Brief Reports 741
recent report that found it to be secondary to venipuncture (2,3). ALHE and common traumatic lesions share similar findings, including elastic tissue alteration, mucosaccharide elaboration, and reactive vessel formation, although multiple factors found in lesions may drive the unique pathologic vascular and inflammatory proliferation seen in ALHE: large numbers of mast cells that release histamine, interleukin-5, and vascular endothelial growth factor; high renin and angiotensin II levels; and a lack of periendothelial cells (1,3,5,6). To our knowledge, this is the first reported case of ALHE secondary to ear piercing. Although lesions can regress spontaneously, various treatments are used to speed resolution (2,5). Simple surgical excision, Mohs surgery, intralesional steroid injections, laser therapy, retinoids, cyro- and radiotherapy, and electrodesiccation have all been successful, with varying rates of recurrence. Therefore, regardless of the modality of treatment, followup is required (1–3,5). It is important for clinicians to consider the diagnosis of ALHE after ear piercing, especially because the lesions can clinically mimic keloids. REFERENCES 1. Olsen TG, Helwig EB. Angiolymphoid hyperplasia with eosinophilia: a clinicopatholgic study of 116 patients. J Am Acad Dermatol 1985;12(5 pt. 1):781–796. 2. Stewart N, Zagarella S, Mann S. Angiolyphoid hyperplasia with eosinophilia occurring after venipuncture trauma. J Dermatol 2013;40:393–395. 3. Vadlamudi G, Schinella R. Traumatic pseudoaneurysm: a possible early lesion in the spectrum of epithelioid hemangioma/angiolymphoid hyperplasia with eosinophilia. Am J Dermatopathol 1998;20:113–117. 4. Chun SI, Ji HG. Kimura’s disease and angiolymphoid hyperplasia with eosinophilia: clinical and histopathologic differences. J Am Acad Dermatol 1992;27(6 Pt 1):954–958. 5. Trindade F, Haro R, Requena L. Giant angiolymphoid hyperplasia with eosinophilia on the chest. J Cutan Pathol 2009;36:493–496. 6. Busquets AC, Sanchez JL. Angiolymphoid hyperplasia with eosinophilia induced by trauma. Int J Dermatol 2006;45:1211–1214. Jonathan S. Okman, M.D., M.B.A.* Tricia R. Bhatti, M.D.† Oksana A. Jackson, M.D.à Adam I. Rubin, M.D.¶ *Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, †Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, àDivision of Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, ¶Department of Dermatology, Division of Dermatopathology, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Address correspondence to Adam I. Rubin, M.D., Department of Dermatology, Division of Dermatopathology, University of Pennsylvania Health System, 2 Maloney, 3600 Spruce Street, Philadelphia, PA 19104, or e-mail: [email protected].
Utility of the “Magnet Sign” in the Differential Diagnosis of a Firm Papule in the Skin Abstract: A symptomatic retained foreign body can be frustrating to physicians and patients alike. Herein we present a case of a retained metal ball bearing from an air gun injury. This brief communication highlights an innovative “bedside” technique that helped to confirm the diagnosis and allow for immediate and definitive management.
