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LOCALISED MUSCULAR ATROPHY IN DIABETES
968 - Since the course of untreated lupus is well known, and the number of cases suitable for treatment was limited, it was decided to dispense with controls. Cases were distributed, so far as possible, equally between the three methods of treatment. Table r shows the results obtained by each method, and table 11 compares the results of those methods. We believe that daily injections would prove as effective as, or even more effective than, the oral administration ; but most patients with lupus are fully employed and daily attendances at hospital impose upon them too much financial loss to make this method practicable in most cases. In pulmonary tuberculosis the development of isoniazid-resistant strains has been reported (Joiner et al. 1952, Lancet 1952). From the continuous and steady manner in which improvement has taken place in almost all our patients for up to thirty weeks we find no evidence ’to suggest that drug resistance has developed. It is likely that isoniazid combined with calciferol will give better and quicker results than either drug alone, because the two drugs seem to act in different ways, isoniazid apparently having a direct action on the organisms, whereas calciferol seems to stimulate the host’s powers of resistance in some undetermined way. We consider that dosage should be at least 300 mg. a day for adults, and 400-600 mg. a day may prove to be optimal, giving maximal effect with minimal incidence of intoxication. We see no reason to estimate the dosage accurately in mg. per kg. body-weight except in children. Deviations from the average weights of adults largely depend on the amounts of fat and fluid in the tissues, for which adjustments in dosage are not needed. Nevertheless it is useful to remember that a dosage of 300 mg. daily for a woman of average build, weighing 91/2 st., provides 5 mg. per kg. body-weight, whereas a taller man of average build, weighing 121/2 st., should receive 400 mg. daily to obtain about the same dosage per kg.
LOCALISED MUSCULAR ATROPHY IN DIABETES CEDRIC HIRSON M.R.C.P. LATELY MEDICAL SENIOR WEST HERTS
HOSPITAL,
HEMEL
REGISTRAR, HEMPSTEAD,
HERTS
CHARACTERISTIC abnormalities in diabetics have been noted in many of the body systems. In the six cases reported here there were localised areas of muscular atrophy suggesting that a specific processindependent of insulin atrophy was operating. CASE-RECORDS
CASE I.-A woman, aged 76, who had beer, diabetic for twelve years and controlled with insulin for four years, complained of pain, worse at night, in the arms with tingling in the feet and weakness of the arms for two years. Examination showed areas of atrophy, which were not strictly symmetrical, in both forearms (fig. 1). The skin was normal, but muscle and subcutaneous tissue were
body-weight. Weekly local injections
are far too infrequent for a maximal response to be obtained with isoniazid, whereas
in the case of calciferol weekly or fortnightly injections As with calciferol, there is a considerable are effective. increase of fibrosis after repeated injections, which makes their administration increasingly difficult. The results obtained so far with isoniazid are impressive, but it remains as important as ever to pay attention to the patient’s nutrition and environment and to try to improve them if they are defective. Calciferol still has a place in the treatment of lupus and is a valuable remedy both for systemic and for local use. General carbon-arc and mercury-vapour baths and the FinsenLomholt and Kromayer lamps also continue to be of value for selected patients in whom for one reason or another drug therapy is inadvisable.
Summary treated with isoniazid are reviewed. Those treated orally were usually given 300 mg. daily, and those treated by injections into the lesions were given 50-250 mg. weekly. Where both methods were used the oral dosage was 300 mg. daily and the injected dose up to 400 mg. per week. Apart from mild urticaria in 1 patient, there was no intolerance. All the patients except 1 showed improvement, and in most of them this was progressive up to the time of 15
cases
of
lupus vulgaris
writing. We wish to thank Sister F. Hall for her great help in the study and treatment of these patients. Roche Products Ltd. supplied the solution of rimifon made up to our specific requirements, and E. R. Squibb & Sons supplied the hydrazid tablets.
