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  • The Internet Journal of Orthopedic Surgery
  • Volume 11
  • Number 2

Original Article

Intravenous Pyogenic Granuloma - A Case Report

S Vijayan, K Vijayan

Keywords

cyst, finger, ganglion, hand, invravenous pyogenic granuloma, lump

Citation

S Vijayan, K Vijayan. Intravenous Pyogenic Granuloma - A Case Report. The Internet Journal of Orthopedic Surgery. 2008 Volume 11 Number 2.

Abstract


Background: Intravenous pyogenic granuloma (IVPG) was first described by cooper et al in 1979. Published literature has shown it to be a rare benign lesion, with a strong history of undertreatment in patients given its poor clinical diagnosis. Case presentation: Here with we present a case of a 16 year old patient who had a small, fluctuant swelling removed from the flexor aspect of the left index finger. Subsequent histological analysis confirmed a rare IVPG; the first of its kind reported in the finger. Treatment consisted of removal of the segment of vein to which the lesion is attached to in order to prevent recurrence. Conclusion: We discuss this clinical case and review the literature in this area.

 

Introduction

Pyogenic granulomas are relatively common mucocutaneous vascular lesions (1). Intravenous pyogenic granuloma (IVPG) is a rare, benign intravenous counterpart of the cutaneous pyogenic granuloma (2). This lesion most commonly presents in the neck and upper extremity as a subcutaneous nodule. There have been four reported cases of IVPG of the hand in the literature and, as far as we are aware, no reports of IVPG of a finger. We present a case of IVPG of the left index finger and a review of the current literature.

Case Report

A 16 year old right hand dominant male presented to General Practice in March 2006. The presenting complaint was of a mass over the flexor aspect of the left index finger. There was no history of trauma, however, the mass had been increasing in size over a period of approximately a few weeks. There were no other changes in its appearance but it had started to interfere with his daily activities, especially sports. Subsequently, the patient was referred from General Practice to the local Orthopaedic Triage Service in May 2006.

On assessment, a pea sized, fluctuant, cystic swelling was noted over the flexor aspect of the left index finger middle phalanx. The mass was not fixed or pulsatile, nor were there any overlying skin changes. The mass was diagnosed, after examination, as a ganglion. As such, the patient was offered excision and accepted. In September 2006, excision of the lesion was undertaken under local anaesthetic. On exploration of the lesion, it appeared to be an arterio-venous malformation originating from a superficial vein. The lesion was carefully dissected out, including a segment of the vein it was attached to, and sent for histo-pathological evaluation. This demonstrated a dilated vessel filled with a lobulated proliferation of capillaries of varying calibre. These features were in keeping with a benign IVPG.

The patient was reviewed 18 months after excision. There was no sign of recurrence and the patient had made an unremarkable recovery with return of full function to the affected finger.

Discussion

IVPG was first described by Cooper et al in 1979 (3), using a series of 18 patients. These benign lesions are, along with their cutaneous counterparts are forms of lobular capillary haemangioma. They are characterised by a lobular proliferation of capillaries similar to cutaneous and sub-cutaneous pyogenic granulomas, but differ by their confinement within the lumen of a vein.

Clinical presentation of the lesion is subtle. It tends to occur as a subcutaneous, slow-growing nodule affecting the neck and upper extremities in middle-aged people (4) however, rarely, it may occur in sites such as the hand (2,4,5,6) and ocular adnexa (7). Furthermore, Mills et al (8) reported on a series of 73 cases of lobular capillary haemangioma involving the oral and nasal mucous membranes. There is normally no history of trauma and pain is rare. The lesion can become painful if ulceration, suppuration or bleeding occurs. We believe this is the fifth case of IVPG to be reported in the hand and, as far as we are aware, the only case to be reported in a finger.

The clinical features are normally of a small, soft, mobile subcutaneous nodule and are not pathognomic. Light microscopy has been tried and shows features of a pyogenic granuloma (9). Ghekiere et al (10) demonstrated the findings of ultrasonography and MRI in a lesion of the right cephalic vein. On ultrasound, the presence of hypervascularity within a lesion allows the exclusion of venous thrombosis to be made. MRI highlighted the intense intravascular topography of the lesion which suggested a tumour of a vascular origin. However, it was clear that skeletal radiology cannot confirm diagnosis of an IVPG; which can only be made with histological analysis of any excised lesion.

