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Muscle necrosis is the death of muscle cells, which can be caused by a variety of factors, including injury, infection, disease, or lack of blood flow. It is a subset of idiopathic inflammatory myopathy, or myositis, and is characterised by the death of muscle cells with less inflammation than other types of myositis. The necrosis of muscle cells can lead to the accumulation of sodium and calcium intracellularly, as well as the release of substances such as potassium, uric acid, phosphorus, lactic acid, and
| Characteristics | Values |
|---|---|
| Medical Definition | Death of body tissue |
| Areas Affected | Bones, skin, and organs |
| Causes | Illness, infection, injury, disease, lack of blood flow to tissues, extreme environmental conditions, drug exposure |
| Types | Liquefactive necrosis, fat necrosis, caseous necrosis, fibrinoid necrosis, gangrenous necrosis, avascular necrosis (osteonecrosis, aseptic necrosis, bone necrosis), pancreatic necrosis, acute tubular necrosis, immune-mediated necrotizing myopathy (also referred to as necrotizing autoimmune myopathy or necrotizing myopathy) |
| Symptoms | Weakness and fatigue in muscles closest to the center of the body, such as shoulders, forearms, hips, thighs, neck, and back; accelerated deterioration in strength and balance, loss of ambulation, contractures in lower extremities and shoulders, kyphoscoliosis, cardiac and respiratory involvement, forward head flexion, lower facial muscle involvement |
| Treatment | Vigorous hydration with bicarbonate-based solutions, alkalinization of urine, steroid treatment |
| Diagnosis | Muscle biopsy to detect necrosis, blood tests to detect autoantibodies |
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What You'll Learn
Types of necrosis
Necrosis is the medical term for the death of body tissue. It can occur due to injuries, infections, diseases, or a lack of blood flow to the tissues. Extreme environmental conditions can also cause necrosis.
There are several types of necrosis, including:
Liquefactive Necrosis
Within hours of death, the dead cells partially or completely dissolve and transform into a thick, sticky liquid. The cells sometimes appear creamy yellow because of pus formation. Infections and a lack of oxygen to the brain can cause liquefactive necrosis.
Fat Necrosis
In fat necrosis, damaged cells release enzymes, causing them to turn to liquid. The liquid cells then combine with calcium, creating chalky, white deposits on the cells. Acute pancreatitis is the most common cause of fat necrosis, but it can also occur in breast tissue.
Caseous Necrosis
Caseous necrosis is characterised by dead cells that look white and soft, resembling cheese. This type of necrosis is unique to infectious lung diseases like tuberculosis.
Fibrinoid Necrosis
In fibrinoid necrosis, the dead cells appear pink and lack structure due to plasma proteins (fibrins) leaking out of the blood vessel walls.
Gangrenous Necrosis
Gangrenous necrosis causes the skin to appear black and begin to rot. It is caused by a lack of blood flow to the affected area, typically the legs, but it can also affect the arms and fingers.
Avascular Necrosis
Avascular necrosis occurs when blood flow to the bone tissue is blocked, causing the bones to break down and eventually die. It goes by many names, including osteonecrosis, aseptic necrosis, and bone necrosis. Hip necrosis is the most common form, and osteonecrosis of the jaw (ONJ) is a type of avascular necrosis that causes severe mouth and jaw pain.
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Causes of muscle necrosis
Muscle necrosis is the death of muscle tissue. It can be caused by a variety of factors, including:
Illness, Infection, or Injury
Infections such as Clostridial gas gangrene, caused by bacteria such as Clostridium perfringens, can lead to muscle necrosis. Traumatic wounds with soil contamination, surgery involving the bowel or biliary system, septic abortions, vascular disease with arterial insufficiency, and injection of medications or illicit drugs can also cause muscle necrosis.
Lack of Blood Flow
Avascular necrosis occurs when blood flow to tissues is blocked, causing the tissue to break down and die. This can happen in the bones, leading to osteonecrosis, or in the jaw, resulting in osteonecrosis of the jaw (ONJ). Lack of blood flow to the legs, arms, or fingers can cause gangrenous necrosis, where the skin turns black and begins to rot.