Fig. I-Muscular atrophy of forearms (case I)., involved in clearly defined areas extending from the lower borders of the deltoid muscles to the elbows. Fasciculation was absent, and the tendon reflexes were brisk in the arms though absent at the ankles. Cutaneous sensation was normal in the arms but impaired in the legs. The patient habitually injected insulin into her thighs, where the musculature was normal.
DR. RUSSELL AND OTHERS:
REFERENCES
Brett, R., Braun-Falco, O. (1953) Derm. Wschr. 127, 1. Collins, D. M. (1952) Brit. med. J. ii, 391. Feinmann, L. (1952) Ibid, p. 1358. Grutz, O. (1952) Münch. med. Wschr. 94, 1297. Joiner, C. L., MacLean, K. S., Pritchard, E. K., Anderson, K., Collard, P., King, M. B., Knox, R. (1952) Lancet, ii, 843. Lancet (1952) i, 1293; ii, 471, 869. Lucius, K. (1952) Z. Haut-Geschlechtskr. 13, 367. Luntz, G. R. W. N., Smith, S. G. (1953) Brit. med. J. i, 296. Obermayer, M. E., Wilson, J. W., Smith, P. N. (1952) J. invest. Derm. 19, 311. Robitzek, E. H., Selikoff, I. J. (1952) Amer. Rev. Tuberc. 65, 402. Russell, B. (1951) Arch. Derm. Syph., Chicago, 64, 676, Schoch, A. (1952) Schweiz. Z. Tuberk. 9, 281. Varadi, S., Kelleher, T. D. (1953) Lancet, i, 145. Zabad, M. (1953) Ibid, p. 295.
969 CASE 2.-A woman, aged 48, whose diabetes had been diagnosed for six years but poorly controlled by diet and insulin, complained of pain and swelling in the thighs. to be Examination showed the reported swellings areas of atrophic tissue between normal of lying prominences
muscle. These were circular, about 3 in. in diameter, overeach iliac crest and lying behind the tensor fascise latae muscles. Less well-defined areas lay in the upper thirds of each thigh. A further lesion, 1 in. in diamter, was present in the right triceps brachialis muscle. Physical examination was otherwise normal. Insulin had usually been injected into the thighs, seldom in the arms, but not into the buttocks.
lying
CASE 3.-A woman, aged 46, who had been in satisfactory on diet and insulin for ten years, noticed weakness and wasting of the thumbs for eight years, loss of flesh in the arms for five years, and in the right buttock for a year. She was found to have circumscribed areas of atrophy of the muscle and fat in the following sites : the right masseter muscle; the biceps muscle of one arm and the triceps muscle of the opposite arm ;the right buttock, on the natal fold. These were such that the examining finger sank into them to the depth of bone. The short adductors of the thumbs were also wasted. She also showed a tabes-like neuropathy, the Wassermann reactions of the blood and of the cerebrospinal fluid being normal.
diabetic control
CASE 4.-An obese female, aged 66, with poor control of her diabetes by diet and insulin, had a deep area of atrophy of fat and muscle, about 1 in. in diameter, in the right deltoid muscle. The deltoid and triceps muscles were weak in this arm and the triceps jerk absent. Neurological examination was otherwise normal. The right hand was always used for insulin injection, which was normally into the left arm. CASE 5.-A woman, aged 69, who was admitted to hospital after cerebral thrombosis, had had diabetes for eleven years, adequately controlled with diet and insulin. Examination showed a right spastic hemiparesis with moderate dysphasia and comprehension defect. Sensory examination gave uncertain results. There were three discrete in the left thigh, immediately areas of muscular atrophy : overlying the femoral artery in Scarpa’s triangle (fig. 2), was a roughly circular a area 3 in. in diameter ; linear lesion, 2 X 1 in., ran below the left deltoid ; and a circular area, 1 in. in diameter, lay in the right triceps brachialis muscle. The patient and her daughter normally cooperated in injecting insulin and invariably used the arms. CASE 6.-A woman, aged 68, who had controlled her diabetes moderately well for eight years with diet and insulin, complained of aching pains in the legs for years and of weakness in the legs since a bowel disturbance with mild ketosis a month before.
