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CORRESPONDENCE
Year : 2022  |  Volume : 67  |  Issue : 4  |  Page : 420-421
Muscle herniation of the extremities coexistent with piezogenic pedal papules: A case report


1 From the Department of Dermatology, Faculty of Medicine, Düzce University, Düzce, Turkey
2 Department of Radiology, Faculty of Medicine, Düzce University, Düzce, Turkey
3 Department of Pathology, Faculty of Medicine, Düzce University, Düzce, Turkey
4 Department of Dermatology, Medicalpark Keçiören Hospital, Ankara, Turkey

Date of Web Publication2-Nov-2022

Correspondence Address:
Uyar Belkiz
From the Department of Dermatology, Faculty of Medicine, Düzce University, Düzce
Turkey
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.ijd_952_21

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How to cite this article:
Belkiz U, Ali &M, Mehmet G, Yunus &, Müge AE. Muscle herniation of the extremities coexistent with piezogenic pedal papules: A case report. Indian J Dermatol 2022;67:420-1

How to cite this URL:
Belkiz U, Ali &M, Mehmet G, Yunus &, Müge AE. Muscle herniation of the extremities coexistent with piezogenic pedal papules: A case report. Indian J Dermatol [serial online] 2022 [cited 2022 Dec 8];67:420-1. Available from: https://www.e-ijd.org/text.asp?2022/67/4/420/360370




Sir,

Muscle herniation is clinically characterized by skin-coloured subcutaneous papules or nodules on the legs that may disappear in specific positions of the extremities.[1]

Piezogenic pedal papules (PPPs) usually present as multiple, soft, and skin-coloured confidential papules on heels, occasionally on wrists, which are visible only when bearing weight or when a pressure is applied.[2]

We present a 54-year-old woman with sarcoidosis, whose muscle herniation of the extremities is coexistent with PPP. To the best of our knowledge, only two cases of PPP coexistent with muscle herniation have been reported in the literature [Table 1].[1],[3]
Table 1: Patients with PPP* coexisting with muscle herniation in the literature and our case

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A 54-year-old woman presented with bilateral painful masses that started on the right lower leg 20 years ago and spread to both lower legs and arms in the last 3 years.

Dermatological examination revealed soft 1–3 cm in diameter subcutaneous nodules covered with normal skin on both lower legs and less frequently on the arms, which could disappear or shrink while the extremity was in plantarflexion [Figure 1]. Ultrasonographic examination of the lower legs revealed partial discontinuity in the fascia through which muscle protruded [Figure 2].
Figure 1: (a and b) Subcutaneous nodules covered with normal skin on lower legs, which could disappear or shrink while the extremity was in plantarflexion (black arrows)

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Figure 2: Ultrasonographic examination of the right leg shows a partial defect in the fascia and the protrusion of the tibialis anterior muscle. Black arrowhead; tibia, star; tibialis anterior muscle, white arrow; muscle fascia, black arrow; herniated muscle tissue

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Additionally, soft subcutaneous papules, the largest of which was 1 cm in diameter, were observed on the heels. These papules were more prominent when the patient was standing [Figure 3].
Figure 3: Soft, subcutaneous papules appear on the side of the left heel which was more prominent when the patient was standing (white arrows)

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On medical history, the patient stated that she had sarcoidosis for 2 years. Antinuclear antibodieswere dense fine speckled at a titre of 1/100.

Biopsy was performed from the right lower leg lesion. Histopathology revealed that normal fat tissue had extruded through the dermis. There were no abnormal findings in elastic and connective tissue.

According to characteristic clinical features and ultrasonographic findings, muscle herniation of the lower legs with PPPs was diagnosed.

Compression stockings are recommended.

Muscle herniation can be traumatic or constitutional. Although more than 200 cases have been reported in the literature, very few of them have been reported by dermatologists. Constitutional muscle hernias are often bilateral and may be due to a mesodermal insufficiency resulting in weakening and a predisposition to fascial tearing, for instance at points of entry for neurovascular bundles.[4]

Although the aetiopathogenesis of PPP is unclear, most of the published cases were athletes, obese persons, or patients with Ehlers–Danlos syndrome; thus, repetitive stress, trauma, and connective tissue defect are considered the major factors contributing to the development of PPP.[2] The development of PPP has been reported in patients with rheumatoid arthritis, rheumatic heart disease, mitral insufficiency, pulmonary hypertension, and mitral valve prolapse.[2]

The most common extrapulmonary manifestations of the sarcoidosis are arthritis, periarthritis, arthralgia, acute nodular myositis, and chronic myopathy, where the differential diagnosis is made with rheumatoid arthritis and other connective tissue disorders.[5]

Our patient stated that she never did sports in her life and lived a sedentary life, and the patient's medical history and physical examination did not have any problems other than sarcoidosis. There is evidence that sarcoidosis may relate to connective tissue diseases in the literature.[5] Therefore, we considered that muscle herniation of the extremities and PPP which are posture-dependent herniation of two distinct sites may be related to sarcoidosis in our patient.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mai Y, Nishie W, Sugai T, Imafuku K, Arita K, Shimizu H. Disappearing subcutaneous papules and nodules: Characteristic features of muscle herniation and piezogenic pedal papules. J Dermatol 2017;44:e361-2.  Back to cited text no. 1
    
2.
Altin C, Askin U, Gezmis E, Muderrisoglu H. Piezogenic pedal papules with mitral valve prolapse. Indian J Dermatol 2016;61:234.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Woodrow SL, Brereton-Smith G, Handfield-Jones S. Painful piezogenic pedal papules: Response to local electro-acupuncture. Br J Dermatol 1997;136:628-30.  Back to cited text no. 3
    
4.
Deka JB, Deka NK, Shah MV, Bortolotto C, Draghi F, Jimenez F. Isolated partial tear of extensor digitorum longus tendon with overlying muscle herniation in acute ankle sports injury: Role of high resolution musculoskeletal ultrasound. J Ultrasound 2022;25:369-77.  Back to cited text no. 4
    
5.
Starshinova AA, Malkova AM, Basantsova NY, Zinchenko YS, Kudryavtsev IV, Ershov GA, et al. Sarcoidosis as an autoimmune disease. Front Immunol 2020;10:2933. doi: 10.3389/fimmu. 2019.02933.  Back to cited text no. 5
    


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