Extreme Environmental Conditions
Exposure to extreme environmental conditions can also lead to muscle necrosis.
Drug Exposure
Intramuscular injection of drugs can induce muscle fibre necrosis. Additionally, exposure to certain drugs, such as 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins), can result in muscle necrosis and the release of myoglobin, leading to potential acute kidney injury (AKI).
Strenuous Exercise
Strenuous exercise can cause mild muscle cell necrosis, as evidenced by the presence of myoglobinemia in a cohort of Marine recruits. However, it is important to note that not all cases of muscle necrosis from exercise lead to acute renal failure.
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Symptoms of muscle necrosis
Muscle necrosis is the death of muscle tissue, which can occur totally or in segments. It can lead to muscle fibre destruction, loss of muscle continuity, and subsequent atrophy.
The symptoms of muscle necrosis vary depending on the affected area and the type of necrosis. Here are some general symptoms and effects of muscle necrosis:
- Electrolyte abnormalities and AKI : The release of myoglobin and other intracellular muscle constituents can result in electrolyte abnormalities and acute kidney injury (AKI).
- Renal failure : Acute renal failure can occur due to free radical toxicity, volume depletion, renal vasoconstriction, renal tubular cell damage, and tubular obstruction.
- Mobility issues : Muscle necrosis can cause a deterioration in strength and balance, leading to difficulty walking and, eventually, the need for a wheelchair.
- Contractures : After the loss of ambulation, contractures become more pronounced in the lower extremities and can also involve the shoulders.
- Cardiac and respiratory involvement : In advanced stages of muscle necrosis, cardiac and respiratory functions may be affected, leading to further complications.
- Neck muscle weakness : The head may progressively flex forward as extensor neck muscles lose strength.
- Facial muscle involvement : In the advanced stages of muscle necrosis, lower facial muscles may be affected.
It is important to note that the symptoms of muscle necrosis can vary depending on the underlying cause and the extent of the condition. Therefore, if you suspect any symptoms of muscle necrosis, it is crucial to seek medical advice for a proper diagnosis and treatment plan.
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Diagnosis of muscle necrosis
Muscle necrosis, or myonecrosis, is the death of muscle cells. It is a form of cell injury that results in the premature death of cells in living tissue by autolysis. Myonecrosis is a myopathy involving infarction of skeletal muscle and can appear as an intramuscular mass. It is characterised by swollen, deeply eosinophilic, homogeneous myofibers that lack cross striations.
There are several ways to diagnose muscle necrosis. Firstly, it is important to note that necrosis can occur due to injuries, infections, diseases, lack of blood flow to tissues, or extreme environmental conditions. A healthcare provider can diagnose necrosis and recommend appropriate treatment.
When diagnosing muscle necrosis, it is essential to identify the specific type of necrosis present. There are several types of necrosis, each with its own unique characteristics:
- Coagulative necrosis: Dead cells remain firm and look normal for days after death due to lack of blood flow or oxygen.
- Liquefactive necrosis: Dead cells partially or completely dissolve within hours of death, transforming into a thick, sticky liquid. This type of necrosis is often associated with infections and lack of oxygen to the brain.
- Fibrinoid necrosis: Dead cells appear pink and lack structure due to plasma proteins (fibrins) leaking out of blood vessel walls. It occurs when an autoimmune disease or infection damages blood vessels.
- Gangrenous necrosis: The skin appears black and begins to rot due to lack of blood flow, commonly affecting the legs, arms, or fingers.
- Fat necrosis: Damaged cells release enzymes and combine with calcium, creating chalky, white deposits on the cells.
In addition to the visual identification of necrosis types, there are specific diagnostic markers that can be used to detect muscle necrosis:
- Serum enzymes: Creatine kinase (CK), aspartate transaminase (AST), and lactate dehydrogenase (LDH) are enzymes that are routinely used to assess muscle necrosis. CK is the most sensitive and specific indicator of muscle injury.