The gold standard method of diagnosis of IVPG is excision biopsy of the lesion followed by histo-pathological examination. Surgical technique involves complete local excision with a small portion of the vein in order to minimise recurrence (2,11). Obviously, there is a risk of local bleeding, therefore, strict haemostasis must be maintained during the procedure.

Macroscopically, the tumour appears as an intra-luminal polyp with a fibrovascular stalk (3). As aforementioned, microscopically, the appearance characteristically consists of lobules of capillaries lined by flattened or rounded epithelial cells and separated by a fibromyxoid stroma. In this case, the histological findings were equal to those described by Cooper and subsequent authors on the lesion. Occasionally, on histology, these lesions can be mistaken for other diagnoses including vegetant intravascular haemangioendothelioma (1,12). and angiolymphoid hyperplasia with eosinophilia. IVPG lacks the complex papillary structure of vegetant intravascular haemangioendothelioma whilst, in comparison to angiolymphoid hyperplasia, it lacks the extensive lymphoreticular and eosinophilia components.

Conclusion

This case represents a rare lesion masquerading as something more simple and, as such, it may be encountered in the primary care setting. However, clinicians should be aware of the lesion due to the fact that it is most commonly encountered intra-operatively. This knowledge would lead the clinician to adequately excise the required venous segment whilst maintaining meticulous haemostasis, as described in the literature. In comparison to other hand IVPG’s, this case followed a similar course with adequate excision, thus providing success in both functional outcome and avoidance of recurrence.

Correspondence to

Sridhar Vijayan Intercalating Medical Student (iBSc Orthopaedic Science) University College London, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, London, HA7 4LP Email: s_vijayan@hotmail.com Mob: 07788426073

References

1. Saad RW, Sau P, Mulvaney MP, James WD. Intravenous Pyogenic Granuloma. International Journal of Dermatology 1993 Feb;32(2):130-2.
2. Kocer U, Aksoy HM, Tiftikcioglu YO, Karaaslan O. Intravenous pyogenic granuloma of the hand. Dermatologic Surgery 2003 Sep;29(9):974-6.
3. Cooper PH, Mcallister HA, Helwig EB. Intravenous Pyogenic Granuloma - Study of 18 Cases. American Journal of Surgical Pathology 1979;3(3):221-8.
4. Hayashi H, Shimizu T, Matsumura T, Shimizu H. Intravenous pyogenic granuloma of the hand. Acta Dermato-Venereologica 2001 Aug;81(4):313-4.
5. Difazio F, Mogan J. Intravenous Pyogenic Granuloma of the Hand. Journal of Hand Surgery-American Volume 1989 Mar;14(2):310-2.
6. Anderson WJ. Intravenous Pyogenic Granuloma of the Hand. Journal of Hand Surgery-American Volume 1985;10A(5):728-9.
7. Song MG, Kim HJ, Lee ES. Intravenous pyogenic granuloma. International Journal of Dermatology 2001 Jan;40(1):57-9.
8. Mills SE, Cooper PH, Fechner RE. Lobular Capillary Hemangioma - Underlying Lesion of Pyogenic Granuloma. Laboratory Investigation 1980;42(1):136.
9. Ulbright TM, Santacruz DJ. Intravenous Pyogenic Granuloma - Case-Report with Ultrastructural Findings. Cancer 1980;45(7):1646-52.
10. Ghekiere O, Galant C, Vande BB. Intravenous pyogenic granuloma or intravenous lobular capillary hemangioma. Skeletal Radiol 2005 Jun;34(6):343-6.
11. Qian LH, Hui YZ. Intravenous pyogenic granuloma: immunohistochemical consideration--a case report. Vasc Surg 2001 Jul;35(4):315-9.
12. Kuo T, Rosai J. Massons Vegetant Intravascular Hemangioendothelioma of Skin and Soft-Tissues - Analysis of 17 Cases. Laboratory Investigation 1976;34(3):323.

Author Information

Sridhar Vijayan
Intercalating Medical Student (iBSc Orthopaedic Science), University College London, Royal National Orthopaedic Hospital

Kesavapillai Vijayan, MBBS, D.Ortho, MSc Ortho (London)
General Practioner with special interest in Orthopaedics (GPwSI), Millview Medical Centre

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