Angiolymphoid Hyperplasia with Eosinophilia in a Hand Treated with a Reverse Digital Island Flap and Artificial Skin

Journal of Medical Case Reports
01 Apr, 2019 ,

A 67-year-old Japanese woman presented with a complaint of skin masses on her left thumb and index finger, which had gradually grown in size over the past few months. A biopsy was performed confirming a diagnosis of angiolymphoid hyperplasia with eosinophilia. The aponeurosis on her index finger was resected and tissue was reconstructed using a reverse palmar digital island flap harvested from the base of her index finger. The thumb lesion was also resected and covered with collagen-based artificial skin. Gradual progression of skin epithelialization followed by healing was noted 2 months after the surgery.

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A 67-year-old Japanese woman presented with complaints of a mass of skin on her left thumb and index finger that had been gradually increasing in size over the preceding few months. Her general condition was good (height, 147 cm; weight, 65 kg; heart rate, 62/minute; blood pressure, 136/72 mmHg, and body temperature, 36.3 °C). No abnormal breath or heart sounds were heard during auscultation. An abdominal examination revealed no tenderness, rigidity, or rebound, and her bowel sounds appeared normal. Neurological abnormalities such as absent or brisk deep tendon reflexes, muscle weakness, and hyperesthesia were not observed. In addition, no edema was present. According to the laboratory data, glycated hemoglobin (HbA1c) was high (8.9–9.4 over the previous 6 months); however, no abnormalities were noted in the other parameters. Furthermore, no abnormalities or signs of infection were observed in her urine analysis. 

She was under medication (hypoglycemic agents, antihypertensive drugs, and antihistamine drugs) for diabetes mellitus, hypertension, and allergic rhinitis, respectively. She had a history of smoking 10 cigarettes a day over the past 20 years. She did not drink alcohol, and there was no history of ALHE or other allergic diseases in her family. She was a housewife and was not involved in any specific occupation.

Several skin masses, each approximately 10 mm in diameter, were observed at the base and dorsum of her left thumb and on the volar side of her index finger. They were hard and reddish in color, with the majority of them presenting with a smooth, hairless surface and poor mobility. 

 

The masses were accompanied by pain, itching, and bleeding. A blood test indicated no inflammatory response; however, the eosinophil fraction was higher (11.8%) than the reference value. Magnetic resonance imaging revealed that the tumor was confined to the skin and had not extended to the thumb joint. A biopsy performed at the Department of Dermatology indicated signs of ALHE. She was then referred to the Department of Orthopedic Surgery for a re-examination of the pathological condition, which was performed using tissue excised along the tumor margins on the distal phalanx of her index finger.

The aponeurosis on the flexor digitorum superficialis, which was juxtaposed to the surface of the tumor, was also resected. Reconstruction was performed using a reverse palmar digital island flap harvested from the base of her index finger and the resected aponeurosis tissue was examined. Vascular proliferation in the dermis and infiltration of eosinophils around the surrounding vascular endothelial cells were noted. These findings were consistent with ALHE. Consequently, the lesions on her thumb and index finger were surgically excised using the tumor margins and aponeuroses as the resection range.

The skin defect was covered with collagen-based artificial skin (Pelnac®, Gunze Co. Ltd., Ayabe, Japan). Subsequently, the interphalangeal and metacarpophalangeal joints of her thumb and the carpometacarpal joint were fixed using a Kirschner wire. She has prescribed loxoprofen sodium (180 mg/day) for approximately 10 days. The Kirschner wire was removed 2 weeks after the surgical procedure. A gradual progression of the epithelialization of the artificial skin was noted along with healing 2 months post-surgery. Mild contracture of the dorsal side of her thumb finger was observed after surgery; however, no hindrances in daily life activities were reported. Importantly, no tumor recurrence was noted at the 12-month follow-up.