Case and Research Letter
Wooly Pattern as a Characteristic Ultrasound Finding in Angiolymphoid Hyperplasia With Eosinophilia
Patrón en ovillo de lana como hallazgo ecográfico característico de hiperplasia angiolinfoide con eosinofilia
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Panorámica, capas superficiales sin alteraciones, con presencia de agregados linfocitarios en las capas profundas (hematoxilina-eosina ×<span class="elsevierStyleHsp" style=""></span>25). B. Detalle con presencia abundantes eosinófilos dispersos en el estroma (hematoxilina-eosina ×<span class="elsevierStyleHsp" style=""></span>200).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "M. Lorente-Luna, F. Alfageme-Roldán, D. Suárez-Massa, E. Jiménez-Blázquez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "M." "apellidos" => "Lorente-Luna" ] 1 => array:2 [ "nombre" => "F." "apellidos" => "Alfageme-Roldán" ] 2 => array:2 [ "nombre" => "D." "apellidos" => "Suárez-Massa" ] 3 => array:2 [ "nombre" => "E." 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Lorente-Luna, F. Alfageme-Roldán, D. Suárez-Massa, E. Jiménez-Blázquez" "autores" => array:4 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "Lorente-Luna" "email" => array:2 [ 0 => "m.lorente.luna@gmail.com" 1 => "mlorentel@sescam.jccm.es" ] "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" => "F." "apellidos" => "Alfageme-Roldán" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "D." "apellidos" => "Suárez-Massa" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Jiménez-Blázquez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Guadalajara, Guadalajara, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Dermatología, Hospital Universitario Puerta de Hierro, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anatomía Patológica, Hospital Universitario Puerta de Hierro, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Patrón en ovillo de lana como hallazgo ecográfico característico de hiperplasia angiolinfoide con eosinofilia" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 949 "Ancho" => 1344 "Tamanyo" => 347103 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, At low magnification, the superficial layers show no changes, and lymphocyte aggregates are seen in the deeper layers (hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>25). B, Detail showing the presence of numerous eosinophils throughout the stroma (hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>200).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Angiolymphoid hyperplasia with eosinophilia (AHE) is a rare, benign vascular proliferation with a chronic clinical course. It typically presents as erythematous or brownish papules and plaques or subcutaneous lesions predominantly affecting the head and neck, especially in the periauricular region.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Histology reveals endothelial cells of epithelioid appearance within the vascular lumen, associated with an inflammatory infiltrate and abundant eosinophils. This disorder has a broad differential diagnosis with other subcutaneous lesions. Ultrasound is a noninvasive technique that is very useful for the study of these lesions. We present a case of AHE and describe the ultrasound findings.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 37-year-old woman with no past medical history of interest. She was seen in dermatology outpatients for an asymptomatic lesion that had arisen on her chin several months earlier. On examination there was a brownish nodule of 2<span class="elsevierStyleHsp" style=""></span>cm diameter, with a rubbery consistency (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). There were no palpable lymph nodes. The lesion was excised. Histology showed no changes in the epidermis, but vessels lined by endothelial cells of epithelioid appearance were present in the deeper layers, associated with aggregates of lymphocytes and eosinophils (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, A and<span class="elsevierStyleHsp" style=""></span>B). Eosinophilia was detected in the blood tests, with no changes in other laboratory parameters. Based on these findings, a diagnosis of AHE was made. Ultrasound monitoring (Esaote My Lab One, using a variable frequency linear probe of 18-22<span class="elsevierStyleHsp" style=""></span>MHz with a lateral resolution of 240<span class="elsevierStyleHsp" style=""></span>microns) was performed throughout follow-up. In the dermis there was a mass with poorly defined borders; this mass was composed of intertwined hyperechoic and hypoechoic bundles, forming an image of a “ball of wool” surrounded by a hyperechoic halo (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>A). Doppler study (Esaote My Lab One with a linear probe in power Doppler mode; frequency, 18<span class="elsevierStyleHsp" style=""></span>MHz; pulse repetition frequency, 750<span class="elsevierStyleHsp" style=""></span>MHz) showed increased vascularization (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>B). This image has persisted unchanged despite the treatments performed.