Diabetic Muscle Infarction After Kidney and Pancreas Transplanation: Case Report and Literature Review E. Theodoropoulou, E. Chelioti, K. Revenas, N. Katsilambros, A. Kostakis, and J.N. Boletis ABSTRACT Diabetic muscle infarction (DMI) is a rare, long-term complication of poorly controlled diabetes (typically of type I). DMI was first described in 1965 and more than 100 cases have been reported thereafter in the English literature. Usually, there is a coexistence with concomitant nephropathy, neuropathy, and retinopathy. The etiology remains uncertain, but appears to be attributable to diabetic microangiopathy and hypercoagulability and is believed that hypoxia–reperfusion injury is involved. DMI presents with sudden onset of pain associated with a tender mass in the thigh in most instances. The diagnosis is based on magnetic resonance imaging, which is not specific but highly indicative. Treatment is conservative with relapses occurring in 50% of the patients, but not necessarily in the same muscle group. We describe a case of DMI that occurred 4 months after simultaneous kidney and pancreas transplantation in one patient with type I diabetes mellitus and end-stage renal disease. D iabetic muscle infarction (DMI) is a rare, long-term complication of poorly controlled diabetes (typically of type I). This entity was first described in 1965 and more than 100 cases have been reported thereafter in the English literature. Usually, there is a coexistence with concomitant nephropathy, neuropathy, and retinopathy. The etiology remains uncertain but appears to be attributable to diabetic microangiopathy and hypercoagulability; it is believed that hypoxia–reperfusion injury is involved. DMI presents with a sudden onset of pain associated with a tender mass in the thigh in most instances. The diagnosis is based on magnetic resonance imaging, which is not specific but highly indica- tive. Treatment is conservative with relapses occurring in 50% of the patients but not necessarily in the same muscle group. We describe a case of DMI that occurred 4 months after simultaneous kidney and pancreas transplantation in a patient with type I diabetes mellitus and end-stage renal disease. CASE A 29-year-old woman with a 20-year history of type I diabetes underwent simultaneous kidney/pancreas transplantation. The pancreatic graft was bladder drained with systemic venous effluent. The complications of her diabetes at the time of transplantation were neuropathy and retinopathy in addition to nephropathy and hypertension. Four months after transplantation, the patient was normoglyce- mic with adequate renal function (serum creatinine 1.5 mg/dL). Her immunosupressive therapy consisted of 1 g mycophenolate mofetil (MMF), 4 mg tacrolimus, and 4 mg methylprednisolone daily. She was also taking 100 mg aspirin daily. At this stage she presented with pain in the right gastrocnemius muscle, which had been of sudden onset 10 days previously. She also complained of swelling in the same area and denied any trauma. The patient was apyrexic. Examination revealed a tender mass in the gastrocnemius muscle in addition to edema. Homan’s sign was negative and there was no indication of arteriopathy. The white cell count was low (4500/mL) and the bleeding time, fibrin- ogen, and factor VII levels were normal. Creatine phosphokinase was 160 U/L and the erythrocyte sedimentation rate was 28 mm in the first hour. The glycosylated hemoglobin was 5% and the tacrolimus level was deemed satisfactory at 9.8 pg/mL. Plain x-ray of the calf failed to demonstrate any abnormality; color Doppler of the lower leg vessels failed to show obstruction, thrombosis, or fluid collection. Subcutaneous edema was demonstrated in the area over the right gastrocnemius muscle with extension into the underlying muscle. Magnetic resonance imaging demonstrated foci of abnormal strength signals within the muscle. The signal strength was reduced in T 1 (Fig 1) and increased in T 2 (Fig 2) images. Sites of abnormal signal strength were noted in the right gastrocnemius, in a small part of the right soleus, and in the upper part of the right peroneus brevis. The architecture of the muscles was preserved and abnor- From Laiko Hospital, Athens, Greece. Address reprint requests to Dr Eleni Theodoropoulou, Laiko Hospital, Transplant Center, Agiou Thoma 17, Athens, Greece. E-mail: htheodoropoulou@yahoo.gr © 2006 by Elsevier Inc. All rights reserved. 0041-1345/06/$–see front matter 360 Park Avenue South, New York, NY 10010-1710 doi:10.1016/j.transproceed.2006.08.093 Transplantation Proceedings, 38, 3147–3150 (2006) 3147