A 17-year-old boy presented to the department of pediatric and adolescent dermatology for evaluation of a persistent “hard bump” within his right medial eyebrow. He noted the lesion was “pretty close” to where, 2 years before, he had been accidentally shot by a ball bearing (BB) air gun. The patient had thought that the BB had “bounced off” of his skin after the injury, so he did not sought medical care at that time. Other than frequent, focal headaches emanating from the site of the lesion, the patient’s past medical, surgical, family, and social histories were otherwise unremarkable. The patient denied any suicidal or homicidal ideation and screened negative for depression. During physical examination, the patient was noted to be an active, well-developed, well-appearing boy with no signs of physical or emotional distress. His vital signs were normal. Local head and neck examination revealed a 6-mm-diameter, smooth, firm, somewhat-mobile papule located at the right medial eyebrow with no overlying skin changes and no central punctum. There were no neurologic or functional impairments to cranial nerves I to XII and no noted behavioral problems or signs of dysphoric mood. Given the patient’s uncertain history, lack of overlying skin changes, and anatomic location and size of the lesion (larger than what might be expected for a normal BB), a broad differential diagnosis was considered, including pilomatricoma, dermoid cyst,
742 Pediatric Dermatology Vol. 31 No. 6 November/December 2014
and granulomatous foreign body reaction. Definitive management strategies of these potential etiologies differ greatly, so several physical examination maneuvers were performed to help narrow the diagnosis. Transillumination of the skin with an otoscope revealed a dark blue-grey, ovoid papule in the skin, suggesting that the lesion was not a fluid-filled cyst. The “teetertotter” sign (pushing down one edge of the lesion causes elevation of the opposite side), which is classically associated with pilomatricoma, was absent. The definitive diagnosis of retained metal BB was made when a magnet, borrowed from the clinic’s scheduling board, was placed over the affected area; it strongly adhered to the patient’s skin and confirmed the presence of a ferromagnetic material (what we have called the positive “magnet sign”). The object was excised for symptomatic relief and to prevent further complications and a 4-mm-diameter, greyblack BB pellet was excised from the patient’s middermis (Fig. 1). The area healed with excellent functional and cosmetic results and the patient’s headaches resolved postoperatively.
This case reveals that the greatest risk of managing air gun (nonpowder gun) injuries may be the tendency to underestimate their destructive power. Every year approximately 30,000 air gun injuries are treated in emergency departments across the United States, with half of these injuries occurring in children ages 5 to 14 years (1). The number of reported injuries peaks in January, which may be related to BB guns being given to children as holiday gifts (2). Since the 1980s, approximately four deaths per year have been directly attributed to BB gun– related injuries (3). One study spanning a 12-year period reported 30% mortality from intracranial injuries in 101 children injured by nonpowder guns (4). The eye is particularly susceptible to air gun injury, and the American Academy of Ophthalmology considers BB and pellet injuries to be a major cause of devastating ocular injury in children (2). Clinicians should consider the full differential diagnosis and varying management strategies of a firm papule above the eye. Many people do not consider air guns to be weapons, so it is important to
Figure 1. (Top left) Preoperative photo: dermal nodule of the right medial brow. (Top right) Positive magnet sign. (Bottom left) Intraoperative photo: BB extraction. (Bottom right) Postoperative photo of the extracted foreign body.
Brief Reports 743
ask specifically about them when assessing potential hazards in a patient’s or family’s home. When an injury occurs, children may avoid reporting an injury out of fear of having the air gun taken away as punishment, and patients and parents of children involved in air gun trauma may fail to recognize the potential magnitude of injuries because of the seemingly innocuous mechanism of injury and the characteristically small associated wounds. This may greatly delay care and lead to comorbidities such as the chronic, focal headaches that our patient experienced. Providers should counsel patients and families on the importance of safety precautions when using air guns and parental supervision should be stressed to help ensure everyone’s safety. REFERENCES 1. Centers for Disease Control and Prevention (CDC). BB and pellet gun-related injuries—United States, June 1992–May 1994. MMWR Morb Mortal Wkly Rep 1995;44:909–913. 2. McNeill AM, Annest JL. The ongoing hazard of BB gun and pellet gun-related injuries in the United States. Ann Emerg Med 1995;26:187–194. 3. Laraque D, American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Injury risk of nonpowder guns. Pediatrics 2004;114:1357–1361. 4. Isaac A, Al Qudehy Z, El-Hakin H. Penetrating injury to the parapharyngeal space caused by a BB gun in a pediatric patient. J Pediatr Surg Case Rep 2013;1:25–27. Andrew C. Krakowski, M.D.*,† Lauren Bennett, P.A.-C., M.M.Sc.† Samar Kaifi, M.B.B.S.† *Kids’ Scar Treatment and Revision Program, San Diego, California, †Pediatric and Adolescent Dermatology, Rady Children’s Hospital, San Diego, California Address correspondence to Lauren Bennett, P.A.-C., 8010 Frost Street, Suite 602, San Diego, CA 92123, or e-mail: LNBennett@ RCHSD.org.