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The differential diagnosis of AHE includes a wide range of benign and malignant subcutaneous lesions. Ultrasound is useful as many of these lesions present characteristic sonographic patterns. Of the benign lesions, epidermal cysts appear as well-defined, round anechoic structures in the dermis or subcutaneous tissue, with a tract that connects it to the epidermis, and posterior acoustic enhancement.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Pilomatrixomas are also easy to exclude as the image they present is of an oval target image with a hypoechoic ring around hyperechoic center formed of calcified material.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Lipomas appear in the subcutaneous cellular tissue as elongated, isoechoic structures with hyperechoic septa.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> Glomus tumors are seen on ultrasound as well-defined, hypoechoic nodular lesions with prominent vascularization observed on Doppler study.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Blood vessels can also be observed adjacent to the lesion. Finally, among the benign lesions, we must consider those of vascular origin. Doppler study is a fundamental component of the investigation for the diagnosis and classification of all of these lesions. Hemangiomas present a sonographic pattern that varies according to their phase of development. These lesions are hypoechoic and hypervascular in the proliferative phases and hyperechoic and hypovascular during regression.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The sonographic image of vascular malformations can be variable. Doppler study allows them to be classified according to blood flow.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In the differential diagnosis with malignant lesions, we must exclude skin metastases and B-cell lymphoma. The diagnosis of these lesions must be confirmed histologically. Skin metastases, most commonly from melanoma, are seen as oval anechoic structures with dense vascularization.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> B-cell lymphoma presents as a well-defined, hypoechoic nodular lesion with a good vascular supply in the dermis or subcutaneous cellular tissue.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">There is only 1 report of a case of cutaneous AHE that gives a description of its sonographic pattern.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> In that case, a hyperechoic lesion was observed on the forearm and had a peripheral hypoechoic ring and increased blood flow on Doppler study. The absence of other reports is probably because the condition was considered part of the spectrum of Kimura disease until a few years ago. The 2 diseases, though clinically similar, are now considered to be different entities because of the differences in extracutaneous involvement, laboratory tests, and histological findings, leading to a completely different prognosis. A larger number of articles have been published on Kimura disease. The characteristic image is of a heterogeneous hypoechoic mass with poorly defined borders, situated in the dermis and subcutaneous cellular tissue, with intermingled, hyperechoic and hypoechoic curvilinear structures, which has been called a “woolly” pattern.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> The vascularization of the lesions is variable.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Our case shows the sonographic characteristics of both diseases as the woolly pattern was observed, associated with hypervascularization and a hypoechoic halo.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Skin ultrasound is a useful tool for the diagnosis of subcutaneous lesions. Although the woolly pattern is characteristic, it does not enable us to distinguish between AHE and Kimura disease. These findings testify to the difficulty of differentiating between the 2 diseases and to the need for histological confirmation.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Lorente-Luna M, Alfageme-Roldán F, Suárez-Massa D, Jiménez-Blázquez E. Patrón en ovillo de lana como hallazgo ecográfico característico de hiperplasia angiolinfoide con eosinofilia. Actas Dermosifiliogr. 2014;105:718–720.