Letters
schwannomas are the rarest.[2‑4] Schwannoma in male genital system may involve testis, penis, spermatic chord, tunica vaginalis and prostrate.[5,6] Scrotal schwannoma may be testicular or non‑testicular in origin. Most of them occur in young and middle aged adults.[7] Clinically, schwannomas are round or oval, circumscribed nodules varying in size up to 5 cm, usually firm in consistency and tend to be asymptomatic; however, when they enlarge, they result in symptoms related to compression of the surrounding structures.[8]
REFERENCES 1. 2. 3.
4. 5. 6.
Histologically, benign schwannoma are composed of an alternating pattern of Antoni A (highly cellular areas) and B areas (hypo cellular areas with myxoid change).[9] On electron microscopy tumour cells shows typical features of Schwann cells.[10] Immunohistochemistry shows strong and uniform staining with S100.[11] Surgical excision is a mainstay of treatment. Recurrence after complete surgical excision is uncommon. Similarly, malignant transformation in a schwannoma is extremely rare.[12] In the present case, the clinical suspicion was that of a skin appendageal tumour while the radiologic impression was that of a paratesticular tumour. The differential diagnosis of benign paratesteticular tumours includes leiomyoma, lipoma, fibroma or haemangioma.[13] There was no evidence of neurofibromatosis.
7. 8. 9. 10. 11.
12. 13. 14. 15. 16.
As far as our knowledge is concerned, this is the second case reported from India and only the seventh case of benign intrascrotal non‑testicular schwannoma in the literature.[2,5,14‑19] We have reported this case for its rarity and to consider it as differential in the evaluation of scrotal swelling.
17. 18. 19.
Stout AP. The peripheral manifestations of the specific nerve sheath tumor (neurilemmoma). Am J Cancer 1935;24:751‑96. Matsui F, Kobori Y, Takashima H, Amano T, Takemae K. A case of intrascrotal schwannoma. Hinyokika Kiyo 2002;48:749‑51. Rodríguez EZ, González IF, Galán ML, Muñoz PO, Sánchez AB. Schwannoma of the scrotum: Report of case and review of the literature. Actas Urol Esp 1997;21:1012‑3. Amano T, Nikura S, Kouno M, Takemae K. A case of intrascrotal extratesticular malignant schwannoma. Acta Urol Jpn 2002;48:749‑51. Jiang R, Chen JH, Chen M, Li QM. Male genital schwannoma, review of 5 cases. Asian J Androl 2003;5:251‑4. Sighinolfi MC, Mofferdin A, De Stefani SS, Celia A, Micali S, Saredi G, et al. Benign intratesticular schwannoma: A rare finding. Asian J Androl 2006;8:101‑3. Oberman HA, Sullenger G. Neurogenous tumors of the head and neck. Cancer 1967;20:1992‑2001. Mercantini ES, Mopper C. Neurilemmoma of the tongue. AMA Arch Derm 1959;79:542‑4. Sian CS, Ryan SF. The ultrastructure of neurilemoma with emphasis on Antoni B tissue. Hum Pathol 1981;12:145‑60. Waggener JD. Ultrastructure of benign peripheral nerve sheath tumors. Cancer 1966;19:699‑70. Weiss SW, Langloss JM, Enzinger FM. Value of S‑100 protein in the diagnosis of soft tissue tumors with particular reference to benign and malignant Schwann cell tumors. Lab Invest 1983;49:299‑308. Geschikler CF. Tumours of the peripheral nerves. Am J Cancer 1935;25:377‑89. Agarwal PK, Palmer JS. Testicular and paratesticular neoplasms in prepubertal males. J Urol 2006;176:875‑81. Cowen R. Tumor of the tunica vaginalis testis: Case report of neurilemmoma. J Urol 1957;77:59‑61. Fernandez MJ, Martino A, Khan H, Considine TJ, Burden J. Giant neurilemoma: Unusual scrotal mass. Urology 1987;30:74‑6. Arciola AJ, Golden S, Zapinsky J, Fracchia JA. Primary intrascrotal nontesticular schwannoma. Urology 1985;26:304‑6. Montgomery JS, Hollenbeck BK, Fisher PC, Murphy HS, Underwood W 3rd. Benign paratesticular schwannoma. Can J Urol 2004;11:2393‑5. Shimizu H, Tsuchiya A, Kusama H. A case of intrascrotal neurilemmoma. Hinyokika Kiyo 1991;37:303‑4. Bhanvadia V, Santwani P. Intrascrotal extratesticular schwannoma. J Cytol 2010;27:37‑9. Access this article online
Quick Response Code:
Nitin G Barde, S Sacchidanand, C Madura, Vishal Chugh Bangalore Medical College and Research Institute, Bangalore, India E‑mail: [email protected]
Website: www.jcasonline.com
DOI: 10.4103/0974-2077.118434
Benign Subcutaneous Emphysema Following Punch Skin Biopsy Sir, A 45‑year‑old woman, clinically diagnosed as a case of disseminated discoid lupus erythematosus was
admitted in dermatology in‑patients. A punch biopsy was performed from the lesion present over the dorsum of the right hand. About 18 h later, she complained of
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2013, Volume 6, Issue 3
171
Letters
a diffuse swelling involving the back of the right hand that extended rapidly to involve the entire forearm until elbow joint in next 5‑6 h. It was associated with mild discomfort and no systemic symptoms. Examination revealed a diffuse swelling involving the dorsum of the right hand around a loosely sutured punch biopsy wound and the forearm. A diffuse crackling (crepitus) was palpated over the swelling. There was no evidence of accompanying foul smelling discharge, other local signs of inflammation, discoloration, bulla formation or necrosis. Radiograph of the hand and forearm revealed the presence of gas in a linear fashion in the subcutaneous tissue [Figure 1]; however, there was no gas in the deeper tissues. Ultrasound also confirmed the same findings. Pus culture for aerobic as well as anaerobic organisms was sterile. Thus, a diagnosis of benign subcutaneous emphysema (SE) was made. We removed the suture and decided to keep patient on conservative management. Next day onwards, the swelling started decreasing and resolved completely by the 4th day. The word emphysema arises from ancient Greek language and means “to blow in.”[1] SE is an entity rarely encountered in dermatology literature.[2,3] SE is a condition, in which air or other gases penetrate the skin and sub mucosa resulting in soft‑tissue distension. Surgical emphysema may either be traumatic, iatrogenic or spontaneous. A sudden and dramatic swelling appears on the cutaneous surface due to leakage of air into the skin and subcutaneous tissue. The acute onset and a distinct crackling sound (crepitus) upon palpation, characterise this entity.[3] Large amount of free air entering and spreading along the deep fascia and subcutaneous tissue along the path of least resistance due to a ball‑valve mechanism has been proposed as a possible mechanism in such cases of SE following skin biopsy.[4] SE may be a benign or a potentially lethal condition. The most serious cause of SE is gas gangrene, which has a history of preceding trauma and causes extensive destruction of tissue. It presents with a sudden onset swelling with foul smell and systemic signs and symptoms. Culture from tissue material and blood culture is positive for Clostridium species. It shows no spontaneous recovery and is a potentially fatal condition without treatment. Benign, non‑infectious SE is a post‑traumatic condition. Trauma may be due to: (1) iatrogenic manoeuvres performed in emergency and intensive care settings, such as positive pressure ventilation or endotracheal intubation; (2) perforation of the pulmonary or digestive tracts; [5] (3) blast and air‑gun injuries; (4) dental extraction; and (5) dermatologic conditions.[4] SE has also
172
Figure 1: Lateral view radiograph of the hand showing soft tissue swelling involving the dorsum of hand with radiolucent shadow of entrapped subcutaneous air (arrow)
followed cases of irrigation of wounds with hydrogen peroxide or as a result of cryotherapy.[6] Benign SE resolves spontaneously as in the present report and treatment involves management of the underlying cause, if persistent. Sudden appearance of swelling following a simple office procedure such as punch biopsy, may be an alarming sign to a resident, but proper examination and investigations may help to ascertain the diagnosis of benign SE; a self‑limiting entity.