inherited variant, with involvement of all digits and toes (1). We present a 4-year-old boy with severe total congenital anonychia whose parents were first-degree cousins. CASE REPORT A 4-year-old boy presented to the pediatric dermatology clinic with a history of absence of all fingernails and toenails from birth. He was the only child of his parents, born at full term after an uncomplicated pregnancy, and his mother had not taken any drug during her pregnancy. He did not have affected relatives, but his parents were first-degree cousins. He was otherwise healthy, with normal development and intelligence according to his age. Physical examination was within normal limits, but dermatologic examination revealed the absence of all nails of the hands and feet (Figs. 1 and 2) with normal teeth and hair. Radiographic investigation of the hands and feet showed no bone abnormalities. Clinically the patient was diagnosed with total congenital anonychia, probably inherited as an autosomal recessive trait. DISCUSSION Congenital anonychia is a rare disorder characterized by the absence of several or all fingernails, toenails, or both from birth. This condition may be present as a single feature or as part of a syndrome or condition. The skin in the region of the absent nails is normal and the nail bed and nail matrix or fold are present in all fingers and toes (2). Anonychia can be inherited by autosomal dominant or recessive means (1). Because the parents of our patient were first-degree cousins and were unaffected,
Total Congenital Anonychia Abstract: Total or partial absence of nails at birth is rare. Anonychia can be inherited as an autosomal dominant or recessive trait. An otherwise healthy 4-year-old boy whose parents were first-degree relatives was diagnosed with total congenital anonychia.
Isolated, nonsyndromic anonychia without additional features is a rare entity that may present in a partial autosomal dominant form that affects only the thumbs or, in its most severe, autosomal recessively
Figure 1. Total anonychia of hands and feet.
recent report that found it to be secondary to venipuncture (2,3). ALHE and common traumatic lesions share similar findings, including elastic tissue alteration, mucosaccharide elaboration, and reactive vessel formation, although multiple factors found in lesions may drive the unique pathologic vascular and inflammatory proliferation seen in ALHE: large numbers of mast cells that release histamine, interleukin-5, and vascular endothelial growth factor; high renin and angiotensin II levels; and a lack of periendothelial cells (1,3,5,6). To our knowledge, this is the first reported case of ALHE secondary to ear piercing. Although lesions can regress spontaneously, various treatments are used to speed resolution (2,5). Simple surgical excision, Mohs surgery, intralesional steroid injections, laser therapy, retinoids, cyro- and radiotherapy, and electrodesiccation have all been successful, with varying rates of recurrence. Therefore, regardless of the modality of treatment, followup is required (1–3,5). It is important for clinicians to consider the diagnosis of ALHE after ear piercing, especially because the lesions can clinically mimic keloids. REFERENCES 1. Olsen TG, Helwig EB. Angiolymphoid hyperplasia with eosinophilia: a clinicopatholgic study of 116 patients. J Am Acad Dermatol 1985;12(5 pt. 1):781–796. 2. Stewart N, Zagarella S, Mann S. Angiolyphoid hyperplasia with eosinophilia occurring after venipuncture trauma. J Dermatol 2013;40:393–395. 3. Vadlamudi G, Schinella R. Traumatic pseudoaneurysm: a possible early lesion in the spectrum of epithelioid hemangioma/angiolymphoid hyperplasia with eosinophilia. Am J Dermatopathol 1998;20:113–117. 4. Chun SI, Ji HG. Kimura’s disease and angiolymphoid hyperplasia with eosinophilia: clinical and histopathologic differences. J Am Acad Dermatol 1992;27(6 Pt 1):954–958. 5. Trindade F, Haro R, Requena L. Giant angiolymphoid hyperplasia with eosinophilia on the chest. J Cutan Pathol 2009;36:493–496. 6. Busquets AC, Sanchez JL. Angiolymphoid hyperplasia with eosinophilia induced by trauma. Int J Dermatol 2006;45:1211–1214. Jonathan S. Okman, M.D., M.B.A.* Tricia R. Bhatti, M.D.† Oksana A. Jackson, M.D.à Adam I. Rubin, M.D.¶ *Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, †Department of Pathology and Laboratory Medicine, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, àDivision of Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, ¶Department of Dermatology, Division of Dermatopathology, Perelman
School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania Address correspondence to Adam I. Rubin, M.D., Department of Dermatology, Division of Dermatopathology, University of Pennsylvania Health System, 2 Maloney, 3600 Spruce Street, Philadelphia, PA 19104, or e-mail: [email protected].