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1080 "Ancho" => 1028 "Tamanyo" => 161370 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical image. Erythematous-brownish nodule of 2<span class="elsevierStyleHsp" style=""></span>cm diameter, situated on the chin.</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" => 949 "Ancho" => 1344 "Tamanyo" => 347103 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A, At low magnification, the superficial layers show no changes, and lymphocyte aggregates are seen in the deeper layers (hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>25). B, Detail showing the presence of numerous eosinophils throughout the stroma (hematoxylin-eosin, original magnification ×<span class="elsevierStyleHsp" style=""></span>200).</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 433 "Ancho" => 1345 "Tamanyo" => 99378 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Ultrasound image of the lesion. A, A poorly-defined nodule is present in the dermis; hyperechoic and hypoechoic bundles are seen to form a woolly pattern<span class="elsevierStyleHsp" style=""></span>(*). B, Color Doppler study of the lesion showing increased vascularization. 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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 5 | 2 | 7 |
| 2024 Octubre | 64 | 34 | 98 |
| 2024 Septiembre | 87 | 19 | 106 |
| 2024 Agosto | 87 | 48 | 135 |
| 2024 Julio | 79 | 44 | 123 |
| 2024 Junio | 94 | 33 | 127 |
| 2024 Mayo | 69 | 33 | 102 |
| 2024 Abril | 63 | 27 | 90 |
| 2024 Marzo | 73 | 31 | 104 |
| 2024 Febrero | 57 | 40 | 97 |
| 2024 Enero | 38 | 36 | 74 |
| 2023 Diciembre | 68 | 18 | 86 |
| 2023 Noviembre | 74 | 26 | 100 |
| 2023 Octubre | 76 | 15 | 91 |
| 2023 Septiembre | 88 | 31 | 119 |
| 2023 Agosto | 52 | 17 | 69 |
| 2023 Julio | 54 | 29 | 83 |
| 2023 Junio | 65 | 25 | 90 |
| 2023 Mayo | 52 | 31 | 83 |
| 2023 Abril | 68 | 17 | 85 |
| 2023 Marzo | 51 | 19 | 70 |
| 2023 Febrero | 54 | 14 | 68 |
| 2023 Enero | 59 | 28 | 87 |
| 2022 Diciembre | 55 | 27 | 82 |
| 2022 Noviembre | 24 | 26 | 50 |
| 2022 Octubre | 29 | 19 | 48 |
| 2022 Septiembre | 32 | 40 | 72 |
| 2022 Agosto | 22 | 26 | 48 |
| 2022 Julio | 20 | 37 | 57 |
| 2022 Junio | 14 | 19 | 33 |
| 2022 Mayo | 31 | 33 | 64 |
| 2022 Abril | 47 | 25 | 72 |
| 2022 Marzo | 33 | 34 | 67 |
| 2022 Febrero | 32 | 25 | 57 |
| 2022 Enero | 35 | 37 | 72 |
| 2021 Diciembre | 25 | 27 | 52 |
| 2021 Noviembre | 45 | 37 | 82 |
| 2021 Octubre | 34 | 52 | 86 |
| 2021 Septiembre | 42 | 36 | 78 |
| 2021 Agosto | 47 | 25 | 72 |
| 2021 Julio | 48 | 33 | 81 |
| 2021 Junio | 51 | 36 | 87 |
| 2021 Mayo | 38 | 21 | 59 |
| 2021 Abril | 45 | 48 | 93 |
| 2021 Marzo | 60 | 18 | 78 |
| 2021 Febrero | 52 | 16 | 68 |
| 2021 Enero | 24 | 6 | 30 |
| 2020 Diciembre | 22 | 11 | 33 |
| 2020 Noviembre | 20 | 3 | 23 |
| 2020 Octubre | 13 | 3 | 16 |
| 2020 Septiembre | 19 | 8 | 27 |
| 2020 Agosto | 19 | 12 | 31 |
| 2020 Julio | 21 | 10 | 31 |
| 2020 Junio | 24 | 10 | 34 |
| 2020 Mayo | 14 | 13 | 27 |
| 2020 Abril | 19 | 13 | 32 |
| 2020 Marzo | 28 | 15 | 43 |
| 2020 Febrero | 5 | 0 | 5 |
| 2020 Enero | 0 | 1 | 1 |
| 2019 Diciembre | 6 | 4 | 10 |
| 2019 Noviembre | 0 | 1 | 1 |
| 2019 Septiembre | 7 | 0 | 7 |
| 2019 Julio | 0 | 3 | 3 |
| 2019 Junio | 2 | 1 | 3 |
| 2019 Mayo | 0 | 10 | 10 |
| 2019 Abril | 0 | 1 | 1 |
| 2019 Marzo | 2 | 6 | 8 |
| 2019 Enero | 2 | 0 | 2 |
| 2018 Noviembre | 2 | 0 | 2 |
| 2018 Octubre | 3 | 0 | 3 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Mayo | 0 | 6 | 6 |
| 2018 Abril | 0 | 1 | 1 |
| 2018 Febrero | 24 | 3 | 27 |
| 2018 Enero | 36 | 4 | 40 |
| 2017 Diciembre | 31 | 3 | 34 |
| 2017 Noviembre | 34 | 10 | 44 |
| 2017 Octubre | 25 | 5 | 30 |
| 2017 Septiembre | 21 | 5 | 26 |
| 2017 Agosto | 23 | 17 | 40 |
| 2017 Julio | 22 | 18 | 40 |
| 2017 Junio | 33 | 14 | 47 |
| 2017 Mayo | 20 | 20 | 40 |
| 2017 Abril | 29 | 17 | 46 |
| 2017 Marzo | 18 | 41 | 59 |
| 2017 Febrero | 16 | 6 | 22 |
| 2017 Enero | 24 | 16 | 40 |
| 2016 Diciembre | 32 | 10 | 42 |
| 2016 Noviembre | 45 | 15 | 60 |
| 2016 Octubre | 33 | 12 | 45 |
| 2016 Septiembre | 30 | 15 | 45 |
| 2016 Agosto | 1 | 3 | 4 |
| 2016 Julio | 5 | 1 | 6 |
| 2016 Junio | 11 | 1 | 12 |
| 2016 Mayo | 3 | 3 | 6 |
| 2016 Abril | 6 | 1 | 7 |
| 2016 Marzo | 4 | 8 | 12 |
| 2016 Febrero | 7 | 8 | 15 |
| 2016 Enero | 9 | 4 | 13 |
| 2015 Diciembre | 7 | 16 | 23 |
| 2015 Noviembre | 7 | 14 | 21 |
| 2015 Octubre | 8 | 22 | 30 |
| 2015 Septiembre | 10 | 16 | 26 |
| 2015 Agosto | 9 | 0 | 9 |
| 2015 Julio | 38 | 5 | 43 |
| 2015 Junio | 40 | 7 | 47 |
| 2015 Mayo | 31 | 7 | 38 |
| 2015 Abril | 22 | 13 | 35 |
| 2015 Marzo | 27 | 4 | 31 |
| 2015 Febrero | 21 | 7 | 28 |
| 2015 Enero | 14 | 2 | 16 |
| 2014 Diciembre | 19 | 7 | 26 |
| 2014 Noviembre | 17 | 6 | 23 |
| 2014 Octubre | 20 | 5 | 25 |
| 2014 Septiembre | 10 | 3 | 13 |
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