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Nasal tip infantile hemangioma, a case of mistaken identity.

INTRODUCTION

Vascular lesions in the pediatric population are classified as either tumors or vascular malformations. (1) Infantile hemangiomas constitute the most common vascular tumor in infants and children with an estimated 4% to 5% of the Caucasian population affected. (2) These benign tumors of vascular endothelium are characterized by a growth phase followed by involution. Pyogenic granulomas or lobular capillary hemangiomas are also benign vascular tumors of the skin and mucosa, which are thought to constitute only 0.5% of all childhood skin nodules and are characterized by rapid growth and a brittle surface. (3) These tumors can be associated with trauma and tend to ulcerate and bleed. Kaposiform hemangioendothelioma or tufted angiomas are also characterized by rapid growth but can be associated with a low platelet count in the case of the Kasabach-Merritt phenomenon. (4) Other tumors, which should be considered in the differential diagnosis of a vascular tumor, include angiosarcoma or hemangioperiocytoma. (5)

Arriving at a proper diagnosis when evaluating a possible vascular tumor can be done in the majority of cases based on the history and physical exam. (6) The history should focus on the time at which the lesion first appeared, the general nature of the lesion's behavior, and a physical exam looking for signs of ulceration or infection. (4) While a discussion of the similarities between vascular tumors is beyond the scope of this report, it is worthwhile to note that the only way to definitively diagnose the type of vascular tumor is through biopsy with appropriate staining.

CASE REPORT

A 3 1/2-year-old Caucasian female presented to her primary care physician with a prominent nasal tip lesion. The child's mother explains that at birth there was a less than 1 mm maroon "stain" on the child's columella, and it remained unchanged until she was approximately three years old. At the age of 3, the lesion began to grow and become more prominent and was assumed by the child's primary physician to be an infantile hemangioma. The child was treated with a short course of oral steroids, however, the lesion continued to grow and had enlarged rapidly over the prior several weeks. The decision was made to seek surgical removal of the lesion.

Physical examination revealed a healthy 3-year-old child with a 1 cm round pedunculated lesion emanating from the columella (Figure 1). The lesion was dark red with a scaly appearance, and the surrounding nasal tissue appeared normal. She had no other lesions on exam. There was no history of trauma to the area. The child was taken to the operating groom for excision of the lesion and closure. Grossly, the specimen measured 1 cm round, and the surgical pathology was consistent with pyogenic granuloma (Figure 2). She enjoyed an uneventful postoperative course.

DISCUSSION

Initial evaluation and diagnosis of the lesion by the primary care physician as an infantile hemangioma is supported by recent literature. Infantile hemangiomas tend to appear in the first few days to months of life, as was noted in the case report, and tend to occur two to three times more often in females (Figure 3). (7,8) Pyogenic granulomas, however, have a peak incidence in the second to third decades. (9) When pyogenic granulomas occur in children, these lesions tend to appear at years 6 to 7 with a predilection for males. (10-12) While the etiology of pyogenic granulomas is unknown, trauma to the region has been suggested as a cause that was not present in this case. (13) Among the patients with pyogenic granuloma on the head and neck, 36.1% occur on the cheek, 12% occur on the forehead, and 9.6% occur on the scalp. (11) The nose and the nasal cavity are rarely affected. Pyogenic granulomas are normally less than 1 cm in diameter and tend to be complicated with bleeding, which is also in contrast to this case study. (14)

Pathological evaluation contradicted clinical examination in this case report. Infantile hemangiomas are highly expressive for Glucose transporter isoform 1 (GLUT-1) in the proliferative and involution phases. (15) Immunohistochemical staining for pyogenic granulomas will be Glut-1 negative. (16) The pathological report in this case revealed a negative GLUT-1 staining, which argues against the diagnosis of infantile hemangioma and in favor of a pyogenic granuloma. When the diagnosis is in question, referral for biopsy can prevent unnecessary medical treatment and provide physicians with proper histological information in order to deliver the correct treatment. While nasal pyogenic granulomas are rare, they can cause significant bleeding and nasal obstruction in the pediatric population. (17) Pyogenic granulomas treated with surgical excision and closure has the lowest recurrence rate of 3.6% compared to other treatment modalities. (10) This case study highlighted a unique presentation of pyogenic granuloma and the importance of keeping pyogenic granuloma in the differential when evaluating vascular tumors in the pediatric population.