Utility of the “Magnet Sign” in the Differential Diagnosis of a Firm Papule in the Skin Abstract: A symptomatic retained foreign body can be frustrating to physicians and patients alike. Herein we present a case of a retained metal ball bearing from an air gun injury. This brief communication highlights an innovative “bedside” technique that helped to confirm the diagnosis and allow for immediate and definitive management.
A 17-year-old boy presented to the department of pediatric and adolescent dermatology for evaluation of a persistent “hard bump” within his right medial eyebrow. He noted the lesion was “pretty close” to where, 2 years before, he had been accidentally shot by a ball bearing (BB) air gun. The patient had thought that the BB had “bounced off” of his skin after the injury, so he did not sought medical care at that time. Other than frequent, focal headaches emanating from the site of the lesion, the patient’s past medical, surgical, family, and social histories were otherwise unremarkable. The patient denied any suicidal or homicidal ideation and screened negative for depression. During physical examination, the patient was noted to be an active, well-developed, well-appearing boy with no signs of physical or emotional distress. His vital signs were normal. Local head and neck examination revealed a 6-mm-diameter, smooth, firm, somewhat-mobile papule located at the right medial eyebrow with no overlying skin changes and no central punctum. There were no neurologic or functional impairments to cranial nerves I to XII and no noted behavioral problems or signs of dysphoric mood. Given the patient’s uncertain history, lack of overlying skin changes, and anatomic location and size of the lesion (larger than what might be expected for a normal BB), a broad differential diagnosis was considered, including pilomatricoma, dermoid cyst,
742 Pediatric Dermatology Vol. 31 No. 6 November/December 2014
and granulomatous foreign body reaction. Definitive management strategies of these potential etiologies differ greatly, so several physical examination maneuvers were performed to help narrow the diagnosis. Transillumination of the skin with an otoscope revealed a dark blue-grey, ovoid papule in the skin, suggesting that the lesion was not a fluid-filled cyst. The “teetertotter” sign (pushing down one edge of the lesion causes elevation of the opposite side), which is classically associated with pilomatricoma, was absent. The definitive diagnosis of retained metal BB was made when a magnet, borrowed from the clinic’s scheduling board, was placed over the affected area; it strongly adhered to the patient’s skin and confirmed the presence of a ferromagnetic material (what we have called the positive “magnet sign”). The object was excised for symptomatic relief and to prevent further complications and a 4-mm-diameter, greyblack BB pellet was excised from the patient’s middermis (Fig. 1). The area healed with excellent functional and cosmetic results and the patient’s headaches resolved postoperatively.
This case reveals that the greatest risk of managing air gun (nonpowder gun) injuries may be the tendency to underestimate their destructive power. Every year approximately 30,000 air gun injuries are treated in emergency departments across the United States, with half of these injuries occurring in children ages 5 to 14 years (1). The number of reported injuries peaks in January, which may be related to BB guns being given to children as holiday gifts (2). Since the 1980s, approximately four deaths per year have been directly attributed to BB gun– related injuries (3). One study spanning a 12-year period reported 30% mortality from intracranial injuries in 101 children injured by nonpowder guns (4). The eye is particularly susceptible to air gun injury, and the American Academy of Ophthalmology considers BB and pellet injuries to be a major cause of devastating ocular injury in children (2). Clinicians should consider the full differential diagnosis and varying management strategies of a firm papule above the eye. Many people do not consider air guns to be weapons, so it is important to
Figure 1. (Top left) Preoperative photo: dermal nodule of the right medial brow. (Top right) Positive magnet sign. (Bottom left) Intraoperative photo: BB extraction. (Bottom right) Postoperative photo of the extracted foreign body.
