Correspondence Address:
Manoharan Krishnaswamy
From the Department of Dermatology, Venereology and Leprosy, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu
India

Full Text



Sir,

Verrucous haemangiomas (VHs) are capillary or venous proliferations principally on the extremities. Arising by two years of age, they may involute spontaneously or persist. These GLUT1 positive[1] lesions are commonly thought to be a reactive phenomenon to several insults thereby explaining the adult onset in a few cases.

Acral pseudolymphomatous angiokeratoma of children (APACHE) first described by Ramsay et al.,[2] is a rare entity of unknown aetiology which presents as erythematous or mildly pigmented, single or multiple papules or keratotic plaques on distal extremities. Despite what the terminology implies it can occur in extra-acral sites and also in adults, thereby supporting a proposed terminology 'papular angiolymphoid hyperplasia'.

A 20-year-old female presented with a pigmented and eroded verrucous nodule on the left leg above the medial malleolus for six months [Figure 1]a. She did not complain of lesions elsewhere. There were no known systemic associations. It began as a pigmented flat patch at birth, over which few keratotic papules gradually developed in the following years. After a trivial trauma to the site six months ago, the lesion rapidly evolved into a pigmented, eroded verrucous nodule that bleeds on touch. On examination the pigmented lesion measured 2 × 3 cm with a verrucous surface and superficial erosions. The perilesional area showed intense pigmentation [Figure 1]b. Spontaneous discharge was absent. On manipulation, the lesion bled mildly. Absence of warmth, tenderness, pulsatility, and localized lymphadenopathy was noted. Clinical differential diagnoses were pyogenic granuloma, angiokeratoma, VH, nodular melanoma, Kaposi's sarcoma, and cornu cutaneum over a keratoacanthoma. On excision biopsy the lesion bled profusely indicating a vascular aetiology. Histopathology revealed pseudo-epitheliomatous hyperplasia, marked vascular proliferation in the entire dermis, and a massive aggregate of lymphocytes and histiocytes in a band like fashion with moderate numbers of interspersed plasma cells and eosinophils present peri-vascularly [Figure 2]a, [Figure 2]b and [Figure 3]a, [Figure 3]b. A positive GLUT1 on immunohistochemistry coupled with histopathological features favoured a diagnosis of VH [Figure 4]a, [Figure 4]b; however, the type and arrangement of the inflammatory cell infiltrate (which included a confluent band like dermal infiltrate composed of lymphocytes, histiocytes, plasma cells, and eosinophils, aggregates of lympho-histiocytes in a pseudolymphomatous pattern, and proliferation of blood vessels[3]) pointed towards the coexistence of a rarer entity named 'APACHE)', which characteristically presents with coinciding histopathology and is considered as a pseudolymphoma per se as per published reports.[4]{Figure 1}{Figure 2}{Figure 3}{Figure 4}

We hence conclude by stating this is a singular case of a reactive GLUT1 positive VH developing over a pre-existing APACHE.

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