Fig. 3-Muscular atrophy
on
inner aspect of
right thigh (case 6).
Examination showed areas of muscular atrophy 1/2 to 1 in. in diameter, on the inner aspects of each thigh and the outer aspect of the left thigh (fig. 3). The patient normally injected insulin into her arms and insisted that only on three or four occasions had she had
injections
in her
legs. DISCUSSION
These localised
atrophy in diabetics In the present cases the usual sites of been spared, and the characteristic induration found with insulin lesions has been absent., The atrophy has been found in unusual places for injection ; in case 3 injection in the situation of the lesions may be regarded as impossible. I have not seen any similar lesion in a patient not taking insulin, but in the pre-insulin era apparently similar lesions were reported by Bernard and Fere (1882), Auche (1890), and Pitres and Marchand (1917). Joslin (1946) described ectopic lipodystrophy -in the face, breast, and submental regions. A photograph published by Rudy and Epstein (1945) appears to be of a lesion of the kind described here, and Rudy (1945) expressed the view that " occasionally isolated muscle atrophy may be mistaken for insulin atrophy." Yohalem and Pollack (1949) found no evidence of insulin atrophy remote from the site of injection.. Panatrophy (Kinnier Wilson 1940) has not been described in diabetes, and in panatrophy the skin is abnormal, a feature absent in the present cases. Half the cases described showed neurological abnormalities, but the muscle lesions did not correspond to any The existence of separate diabetic nerve distribution. lesions in one patient is a common chance occurrence. are
areas
of muscular
distinct from insulin
atrophy. injection have
"SUMMARY
Six cases of localised areas of atrophy of muscle and subcutaneous tissues in diabetes are described. The condition probably represents a specific diabetic lesion and is independent of insulin lipodystrophy. REFERENCES
Auché, B. (1890) Ach. Méd. exp. 2, 635. Bernard, D., Féré, C. (1882) Arch. Neurol., Paris, 4, 336. Joslin, E. P. (1946) The Treatment of Diabetes Mellitus. London.
Pitres, A., Marchand, L. (1917) Progr. méd., Paris, 36, 295. Rudy, A. (1945) New Engl. J. Med. 233, 684. Epstein, S. H. (1945) J. clin. Endocrin. 5, 92. Wilson, S. A. K. (1940) Neurology. London. Yohalem, M., Pollack, H. (1949) J. Mt Sinai Hosp. 15, 320. —
Fíg. 2-Mu$cular atrophy over Scarpa’s triangle
in left
thigh (case 5).
8th ed.,
LOCALISED MUSCULAR ATROPHY IN DIABETES CEDRIC HIRSON M.R.C.P. LATELY MEDICAL SENIOR WEST HERTS
HOSPITAL,
HEMEL
REGISTRAR, HEMPSTEAD,
HERTS
CHARACTERISTIC abnormalities in diabetics have been noted in many of the body systems. In the six cases reported here there were localised areas of muscular atrophy suggesting that a specific processindependent of insulin atrophy was operating. CASE-RECORDS
CASE I.-A woman, aged 76, who had beer, diabetic for twelve years and controlled with insulin for four years, complained of pain, worse at night, in the arms with tingling in the feet and weakness of the arms for two years. Examination showed areas of atrophy, which were not strictly symmetrical, in both forearms (fig. 1). The skin was normal, but muscle and subcutaneous tissue were
body-weight. Weekly local injections
are far too infrequent for a maximal response to be obtained with isoniazid, whereas
in the case of calciferol weekly or fortnightly injections As with calciferol, there is a considerable are effective. increase of fibrosis after repeated injections, which makes their administration increasingly difficult. The results obtained so far with isoniazid are impressive, but it remains as important as ever to pay attention to the patient’s nutrition and environment and to try to improve them if they are defective. Calciferol still has a place in the treatment of lupus and is a valuable remedy both for systemic and for local use. General carbon-arc and mercury-vapour baths and the FinsenLomholt and Kromayer lamps also continue to be of value for selected patients in whom for one reason or another drug therapy is inadvisable.