- Serum myoglobin: Myoglobin is a low-molecular-weight protein that leaks into the plasma immediately after muscle damage and can be detected in the urine. Elevated levels of serum myoglobin indicate acute muscle damage.
- Electrophoretic separation: This technique can identify elevations in LDH, which may be indicative of rhabdomyolysis, myocardial necrosis, or hepatic necrosis.
- Muscle biopsies: Biopsies can reveal predominant necrosis (death) of muscle cells, often with less inflammation compared to other myositis subsets.
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Treatment of muscle necrosis
Muscle necrosis, or myonecrosis, is the death of muscle cells, which can be caused by myotoxic PLA2 acting directly on the membrane of muscle cells, vascular alterations caused by SVMPs, or proteins that interfere with the ionic control of muscle fibres. Snake venom proteins, known as myotoxins, can also induce muscle necrosis.
Muscle necrosis can be treated in several ways, depending on the underlying cause. Here are some approaches to treating muscle necrosis:
- Vigorous hydration: This is a common clinical practice in rhabdomyolysis, which is a condition characterised by muscle cell necrosis. Administering a bicarbonate-based solution can increase myoglobin solubility and reduce the formation of casts in the kidneys.
- Alkalinisation of urine: By increasing the pH of urine to above 6.5, myoglobin solubility is enhanced, which helps prevent the formation of kidney stones.
- Anti-inflammatory drugs: In some cases, muscle necrosis is aggravated by an inflammatory reaction. Treatment with anti-inflammatory drugs, particularly inhibitors of eicosanoid formation, can help reduce local muscle damage and improve symptoms.
- Immune-mediated necrotizing myopathy (IMNM): While there is no known cure for IMNM, treatments are available to manage symptoms. These treatments focus on alleviating muscle weakness and improving the patient's ability to perform daily tasks.
- Statin-induced necrotizing myopathy: In some cases, necrotizing myopathy can be triggered by exposure to statins, which are used to lower cholesterol. Discontinuing the use of statins and providing supportive care can help manage this condition.
- Reperfusion in ischemic injury: In cases of ischemic muscle injury, reperfusion can exacerbate damage. Ensuring satellite cells remain viable can enable regeneration following ischemic injury.
- Gangrenous necrosis: This type of necrosis causes the skin to turn black and rot, usually due to a lack of blood flow to the affected area. Treatment involves improving blood circulation and preventing further tissue damage. In severe cases, surgical debridement or amputation may be necessary to remove the dead tissue.
- Pancreatic necrosis: Acute pancreatitis can lead to pancreatic necrosis if the blood supply to the pancreas is cut off. Treatment focuses on managing pain, improving blood flow, and preventing or treating infections. In some cases, surgery may be required to remove necrotic tissue or address complications.
- Fat necrosis: This type of necrosis occurs when damaged cells release enzymes and turn into liquid, forming greasy fluid-filled cysts. Treatment may involve draining the cysts or surgically removing the necrotic tissue, especially in cases affecting the breast.
- Dental pulp necrosis: When the soft tissue inside a tooth dies due to injury or decay, it can become infected. Treatment includes root canal therapy to remove the infected pulp and restore the tooth's function.
It is important to consult a healthcare professional for an accurate diagnosis and tailored treatment plan for muscle necrosis, as the specific approach will depend on the underlying cause and severity of the condition.
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Frequently asked questions
Muscle necrosis is the death of muscle cells, which can be caused by illness, infection, injury, disease, or lack of blood flow to the muscles. It can also be caused by drug exposure, such as 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins).
Muscle necrosis causes muscle weakness, particularly in the muscles closest to the center of the body, such as the shoulders, forearms, hips, thighs, neck, and back. It can also lead to electrolyte abnormalities, acute kidney injury (AKI), and tubular obstruction.
While dead muscle tissue cannot be brought back to health, treatments are available to manage the symptoms of muscle necrosis. Vigorous hydration and alkalinization of the urine are common clinical practices to increase myoglobin solubility and limit cast formation.
