J Pediatr Endocr Met 2015; 28(3-4): 443–447
Patient report Alberto Barasoain-Millán*, Francisco Javier Rodriguez-Contreras, Julio Guerrero-Fernandez, Maria Beato Merino and Isabel Gonzalez-Casado
Pyogenic granuloma, an unusual presentation of peripubertal vaginal bleeding. Case report and review of the literature Abstract: Pyogenic granuloma, also named lobular capillary hemangioma, is a common proliferative vascular lesion known as a benign condition despite its rapid growth. It may appear in any cutaneous or mucosal surface but is usually restricted to the oral cavity. It is characterized by a friable mulberry-like lesion that can be sessile or pedunculated. Bleeding is usually its first clinical manifestation. Locations on respiratory, digestive and genital tracts are uncommon and sporadic. We describe the occurrence of an intravaginal pyogenic granuloma in a peripubertal girl with recurrent vaginal bleeding. This is the first reported case of a genital tract lobular capillary hemangioma in pediatric age to our knowledge. Therefore, we suggest this entity in the differential diagnosis of an unclear peripubertal vaginal bleeding.
DOI 10.1515/jpem-2014-0029 Received January 28, 2014; accepted August 14, 2014; previously published online October 11, 2014
and commonly appears as a reddish, friable and pedunculated lesion. Therefore, it usually shows a tendency to spontaneous bleeding. Its etiology remains unclear so far. Nevertheless, it is widely accepted that it can be reactive to diverse physical (repeated trauma, cutaneous irritation), immunological (infectious) or hormonal (puberty, pregnancy) stimuli. The prevalence of this entity in children remains unknown. In a large study conducted on adult population, lobular capillary hemangioma accounted for 0.51% of all biopsies referred to pathology studies (1). Only 12% of these were mucosal lesions, mainly in the oral cavity followed by nasal mucosa. A pediatric retrospective study (2) established head, neck, chest and upper limbs as the most common locations. In any case, a spontaneous vaginal bleeding in a prepubertal girl, with the exception of endometrial neonatal bleeding, must never be assumed as a normal condition. Medical efforts should be focused on excluding tumoral or any other treatable cause. We report for the first time a pyogenic granuloma on the genital mucosa in a prepubertal girl displaying recurrent vaginal bleedings as exclusive clinical manifestation. We performed an extensive literature review of this condition.
Pyogenic granuloma is a common and benign proliferative lesion affecting all age groups that can be located in any cutaneous or mucosal surface. It has a vascular origin
A 7½-year-old girl was referred presenting recurrent bloody and malodorous vaginal discharge in the previous 10 days for further evaluation. The bleeding quantity fluctuated every 2–5 days and made her replace one to three hygienic sanitary towels per day. The patient did not complain of abdominal or pelvic pain and did not observe changes in urine or stools output. She did not refer pelvic or genital trauma and denied any object trauma either. Familiar and social environment did not suggest risk of sexual abuse. Parents confirmed the absence of any pubertal development
Keywords: estrogens; lobular capillary hemangioma; precocious puberty; premature menarche; pyogenic granuloma; vaginal bleeding; vaginal hemangioma; vaginal tumors.
*Corresponding author: Alberto Barasoain-Millán, Hospital Universitario Fundación Alcorcón, Pediatric Endocrinology and Metabolism Unit, Alcorcón, Spain, E-mail: [email protected]
Francisco Javier Rodriguez-Contreras, Julio Guerrero-Fernandez and Isabel Gonzalez-Casado: Hospital La Paz, Pediatric Endocrinology and Metabolism Unit, Madrid, Spain Maria Beato Merino: Hospital La Paz, Pathology Unit, Madrid, Spain
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444 Barasoain-Millán et al.: Pyogenic granuloma, an unusual presentation of peripubertal vaginal bleeding sign (pubarche, telarche, longitudinal growth). There was no history of previous bleeding in any family member. No medication, either hormonal or homeophatic product, was administered to the patient besides an initial and ineffective B-lactamic antibiotic course. Physical examination showed a girl with normal phenotype and absence of cutaneous stigmata or lesions. The patient lacked any sign of pubertal sexual maturity. Neither masses nor tumors could be identified in lower abdominal exploration. Nevertheless, patient’s underpants were stained with a brownish mucous secretion; perineal examination only revealed an estrogenized vaginal introitum with normal hymeneal integrity. No active bleeding or external lesions could be detected after detailed observation. Initial blood sample tests excluded anemia or any coagulation disorder [international normalized ratio (INR): 1.01]. Baseline hormonal determinations were measured: thyroid function [thyroid stimulating hormone (TSH): 1.99 μU/mL, free thyroxine t4 (FT4): 0.93] and gonadotropin levels [follicle stimulating hormone (FSH): 2.63 mUI/mL, luteinizing hormone (LH): 0.08 mUI/mL, prolactin: 7.61 ng/mL, estradiol