ACKNOWLEDGEMENTS

No financial assistance in the form of grants, equipment, or drugs was given to the authors of this manuscript. Only the individuals listed as authors contributed to this study.

REFERENCES

(1.) Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new issues). Adv Dermatol 1997; 13:375.

(2.) Kilcline C, Frieden IJ. Infantile hamngiomas: how common are they? A systematic review of the medical literature. Peadiatr Dermatol 2008; 25:168.

(3.) Grimalt R, Caputo R. Symmetric pyogenic granuloma. J Am Acad Dermatol 29 1993; 652.

(4.) Frieden IJ, Eichenfield LF, Esterly NB, et al. Guidelines of care for hemangiomas of infancy. American Academy of Dermatology Guildlines/Outcomes Committee. J Am Acad Dermatol 1997; 37:631.

(5.) Bruckner AL, Frieden IJ. Hemangiomas of infancy. J Am Acad Dermatol 2003; 48:477.

(6.) Finn MC, Glowacki J, Mulliken JB. Congenital vascular lesions: clinical application of a new classification. J Pediatr Surg 1983; 18:894.

(7.) PRATT AG. Birthmarks in infants. AMA Arch Derm Syphilol 1953; 67:302.

(8.) Enjolras O, Gelbert F. Superficial hemangiomas: associations and management. Pediatr Dermatol 1997; 14:173.

(9.) Harris MN, Desai R, Chuang TY, et al. Lobular capillary hemangiomas: An epidemiologic report , with emphasis on cutaneous lesions. J Am Acad Dermatol 2000; 42:1012.

(10.) Gilblin AV, Clover AJ, Athanassopoulos A, Budny PG. Pyogenic granuloma- the quest for optimum treatment: audit of treatment of 408 cases. J Plastic Reconstr Aesthet Surg 2007; 60:1030.

(11.) Pagliai KA, Cohen BA. Pyogenic granuloma in children. Pediatr Dermatol 2004; 21:10.

(12.) Patrice SJ, Wiss K, Mulliken JB. Pyogenic granuloma (lobular capillary hemangioma): a clinicopathologic study of 178 cases. Pediatr Dermatol 1991; 8:267.

(13.) Lee HM, Lee S, Hwang. A giant pyogenic granuloma in the nasal cavity caused by nasal packing. European Archives of Oto-RhinoLarygology, vol 259,no. 5,pp231-233,2002.

(14.) Frieden IJ, Esterly NB. Pyogenic granulomas of infancy masquerading as strawberry hemangiomas. Pediatrics 1992; 90:989.

(15.) Leon-Villapalos J, Wolfe K, Kangesu L. GLUT-1: an extra diagnostic tool to differentiate between haemangiomas and vascular malformations. Br J Plast Surg 2005; 58:348.

(16.) Nappi O, Wick MR. Disseminated lobular capillary hemangioma (pyogenic granuloma). A clinicopathologic stuffy of two cases. Am J Dermatopathol 1986; 8:379.

(17.) Virbalas JM, Bent JP, Parikh SR. Pediatric nasal lobular capillary hemangioma. Case Rep Med. 2012; 2012:769630.

Sara A. Gaines, BS; Craig Blum, MD; Ernest S. Chiu, MD

Ms. Gaines is with the Tulane University School of Medicine in New Orleans. Dr. Blum is a Plastic Surgery Fellow at Tulane University School of Medicine. Dr. Chiu is a Past Clinical Associate Professor of Surgery and Director of Plastic Surgery Research at Tulane University School of Medicine.
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Author:Gaines, Sara A.; Blum, Craig; Chiu, Ernest S.
Publication:The Journal of the Louisiana State Medical Society
Article Type:Case study
Date:Sep 1, 2013
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