Pravesh Yadav, Deepika Pandhi, Archana Singal Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, Dilshad Garden, Delhi, India E‑mail: [email protected]
REFERENCES 1.
2. 3.
4.
5.
6.
Kaufman E, Leviner E, Galili D, Garfunkel AA. Subcutaneous air emphysema – A rare condition (four case reports). J Oral Med 1984;39:47‑50. Verma SB. Subcutaneous emphysema: A rarity in dermatology. J Eur Acad Dermatol Venereol 2007;21:248‑9. Falco OB, Plewig G, Wolff HH, Burgdorf WH, Landthaler M. Dermatologie und Venerologie. 5th ed. Berline‑Heidelberg‑NewYork: Springer‑Verlag; 2005. Sánchez‑Martín J, Vázquez‑López F, Gómez‑Díez S, Pérez‑Oliva N. Letter: Benign subcutaneous emphysema after a skin biopsy. Dermatol Surg 2008;34:1141‑2. Treasure T. The thorax. In: Williams NS, Bulstrode CJ, O’Connell PR, editors. Bailey and Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold; 2008. p. 879. Lambert TJ, Wells MJ, Wisniewski KW. Subcutaneous emphysema resulting from liquid nitrogen spray. J Am Acad Dermatol 2006;55:S95‑6. Access this article online
Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.118441
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2013, Volume 6, Issue 3
Copyright of Journal of Cutaneous & Aesthetic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of Journal of Cutaneous & Aesthetic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
schwannomas are the rarest.[2‑4] Schwannoma in male genital system may involve testis, penis, spermatic chord, tunica vaginalis and prostrate.[5,6] Scrotal schwannoma may be testicular or non‑testicular in origin. Most of them occur in young and middle aged adults.[7] Clinically, schwannomas are round or oval, circumscribed nodules varying in size up to 5 cm, usually firm in consistency and tend to be asymptomatic; however, when they enlarge, they result in symptoms related to compression of the surrounding structures.[8]
REFERENCES 1. 2. 3.
4. 5. 6.
Histologically, benign schwannoma are composed of an alternating pattern of Antoni A (highly cellular areas) and B areas (hypo cellular areas with myxoid change).[9] On electron microscopy tumour cells shows typical features of Schwann cells.[10] Immunohistochemistry shows strong and uniform staining with S100.[11] Surgical excision is a mainstay of treatment. Recurrence after complete surgical excision is uncommon. Similarly, malignant transformation in a schwannoma is extremely rare.[12] In the present case, the clinical suspicion was that of a skin appendageal tumour while the radiologic impression was that of a paratesticular tumour. The differential diagnosis of benign paratesteticular tumours includes leiomyoma, lipoma, fibroma or haemangioma.[13] There was no evidence of neurofibromatosis.
7. 8. 9. 10. 11.
12. 13. 14. 15. 16.
As far as our knowledge is concerned, this is the second case reported from India and only the seventh case of benign intrascrotal non‑testicular schwannoma in the literature.[2,5,14‑19] We have reported this case for its rarity and to consider it as differential in the evaluation of scrotal swelling.
17. 18. 19.
