oa Diabetic muscle infarction with pelvic vein thrombosis - An uncommon presentation to the Emergency Department

Background: DMI itself is a benign condition unless complicated by compartment syndrome or superadded infection. However, coexistence of extensive DVT may have serious complications such as pulmonary embolism. We report 2 cases of DMI with iliac vein thrombosis presented to our ED.

Case presentation: Case 1 A 40-year-old lady with diabetes, presented with a swollen and painful left leg for a day. A bedside Doppler ultrasound confirmed the presence of weak pulsation in the dorsalis pedis and posterior tibial arteries. Orthopedic and vascular teams were consulted as the patient continued to have pain despite repeat IV analgesia, raising the possibility of compartment syndrome. The vascular surgeons requested a CT angiogram to exclude extension to the pelvic vessels. The CT angiogram report revealed delayed filling below the knee compared to the right side. Following admission to the medical ward, MRV examination was performed. The MRI findings were suggestive of DMI. Case 2 A 58-year-old man presented with a swollen and painful left lower limb for 12 hours. Compartment syndrome was excluded by measuring bedside compartment pressure. The ultrasound examination was suboptimal due to extensive swelling in the muscles of the thigh. CT angiogram reported thrombosis of the iliac veins with grossly edematous left thigh muscles. The MRV was reported as diffuse enlargement of the lower limb muscles associated with edema in the fascia and subcutaneous tissue and was compatible with the muscle infarction. The muscle swelling and bullae resolved slowly and the patient was discharged after three weeks with an optimum INR.

Discussion: Diabetic muscle infarction may be associated with pelvic vein thrombosis. Possible differential diagnoses may include venous thrombosis of lower limbs, myositis, pyomyositis, muscle hematoma, neoplasm, necrotizing fasciitis, and osteomyelitis. Contrast magnetic resonance imaging (MRV) is ideal for making the diagnosis.