Brief Reports 743
ask specifically about them when assessing potential hazards in a patient’s or family’s home. When an injury occurs, children may avoid reporting an injury out of fear of having the air gun taken away as punishment, and patients and parents of children involved in air gun trauma may fail to recognize the potential magnitude of injuries because of the seemingly innocuous mechanism of injury and the characteristically small associated wounds. This may greatly delay care and lead to comorbidities such as the chronic, focal headaches that our patient experienced. Providers should counsel patients and families on the importance of safety precautions when using air guns and parental supervision should be stressed to help ensure everyone’s safety. REFERENCES 1. Centers for Disease Control and Prevention (CDC). BB and pellet gun-related injuries—United States, June 1992–May 1994. MMWR Morb Mortal Wkly Rep 1995;44:909–913. 2. McNeill AM, Annest JL. The ongoing hazard of BB gun and pellet gun-related injuries in the United States. Ann Emerg Med 1995;26:187–194. 3. Laraque D, American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Injury risk of nonpowder guns. Pediatrics 2004;114:1357–1361. 4. Isaac A, Al Qudehy Z, El-Hakin H. Penetrating injury to the parapharyngeal space caused by a BB gun in a pediatric patient. J Pediatr Surg Case Rep 2013;1:25–27. Andrew C. Krakowski, M.D.*,† Lauren Bennett, P.A.-C., M.M.Sc.† Samar Kaifi, M.B.B.S.† *Kids’ Scar Treatment and Revision Program, San Diego, California, †Pediatric and Adolescent Dermatology, Rady Children’s Hospital, San Diego, California Address correspondence to Lauren Bennett, P.A.-C., 8010 Frost Street, Suite 602, San Diego, CA 92123, or e-mail: LNBennett@ RCHSD.org.
inherited variant, with involvement of all digits and toes (1). We present a 4-year-old boy with severe total congenital anonychia whose parents were first-degree cousins. CASE REPORT A 4-year-old boy presented to the pediatric dermatology clinic with a history of absence of all fingernails and toenails from birth. He was the only child of his parents, born at full term after an uncomplicated pregnancy, and his mother had not taken any drug during her pregnancy. He did not have affected relatives, but his parents were first-degree cousins. He was otherwise healthy, with normal development and intelligence according to his age. Physical examination was within normal limits, but dermatologic examination revealed the absence of all nails of the hands and feet (Figs. 1 and 2) with normal teeth and hair. Radiographic investigation of the hands and feet showed no bone abnormalities. Clinically the patient was diagnosed with total congenital anonychia, probably inherited as an autosomal recessive trait. DISCUSSION Congenital anonychia is a rare disorder characterized by the absence of several or all fingernails, toenails, or both from birth. This condition may be present as a single feature or as part of a syndrome or condition. The skin in the region of the absent nails is normal and the nail bed and nail matrix or fold are present in all fingers and toes (2). Anonychia can be inherited by autosomal dominant or recessive means (1). Because the parents of our patient were first-degree cousins and were unaffected,
Total Congenital Anonychia Abstract: Total or partial absence of nails at birth is rare. Anonychia can be inherited as an autosomal dominant or recessive trait. An otherwise healthy 4-year-old boy whose parents were first-degree relatives was diagnosed with total congenital anonychia.
Isolated, nonsyndromic anonychia without additional features is a rare entity that may present in a partial autosomal dominant form that affects only the thumbs or, in its most severe, autosomal recessively
Figure 1. Total anonychia of hands and feet.