Stout AP. The peripheral manifestations of the specific nerve sheath tumor (neurilemmoma). Am J Cancer 1935;24:751‑96. Matsui F, Kobori Y, Takashima H, Amano T, Takemae K. A case of intrascrotal schwannoma. Hinyokika Kiyo 2002;48:749‑51. Rodríguez EZ, González IF, Galán ML, Muñoz PO, Sánchez AB. Schwannoma of the scrotum: Report of case and review of the literature. Actas Urol Esp 1997;21:1012‑3. Amano T, Nikura S, Kouno M, Takemae K. A case of intrascrotal extratesticular malignant schwannoma. Acta Urol Jpn 2002;48:749‑51. Jiang R, Chen JH, Chen M, Li QM. Male genital schwannoma, review of 5 cases. Asian J Androl 2003;5:251‑4. Sighinolfi MC, Mofferdin A, De Stefani SS, Celia A, Micali S, Saredi G, et al. Benign intratesticular schwannoma: A rare finding. Asian J Androl 2006;8:101‑3. Oberman HA, Sullenger G. Neurogenous tumors of the head and neck. Cancer 1967;20:1992‑2001. Mercantini ES, Mopper C. Neurilemmoma of the tongue. AMA Arch Derm 1959;79:542‑4. Sian CS, Ryan SF. The ultrastructure of neurilemoma with emphasis on Antoni B tissue. Hum Pathol 1981;12:145‑60. Waggener JD. Ultrastructure of benign peripheral nerve sheath tumors. Cancer 1966;19:699‑70. Weiss SW, Langloss JM, Enzinger FM. Value of S‑100 protein in the diagnosis of soft tissue tumors with particular reference to benign and malignant Schwann cell tumors. Lab Invest 1983;49:299‑308. Geschikler CF. Tumours of the peripheral nerves. Am J Cancer 1935;25:377‑89. Agarwal PK, Palmer JS. Testicular and paratesticular neoplasms in prepubertal males. J Urol 2006;176:875‑81. Cowen R. Tumor of the tunica vaginalis testis: Case report of neurilemmoma. J Urol 1957;77:59‑61. Fernandez MJ, Martino A, Khan H, Considine TJ, Burden J. Giant neurilemoma: Unusual scrotal mass. Urology 1987;30:74‑6. Arciola AJ, Golden S, Zapinsky J, Fracchia JA. Primary intrascrotal nontesticular schwannoma. Urology 1985;26:304‑6. Montgomery JS, Hollenbeck BK, Fisher PC, Murphy HS, Underwood W 3rd. Benign paratesticular schwannoma. Can J Urol 2004;11:2393‑5. Shimizu H, Tsuchiya A, Kusama H. A case of intrascrotal neurilemmoma. Hinyokika Kiyo 1991;37:303‑4. Bhanvadia V, Santwani P. Intrascrotal extratesticular schwannoma. J Cytol 2010;27:37‑9. Access this article online
Quick Response Code:
Nitin G Barde, S Sacchidanand, C Madura, Vishal Chugh Bangalore Medical College and Research Institute, Bangalore, India E‑mail: [email protected]
Website: www.jcasonline.com
DOI: 10.4103/0974-2077.118434
Benign Subcutaneous Emphysema Following Punch Skin Biopsy Sir, A 45‑year‑old woman, clinically diagnosed as a case of disseminated discoid lupus erythematosus was
admitted in dermatology in‑patients. A punch biopsy was performed from the lesion present over the dorsum of the right hand. About 18 h later, she complained of
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2013, Volume 6, Issue 3
171
Letters
a diffuse swelling involving the back of the right hand that extended rapidly to involve the entire forearm until elbow joint in next 5‑6 h. It was associated with mild discomfort and no systemic symptoms. Examination revealed a diffuse swelling involving the dorsum of the right hand around a loosely sutured punch biopsy wound and the forearm. A diffuse crackling (crepitus) was palpated over the swelling. There was no evidence of accompanying foul smelling discharge, other local signs of inflammation, discoloration, bulla formation or necrosis. Radiograph of the hand and forearm revealed the presence of gas in a linear fashion in the subcutaneous tissue [Figure 1]; however, there was no gas in the deeper tissues. Ultrasound also confirmed the same findings. Pus culture for aerobic as well as anaerobic organisms was sterile. Thus, a diagnosis of benign subcutaneous emphysema (SE) was made. We removed the suture and decided to keep patient on conservative management. Next day onwards, the swelling started decreasing and resolved completely by the 4th day. The word emphysema arises from ancient Greek language and means “to blow in.”