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E-IJD CORRESPONDENCE
Year : 2015  |  Volume : 60  |  Issue : 2  |  Page : 217
Acroangiodermatitis associated with iatrogenic arteriovenous fistula mimicking verruca vulgaris


1 From the Department of Dermatology and Venereology, Karnataka Institute of Medical Sciences, Hubli, Karnataka, India
2 All India Institute of Medical Sciences, Bhopal, India

Date of Web Publication3-Mar-2015

Correspondence Address:
Chandramohan Kudligi
From the Department of Dermatology and Venereology, Karnataka Institute of Medical Sciences, Hubli, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.152589

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How to cite this article:
Kudligi C, Bhagwat PV, Asati DP, Lingaiah KK, Odugoudar SG. Acroangiodermatitis associated with iatrogenic arteriovenous fistula mimicking verruca vulgaris. Indian J Dermatol 2015;60:217

How to cite this URL:
Kudligi C, Bhagwat PV, Asati DP, Lingaiah KK, Odugoudar SG. Acroangiodermatitis associated with iatrogenic arteriovenous fistula mimicking verruca vulgaris. Indian J Dermatol [serial online] 2015 [cited 2020 Apr 1];60:217. Available from: http://www.e-ijd.org/text.asp?2015/60/2/217/152589


Sir,

A 50-year-old male on dialysis for chronic renal failure presented to us with a six-month history of a gradually increasing, mildly painful, warty lesion on the left hand. The lesion initially started as a smooth-surfaced soft swelling of peanut size, which gradually changed to become verrucous, covering the entire dorsum of the hand and fingers over a period of six months. The patient recollects the onset of the lesion to be after three months of starting dialysis through an arteriovenous fistula created on the left forearm. He consulted a local doctor who performed electrocautery after making a clinical diagnosis of verruca vulgaris. During the postprocedure period of one week, the patient experienced increase in the size of the lesion, increase in the severity of pain, and constant oozing of blood and serum from the eroded surface. The patient was referred to us with the above-mentioned complaints for further evaluation and management. On examination, there were multiple discrete-to-colasing, erythematous, minimally tender soft compressible verrucous papules and nodules covering the dorsal aspect of the left hand and proximal aspects of the fingers [Figure 1]. Differential diagnoses of Kaposi's sarcoma and acroangiodermatitis were considered. Blood investigation revealed hemoglobin 10 g/dL, erythrocyte sedimentation rate 30 mm at first hour, blood urea 50 mg/dL, and serum creatinine 3 mg/dL. Rest of the hematological and biochemical parameters were within normal limits including liver function tests. The patient also tested negative for HIV antibodies and hepatitis B antigen. The nodule over the dorsum of the hand was biopsied and subjected to histopathological examination. It showed multiple dilated capillaries with extravasation of erythrocytes and irregular acanthotic epidermis [Figure 2]. There were no slit-like vascular spaces, spindle cell proliferation, or atypical cells. Based on clinical history, cutaneous examination, presence of iatrogenic arteriovenous fistula, and histopathological features, we made a final diagnosis of acroangiodermatitis. The patient was started on peritoneal dialysis after correcting the arteriovenous fistula on the left forearm. All the lesions subsided completely, leaving behind a thin scar [Figure 3]. The patient is being followed up for the past one year without any signs of recurrence.
Figure 1: Multiple erythematous, verrucous papules and nodules covering dorsal aspect of the left hand and proximal aspects of the fingers

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Figure 2: Photomicrograph of skin biopsy showing multiple dilated capillaries with extravasation of erythrocytes and irregular acanthotic epidermis (H and E, ×40)

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Figure 3: Complete subsidence of the lesions after three months of correcting arteriovenous fistula