Summary treated with isoniazid are reviewed. Those treated orally were usually given 300 mg. daily, and those treated by injections into the lesions were given 50-250 mg. weekly. Where both methods were used the oral dosage was 300 mg. daily and the injected dose up to 400 mg. per week. Apart from mild urticaria in 1 patient, there was no intolerance. All the patients except 1 showed improvement, and in most of them this was progressive up to the time of 15
cases
of
lupus vulgaris
writing. We wish to thank Sister F. Hall for her great help in the study and treatment of these patients. Roche Products Ltd. supplied the solution of rimifon made up to our specific requirements, and E. R. Squibb & Sons supplied the hydrazid tablets.
Fig. I-Muscular atrophy of forearms (case I)., involved in clearly defined areas extending from the lower borders of the deltoid muscles to the elbows. Fasciculation was absent, and the tendon reflexes were brisk in the arms though absent at the ankles. Cutaneous sensation was normal in the arms but impaired in the legs. The patient habitually injected insulin into her thighs, where the musculature was normal.
DR. RUSSELL AND OTHERS:
REFERENCES
Brett, R., Braun-Falco, O. (1953) Derm. Wschr. 127, 1. Collins, D. M. (1952) Brit. med. J. ii, 391. Feinmann, L. (1952) Ibid, p. 1358. Grutz, O. (1952) Münch. med. Wschr. 94, 1297. Joiner, C. L., MacLean, K. S., Pritchard, E. K., Anderson, K., Collard, P., King, M. B., Knox, R. (1952) Lancet, ii, 843. Lancet (1952) i, 1293; ii, 471, 869. Lucius, K. (1952) Z. Haut-Geschlechtskr. 13, 367. Luntz, G. R. W. N., Smith, S. G. (1953) Brit. med. J. i, 296. Obermayer, M. E., Wilson, J. W., Smith, P. N. (1952) J. invest. Derm. 19, 311. Robitzek, E. H., Selikoff, I. J. (1952) Amer. Rev. Tuberc. 65, 402. Russell, B. (1951) Arch. Derm. Syph., Chicago, 64, 676, Schoch, A. (1952) Schweiz. Z. Tuberk. 9, 281. Varadi, S., Kelleher, T. D. (1953) Lancet, i, 145. Zabad, M. (1953) Ibid, p. 295.
969 CASE 2.-A woman, aged 48, whose diabetes had been diagnosed for six years but poorly controlled by diet and insulin, complained of pain and swelling in the thighs. to be Examination showed the reported swellings areas of atrophic tissue between normal of lying prominences
muscle. These were circular, about 3 in. in diameter, overeach iliac crest and lying behind the tensor fascise latae muscles. Less well-defined areas lay in the upper thirds of each thigh. A further lesion, 1 in. in diamter, was present in the right triceps brachialis muscle. Physical examination was otherwise normal. Insulin had usually been injected into the thighs, seldom in the arms, but not into the buttocks.
lying
CASE 3.-A woman, aged 46, who had been in satisfactory on diet and insulin for ten years, noticed weakness and wasting of the thumbs for eight years, loss of flesh in the arms for five years, and in the right buttock for a year. She was found to have circumscribed areas of atrophy of the muscle and fat in the following sites : the right masseter muscle; the biceps muscle of one arm and the triceps muscle of the opposite arm ;the right buttock, on the natal fold. These were such that the examining finger sank into them to the depth of bone. The short adductors of the thumbs were also wasted. She also showed a tabes-like neuropathy, the Wassermann reactions of the blood and of the cerebrospinal fluid being normal.
