and medial compartments) and visualized muscles in the upper part of leg [Figure 1]. These areas were hyperintense to muscle on fat saturated T2W, PD, and STIR sequences. These changes were more marked in the vasti muscles and rectus femoris muscle in right thigh, which appeared slightly bulky [Figure 2]. Mild fluid collection was seen along the outer margin of right vastuslateralis muscle, underneath the tensor fascia lata. These changes were suggestive of muscle ischemia. No significant intramuscular fluid collections or necrotic areas were present in the imaging. Muscle biopsy was not performed. Thereafter, we treated him on the lines of muscle ischemia. He was transfused with three units of packed red blood cell transfusion. We reduced the blood flow to 200 mL/min, reduced the ultrafiltration rate and increased the duration of HD to 6 h to achieve the required Kt/V. He was treated with bed rest, antiplatelets, atorvastatin, and antipyretics. His pain and fever subsided dramatically in 5 days. At four months on follow-up, patient is doing well with above-modified HD sessions and tolerating HD well.
Figure 1: Magnetic resonance imaging showing extensive patchy as well as confluent areas of altered signal intensity involving bilateral thigh muscles (predominantly the anterior and medial compartments).

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Figure 2: Patchy areas of altered signal intensity, more marked in the vasti muscles and rectus femoris muscle in right thigh as compared to left.

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The authors obtained all appropriate consent forms from the patient for the publication of this case report.


   Discussion Top


DMI is a rare complication of DM that is underdiagnosed and thus remains under recognized. DMI presents with the acute onset of muscular pain and swelling, most commonly in the thigh without any preceding history of trauma or fever. Calf pain/swelling was the second most common presentation.[2],[3]

Our patient presented with low-grade fever and pain in right thigh without any demonstrable external swelling. Our patient was extensively investigated for fever including blood culture and urine culture. He received antibiotics, antifungals to which it did not respond. Pain in our patient exacerbated during HD which may be secondary to diminished intravascular volume compartment due to ongoing ultrafiltration and diversion of blood from intravascular compartment into HD circuit. Anemia and abdominal aortic narrowing in our patient may be contributing toward decreased blood flow in affected muscles during HD session. HD prescription was modified by increasing the duration, slowing the ultrafiltration rate, reducing the blood flow rate. He received blood transfusion to correct the anemia. We reduced the dose of antihypertensive drugs to keep blood pressure in higher range (systolic 150–160 mm Hg and diastolic 85–95 mm Hg) to improve the muscle perfusion in view of abdominal aortic narrowing. All above interventions were done with the concept of reducing the steal phenomenon and to improve the perfusion of affected muscles during HD session. These above interventions proved to be beneficial in our patient as pain and fever reduced substantially and patient was able to walk on his own within a week.

Routine laboratory investigations are often nonspecific, though inflammatory markers are elevated in most cases. Even in our case, inflammatory markers such as erythrocyte sedimentation rate and C-reactive protein were raised along with normal serum CPK level and marginally elevated serum LDH level. Patient with long-standing DM complaining of nonspecific muscle pain and fever should be evaluated with inflammatory markers along with muscle enzymes. If inflammatory markers are elevated, DMI should be ruled out by either muscle biopsy or MRI.

Patients with DMI are at high risk of recurrence, a study noted a DMI recurrence rate of 45%.[4] The underlying pathophysiology is yet not very clear. Predisposing factors are atherosclerosis, diabetic microangiopathy, and vasculitis. Ischemia-reperfusion injury has been considered as possible cause. Few reports have linked DMI with antiphospholipid syndrome.[5]

MRI is the diagnostic study of choice for radiological evaluation of patients with suspected DMI. Typical MRI findings include a hyperintense signal on T2-weighted images with associated muscular edema.[6] In our patient, MRI imaging was helpful in making proper diagnosis and muscle biopsy was not performed. The optimal treatment plan for DMI in dialysis dependent patients is not clear. Review article by Horton supports a combination of bed rest, glycemic control, and nonsteroidal anti-inflammatory drug (NSAID) therapy as preferred treatment for DMI. Avoidance of surgery and PT during the acute phase could be recommended given the longer time to resolution. NSAID therapy was associated with the lowest rate of recurrence.[6] The evidence regarding the use of anticoagulants such as heparin in patients with DMI is very limited. Physiotherapy should be avoided in the acute painful state and can be started once patient is out of painful condition. Invasive procedures such as muscle biopsy and surgery appear to prolong recovery time.[6] We avoided NSAID in our patient as he had residual urine output of around 1 L/day. Paracetamol and fentanyl patch was used to control the pain.


   Conclusion Top


DMI is underrecognized complication seen in diabetic nephropathy patients. Fever and muscular pain can be the only presenting symptoms of DMI and needs high index of suspicion to diagnose early in the course of illness. HD prescription should be modified to reduce the muscle ischemia during the acute phase of illness.

Conflict of interest: None declared.



 
   References Top

1.
Melikian N, Bingham J, Goldsmith DJ. Diabetic muscle infarction: An unusual cause of acute limb swelling in patients on hemodialysis. Am J Kidney Dis 2003;41:1322-6.  Back to cited text no. 1
    
2.
Trujillo-Santos AJ. Diabetic muscle infarction: An underdiagnosed complication of longstanding diabetes. Diabetes Care 2003;26:211-5.  Back to cited text no. 2
    
3.
Morcuende JA, Dobbs MB, Crawford H, Buckwalter JA. Diabetic muscle infarction. Iowa Orthop J 2000;20:65-74.  Back to cited text no. 3
    
4.
Kapur S, Brunet JA, McKendry RJ. Diabetic muscle infarction: Case report and review. J Rheumatol 2004;31:190-4.  Back to cited text no. 4
    
5.
Gargiulo P, Schiaffini R, Bosco D, et al. Diabetic microangiopathy: Lupus anticoagulant dependent thrombotic tendency in type 1 (insulin-dependent) diabetes mellitus. Diabet Med 1997;14:132-7.  Back to cited text no. 5
    
6.
Horton WB, Taylor JS, Ragland TJ, Subauste AR. Diabetic muscle infarction: A systematic review. BMJ Open Diabetes Res Care 2015;3: e000082.  Back to cited text no. 6
    

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Correspondence Address:
Manish R Balwani
Department of Nephrology, Jawaharlal Nehru Medical College, Sawangi, Maharashtra
Nagpur
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1319-2442.344771

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    Abstract
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