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Acroangiodermatitis is an uncommon condition characterized by a reactive proliferation of small blood vessels in response to chronic circulatory disturbance. [1] The term acroangiodermatitis was introduced in 1965 by Mali et al., who described peculiar mauve-colored macules and plaques on the extensor surface of feet in 18 patients with chronic venous insufficiency; [2] since then, pseudo-Kaposi's sarcoma has been reported in association with various conditions like arteriovenous fistulae, paralyzed limbs, amputation stumps, vascular syndromes, conditions associated with thrombosis, [1] and rarely with placement of the arteriovenous shunt for hemodialysis in chronic renal failure. [3] The lesions initially appear as brown, red, or violet spots, which can evolve into papules or plaques and sometimes become verrucous or ulcerated. [4] Our patient had involvement of the left hand in the form of verrucous papules and plaques, which misled the treating surgeon to diagnose it as verruca vulgaris and ablate the lesion with electrocautery. Although precise etiology is unknown, it is postulated that altered venous hydrostatic and hydrodynamic conditions may interfere with local microcirculation, resulting in some degree of ischemia in all patients with a fistula. Therefore, the pathogenesis of pseudo-Kaposi's sarcoma with tissue hypoxia distal to an arteriovenous fistula leading to progressive vascular and endothelial proliferation may represent one of the pathogenic mechanisms. [3] This is evidenced by the disappearance of the pseudo-Kaposi's sarcoma which was observed in our patient after successfully correcting the arteriovenous fistula and starting him on peritoneal dialysis. Histopathologic examination shows proliferation of endothelial cells and newly formed vessels with thick walls, often in a lobular pattern and surrounded by pericytes in the dermis. Extravasation of red blood cells, hemosiderin pigment deposition, dermal fibrosis, small thrombi in the lumen, and superficial perivascular infiltrate of lymphocytes, histiocytes, and occasional plasma cells are also found and may resemble Kaposi's sarcoma. [5],[6] This, however, has vascular slits, proliferation of fusiform cells and atypical cells, and the vascular hyperplasia is independent of pre-existing vasculature. [5],[6] Treatment of acroangiodermatitis is barely discussed in the literature and depends upon the nature of underlying circulatory disturbance. [1] Various treatment modalities tried with reasonable successes are compression stockings, oral erythromycin, oral dapsone, topical steroid preparations, and in some cases, pulsed dye laser ablation. Arteriovenous malformations can be surgically managed with elimination of shunts and embolization for small fistulae. Our patient was successfully treated by correcting the iatrogenic fistula with near-complete subsidence of the verrucous lesion.

Pseudo-Kaposi's sarcoma following iatrogenic arteriovenous fistula is a rare complication in patients on dialysis. A Pubmed search located only nine case reports between 1965 and 2013. To the best of our knowledge, this is the first case to be reported from India and is being reported for its rarity and to familiarize the clinicians with the unusual complication of iatrogenic arteriovenous fistula and to help them with proper diagnosis and management of the condition.

 
   References Top

1.
Pimentel MI, Cuzzi T, Azeredo-Coutinho RB, Vasconcellos Éde C, Benzi TS, Carvalho LM. Acroangiodermatitis (pseudo-Kaposi sarcoma): A rarely-recognized condition. A case on the plantar aspect of the foot associated with chronic venous insufficiency. An Bras Dermatol 2011;86:13-6.  Back to cited text no. 1
    
2.
Mali JW, Kuiper JP, Hamers AA. Acroangiodermatitis of the foot. Arch Dermatol 1965;92:515-8.  Back to cited text no. 2
    
3.
Hwang SM, Lee SH, Ahn SK. Pincer nail deformity and pseudo-Kaposi's sarcoma: Complications of an artificial arteriovenous fistula for haemodialysis. Br J Dermatol 1999;141:1129-32.  Back to cited text no. 3
    
4.
Hung NA, Strack M, Van Rij A, North CJ, Blennerhassett JB. Spontaneous acroangiodermatitis in a young woman. Dermatol Online J 2004;10:8.  Back to cited text no. 4
    
5.
Rao B, Unis M, Poulos E. Acroangiodermatitis: A study of ten cases. Int J Dermatol 1994;33:179-83.  Back to cited text no. 5
    
6.
Calonje E. Vascular tumors: Tumors and tumor-like conditions of blood vessels and lymphatics. In: Elder DE, Elenitsas R, Johnson BL, Murphy GF, Xu X, editors. Lever's Histopathology of the Skin. 10 th ed. Philadelphia: Lippincott Williams and Wilkins; 2009. p. 1007-56.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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