diabetic muscle infarction ( dmi ) , which was described for the first time by angervall and stener in 1965 , is a rare complication of dm .
it is usually seen in long - standing dm along with complications , such as , nephropathy , retinopathy and neuropathy . until now
it commonly occurs in the thigh muscles and we have been able to find only five patients with upper extremity involvement.[46 ] in this article , we describe a patient with poorly controlled dm and muscle infarction of her forearm .
a 58 year - old - woman with a three - week history of left upper forearm pain was admitted to our hospital .
she noted a history of type ii dm , which was diagnosed five months ago .
her current condition began with a sudden onset of swelling and pain in the left forearm , extending to her fingers . before this recent admission ,
several antibiotics and non - steroidal anti - inflammatory drugs were prescribed for her , with no improvement . on physical examination
the white blood cell count was 17500 ( normal , 480010800 ) with 80% neutrophils ( normal , 3375% ) .
fasting blood glucose was 235 mg / dl ( normal , 70105 ) and hemoglobin a1c was 6.5% ( normal , < 6% ) .
other laboratory results were as follows : erythrocyte sedimentation rate ( esr ) 17 mm / hour ( normal , 025 ) , creatine kinase ( ck ) 5930 u / l ( normal , 25175 ) , lactate dehydrogenase ( ldh ) 780 u / l ( normal , 0480 ) , aspartate transaminase 89 u / l ( normal , < 31 ) , and alanine transaminase 53 u / l ( normal , < 31 ) .
magnetic resonance imaging ( mri ) showed diffuse edema and abnormal low and high signal intensities in the soft tissues of the left forearm [ figure 1 ] .
her muscle enzymes were gradually decreased to 143 and 504 for creatine kinase ( ck ) and lactate dehydrogenase ( ldh ) , respectively .
she was discharged without any swelling or pain eight days later . on a follow - up visit after two months , she did not have any complaint in her forearm .
after three months , post - treatment mri was performed that showed no abnormal signal intensity in the soft tissues , or bony structures [ figure 2 ] .
it shows diffuse edema and low signal intensities in the left forearm muscles , with subcutaneous soft tissue swelling ( arrowheads ) .
( b ) a sagital t2-weighted magnetic resonance image shows diffuse edema and high signal intensities in the forearm muscles , with subcutaneous soft tissue swelling ( arrow ) ( a ) axial t1-weighted and ( b ) coronal t2-weighted magnetic resonance images after three months show no abnormalities
its exact cause is unknown , but several hypotheses have been described , including , arteriosclerosis and microangiopathy , hypoperfusion - induced anoxia , abnormalities of the coagulation system , association with antiphospholipid antibodies , and hypoxia - reperfusion injury .
most patients are young and females , with a mean age of 42 years . unlike our patient , they usually have long - standing type i dm .
the presentation of dmi ispain and swelling that mostly involves the thigh muscles , and rarely , like in our patient , involves the upper extremity .
the best diagnostic tool is the mri , which shows high and low ( or normal ) signal intensity on t2- and t1-weighted images , respectively . although the diagnosis of dmi can be confirmed by muscle biopsy , and it was done in a majority of the cases in the past , due to nonspecific findings and increased risk of recurrence , it is better for it to be reserved for atypical cases .
the differential diagnosis of dmi is broad and the most common ones are thrombophlebitis , soft tissue infection , and diabetic amyotrophy .
our patient was afebrile , her blood cultures were negative , and we did not find any evidence of muscle or soft tissue infection .
the best method for dmi management is the conservative method , with blood glucose control .
she responded well to the rest , with blood glucose control , and without any recurrence in the follow - up visits .
diabetic muscle infarction should be noted in the differential diagnosis of any diabetic patient presenting with a swollen and painful limb .
 diabetic muscle infarction ( dmi ) is an unusual complication of diabetes mellitus . 
 it is usually seen in long - standing diabetes mellitus . 
 this article presents a case of dmi in the left forearm of a 58-year - old woman . 
 she had a swollen forearm . 
 the level of creatine kinase was 5930 
 u / l . 
 her condition was initially suspected for either cellulitis or venous thrombosis . 
 a magnetic resonance imaging ( mri ) study of the forearm showed diffuse edema and abnormal signals of the left forearm . 
 the diagnosis of dmi was made . 
 she was treated conservatively and her symptoms resolved within a short period of time . 
 dmi should be considered as a differential diagnosis of any painful and swollen limb in diabetic patients . 
INTRODUCTION
CASE REPORT
DISCUSSION