Cases for Diagnosis
A 10-Year History of Ecchymotic Lesions on the Hands
Lesiones equimóticas en las manos de 10 años de evolución
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"apellidos" => "Ballano Ruiz" "email" => array:1 [ 0 => "adrian.baru@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Estopiñán Fortea" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Obispo Polanco, Teruel, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Reumatología, Hospital Obispo Polanco, Teruel, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones equimóticas en las manos de 10 años de evolución" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 994 "Ancho" => 561 "Tamanyo" => 59847 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ecchymotic purpura in the palm of the hand.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case Description</span><p id="par0005" class="elsevierStylePara elsevierViewall">A 55-year-old female nonsmoker, who had no past history of interest and was not undergoing treatment, was seen for recurrent, painful, bluish-violet lesions that initially developed more than 10 years earlier and would suddenly and spontaneously appear on the palms and fingers, subsequently disappearing within 4–5 days. The patient did not associate the lesions with either cold or trauma.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Physical Examination</span><p id="par0010" class="elsevierStylePara elsevierViewall">Physical examination revealed macules of varying sizes, some bluish with an ecchymotic appearance, on the dorsal aspect of a finger and on the palm of the hand (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). Hand temperature was normal and arterial pulses were present.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Additional Tests</span><p id="par0015" class="elsevierStylePara elsevierViewall">The results of a laboratory work up, including a complete blood count, coagulation parameters, thrombophilia testing, autoimmunity markers, cryoglobulins, a proteinogram, lupus anticoagulant, and serology, were normal. Capillaroscopy findings were nonspecific and the results of an arterial Doppler study of the supra-aortic trunks were normal.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">[[?]]What is Your Diagnosis?</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Diagnosis</span><p id="par0025" class="elsevierStylePara elsevierViewall">Paroxysmal finger hematoma or Achenbach syndrome.</p></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Treatment and Evolution</span><p id="par0030" class="elsevierStylePara elsevierViewall">The patient underwent follow-up without receiving any treatment.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">Achenbach syndrome or paroxysmal hematoma of the fingers is a rare disorder of unknown etiology that causes sudden, painful edema in one or more fingers, associated with bluish or hematoma-like discoloration. This condition follows a benign course, is generally self-limiting (resolving within 3–4 days), and may be caused by underlying capillary fragility.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">1</span></a> It is usually spontaneous or caused by minimal trauma, and has occasionally been associated with other disorders such as acrocyanosis, gastrointestinal or biliary diseases, and migraine.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">2</span></a> It is more prevalent in women and individuals aged approximately 50 years.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Diagnosis is based on the exclusion of other potentially more serious diseases. A laboratory work up should be performed, including coagulation parameters, a thrombophilia study, immunological tests, a proteinogram, and analysis of autoimmunity markers. Results of imaging tests such as arterial Doppler ultrasound, arteriography, and radiography are normal; skin biopsy findings are normal or inconclusive; and capillaroscopy reveals neither hemorrhages nor other alterations in capillary morphology or blood flow.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Korzadeh<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">3</span></a> and Brown<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">4</span></a> have proposed different diagnostic algorithms for patients who present bluish discoloration on one or more fingers, as outlined below:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0050" class="elsevierStylePara elsevierViewall">Acute arterial ischemia: older men, smokers, absent pulses.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0055" class="elsevierStylePara elsevierViewall">Thromboangiitis obliterans (Buerger disease): young male smokers, superficial thrombophlebitis, Raynaud syndrome, cold sensitivity. Typical arteriography.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0060" class="elsevierStylePara elsevierViewall">Raynaud syndrome: young age, color change from white to blue when exposed to cold, chronic and recurrent episodes.</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">Acrocyanosis: childhood onset, pale hands, exacerbation in cold environments. There are also forms secondary to paraneoplastic, autoimmune, drug-induced, and neurological processes.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">Perniosis: pain, edema, pallor, itching, and even ulceration in acral areas during colder months.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Other cold-induced disorders: cryoglobulinemia, cryofibrinogenemia.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0080" class="elsevierStylePara elsevierViewall">Gardner-Diamond syndrome: individuals with psychiatric disorders, affects any part of the body, accompanied by vagal symptoms and bleeding.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0085" class="elsevierStylePara elsevierViewall">Digital vein thrombosis: bluish nodule, less painful, situated over interphalangeal joint. Rare in women.</p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Coagulation disorders, antiphospholipid syndrome.</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Vasculitis: palpable purpura, livedo reticularis, nodules.</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Other: calciphylaxis, cholesterol emboli, warfarin necrosis.</p></li></ul></p><p id="par0105" class="elsevierStylePara elsevierViewall">In conclusion, we describe a case of Achenbach syndrome, which although infrequent should be included within the diagnostic algorithm for blue discoloration of the fingers, and diagnosed by exclusion given the absence of any alterations in additional tests.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflicts of Interest</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case Description" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Physical Examination" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Additional Tests" ] 3 => array:3 [ "identificador" => "sec0040" "titulo" => "[[?]]What is Your Diagnosis?" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Diagnosis" ] ] ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Treatment and Evolution" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Discussion" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of Interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 994 "Ancho" => 561 "Tamanyo" => 59847 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ecchymotic purpura in the palm of the hand.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 993 "Ancho" => 561 "Tamanyo" => 71320 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Hematoma on the dorsal aspect of the finger.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:4 [ 0 => array:3 [ "identificador" => "bib0025" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Síndrome de Achenbach: presentación de un caso y revisión sistemática de la literatura" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "P Restrepo Jiménez" 1 => "M.I. Ocampo" 2 => "C Castañeda-Cardona" 3 => "D. Rosselli" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Colomb Reumatol" "fecha" => "2017" "volumen" => "24" "paginaInicial" => "230" "paginaFinal" => "236" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0030" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A case of Achenbach's syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.M. Layton" 1 => "J.A. Cotterill" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2230.1993.tb00970.x" "Revista" => array:6 [ "tituloSerie" => "Clin Exp Dermatol" "fecha" => "1993" "volumen" => "18" "paginaInicial" => "60" "paginaFinal" => "61" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/8440056" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0035" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is Achenbach's syndrome a surgical emergency? A systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "A. Kordzadeh" 1 => "P.L. Caine" 2 => "A. Jonas" 3 => "K.M. Rhodes" 4 => "Y.P. Panayiotopolous" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur J Trauma Emerg Surg" "fecha" => "2015" "volumen" => "42" "paginaInicial" => "439" "paginaFinal" => "443" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0040" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The purple digit: An algorithmic approach to diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P.J. Brown" 1 => "M.J. Zirwas" 2 => "J.C. English" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.2165/11530180-000000000-00000" "Revista" => array:6 [ "tituloSerie" => "Am J Clin Dermatol" "fecha" => "2010" "volumen" => "11" "paginaInicial" => "103" "paginaFinal" => "116" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20141231" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/00017310/0000011300000008/v1_202208290519/S0001731022006159/v1_202208290519/en/main.assets" "Apartado" => array:4 [ "identificador" => "6149" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Casos para el diagnóstico" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/00017310/0000011300000008/v1_202208290519/S0001731022006159/v1_202208290519/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001731022006159?idApp=UINPBA000044" ]
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