diabetic control
CASE 4.-An obese female, aged 66, with poor control of her diabetes by diet and insulin, had a deep area of atrophy of fat and muscle, about 1 in. in diameter, in the right deltoid muscle. The deltoid and triceps muscles were weak in this arm and the triceps jerk absent. Neurological examination was otherwise normal. The right hand was always used for insulin injection, which was normally into the left arm. CASE 5.-A woman, aged 69, who was admitted to hospital after cerebral thrombosis, had had diabetes for eleven years, adequately controlled with diet and insulin. Examination showed a right spastic hemiparesis with moderate dysphasia and comprehension defect. Sensory examination gave uncertain results. There were three discrete in the left thigh, immediately areas of muscular atrophy : overlying the femoral artery in Scarpa’s triangle (fig. 2), was a roughly circular a area 3 in. in diameter ; linear lesion, 2 X 1 in., ran below the left deltoid ; and a circular area, 1 in. in diameter, lay in the right triceps brachialis muscle. The patient and her daughter normally cooperated in injecting insulin and invariably used the arms. CASE 6.-A woman, aged 68, who had controlled her diabetes moderately well for eight years with diet and insulin, complained of aching pains in the legs for years and of weakness in the legs since a bowel disturbance with mild ketosis a month before.
Fig. 3-Muscular atrophy
on
inner aspect of
right thigh (case 6).
Examination showed areas of muscular atrophy 1/2 to 1 in. in diameter, on the inner aspects of each thigh and the outer aspect of the left thigh (fig. 3). The patient normally injected insulin into her arms and insisted that only on three or four occasions had she had
injections
in her
legs. DISCUSSION
These localised
atrophy in diabetics In the present cases the usual sites of been spared, and the characteristic induration found with insulin lesions has been absent., The atrophy has been found in unusual places for injection ; in case 3 injection in the situation of the lesions may be regarded as impossible. I have not seen any similar lesion in a patient not taking insulin, but in the pre-insulin era apparently similar lesions were reported by Bernard and Fere (1882), Auche (1890), and Pitres and Marchand (1917). Joslin (1946) described ectopic lipodystrophy -in the face, breast, and submental regions. A photograph published by Rudy and Epstein (1945) appears to be of a lesion of the kind described here, and Rudy (1945) expressed the view that " occasionally isolated muscle atrophy may be mistaken for insulin atrophy." Yohalem and Pollack (1949) found no evidence of insulin atrophy remote from the site of injection.. Panatrophy (Kinnier Wilson 1940) has not been described in diabetes, and in panatrophy the skin is abnormal, a feature absent in the present cases. Half the cases described showed neurological abnormalities, but the muscle lesions did not correspond to any The existence of separate diabetic nerve distribution. lesions in one patient is a common chance occurrence. are
areas
of muscular
distinct from insulin
atrophy. injection have
"SUMMARY
Six cases of localised areas of atrophy of muscle and subcutaneous tissues in diabetes are described. The condition probably represents a specific diabetic lesion and is independent of insulin lipodystrophy. REFERENCES
Auché, B. (1890) Ach. Méd. exp. 2, 635. Bernard, D., Féré, C. (1882) Arch. Neurol., Paris, 4, 336. Joslin, E. P. (1946) The Treatment of Diabetes Mellitus. London.
Pitres, A., Marchand, L. (1917) Progr. méd., Paris, 36, 295. Rudy, A. (1945) New Engl. J. Med. 233, 684. Epstein, S. H. (1945) J. clin. Endocrin. 5, 92. Wilson, S. A. K. (1940) Neurology. London. Yohalem, M., Pollack, H. (1949) J. Mt Sinai Hosp. 15, 320. —
Fíg. 2-Mu$cular atrophy over Scarpa’s triangle
in left
thigh (case 5).
8th ed.,