[1] SE is an entity rarely encountered in dermatology literature.[2,3] SE is a condition, in which air or other gases penetrate the skin and sub mucosa resulting in soft‑tissue distension. Surgical emphysema may either be traumatic, iatrogenic or spontaneous. A sudden and dramatic swelling appears on the cutaneous surface due to leakage of air into the skin and subcutaneous tissue. The acute onset and a distinct crackling sound (crepitus) upon palpation, characterise this entity.[3] Large amount of free air entering and spreading along the deep fascia and subcutaneous tissue along the path of least resistance due to a ball‑valve mechanism has been proposed as a possible mechanism in such cases of SE following skin biopsy.[4] SE may be a benign or a potentially lethal condition. The most serious cause of SE is gas gangrene, which has a history of preceding trauma and causes extensive destruction of tissue. It presents with a sudden onset swelling with foul smell and systemic signs and symptoms. Culture from tissue material and blood culture is positive for Clostridium species. It shows no spontaneous recovery and is a potentially fatal condition without treatment. Benign, non‑infectious SE is a post‑traumatic condition. Trauma may be due to: (1) iatrogenic manoeuvres performed in emergency and intensive care settings, such as positive pressure ventilation or endotracheal intubation; (2) perforation of the pulmonary or digestive tracts; [5] (3) blast and air‑gun injuries; (4) dental extraction; and (5) dermatologic conditions.[4] SE has also
172
Figure 1: Lateral view radiograph of the hand showing soft tissue swelling involving the dorsum of hand with radiolucent shadow of entrapped subcutaneous air (arrow)
followed cases of irrigation of wounds with hydrogen peroxide or as a result of cryotherapy.[6] Benign SE resolves spontaneously as in the present report and treatment involves management of the underlying cause, if persistent. Sudden appearance of swelling following a simple office procedure such as punch biopsy, may be an alarming sign to a resident, but proper examination and investigations may help to ascertain the diagnosis of benign SE; a self‑limiting entity.
Pravesh Yadav, Deepika Pandhi, Archana Singal Department of Dermatology and STD, University College of Medical Sciences and GTB Hospital, University of Delhi, Dilshad Garden, Delhi, India E‑mail: [email protected]
REFERENCES 1.
2. 3.
4.
5.
6.
Kaufman E, Leviner E, Galili D, Garfunkel AA. Subcutaneous air emphysema – A rare condition (four case reports). J Oral Med 1984;39:47‑50. Verma SB. Subcutaneous emphysema: A rarity in dermatology. J Eur Acad Dermatol Venereol 2007;21:248‑9. Falco OB, Plewig G, Wolff HH, Burgdorf WH, Landthaler M. Dermatologie und Venerologie. 5th ed. Berline‑Heidelberg‑NewYork: Springer‑Verlag; 2005. Sánchez‑Martín J, Vázquez‑López F, Gómez‑Díez S, Pérez‑Oliva N. Letter: Benign subcutaneous emphysema after a skin biopsy. Dermatol Surg 2008;34:1141‑2. Treasure T. The thorax. In: Williams NS, Bulstrode CJ, O’Connell PR, editors. Bailey and Love’s Short Practice of Surgery. 25th ed. London: Hodder Arnold; 2008. p. 879. Lambert TJ, Wells MJ, Wisniewski KW. Subcutaneous emphysema resulting from liquid nitrogen spray. J Am Acad Dermatol 2006;55:S95‑6. Access this article online
Quick Response Code: Website: www.jcasonline.com
DOI: 10.4103/0974-2077.118441
Journal of Cutaneous and Aesthetic Surgery - Jul-Sep 2013, Volume 6, Issue 3
Copyright of Journal of Cutaneous & Aesthetic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Copyright of Journal of Cutaneous & Aesthetic Surgery is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
