A 29-year-old woman, gravida 1 para 0, at 20 weeks gestation comes to the office for evaluation of a lesion on her hand. The patient first noticed the lesion a month ago after working in her garden and scratching her thumb. She initially used a topical antibiotic ointment, but the lesion continued to grow and occasionally bled. There has been no purulent drainage, and the patient has had no associated fever or chills. Her pregnancy has been uncomplicated, and she has no chronic medical conditions. Temperature is 36.7 C (98.1 F), blood pressure is 120/80 mm Hg, and pulse is 65/min. Fetal heart tones are 150/min. Examination of the hand is shown in the image below: Which of the following is the most likely diagnosis in this patient?

Question

A 29-year-old woman, gravida 1 para 0, at 20 weeks gestation comes to the office for evaluation of a lesion on her hand.  The patient first noticed the lesion a month ago after working in her garden and scratching her thumb.  She initially used a topical antibiotic ointment, but the lesion continued to grow and occasionally bled.  There has been no purulent drainage, and the patient has had no associated fever or chills.  Her pregnancy has been uncomplicated, and she has no chronic medical conditions.  Temperature is 36.7 C (98.1 F), blood pressure is 120/80 mm Hg, and pulse is 65/min.  Fetal heart tones are 150/min.  Examination of the hand is shown in the image below:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_daa0_7bc1_bc81_1992373a1826_MD0003_00 This patient has a friable, dome-shaped nodule consistent with pyogenic granuloma (ie, lobular capillary hemangioma). Pyogenic granulomas are small (<1 cm) vascular tumors composed of abnormal capillaries and granulation tissue. They commonly occur in young adults, particularly pregnant women, likely due to the normal pregnancy-mediated increase in vascular endothelial growth factor that may promote pyogenic granuloma growth. Pyogenic granulomas are typically found on the hands (particularly the fingers), trunk, and oral mucosa/gingiva (more common in pregnancy). They typically arise slowly over a few weeks to months and characteristically bleed with minor trauma. Diagnosis is clinically based. Treatment options include surgical excision, laser therapy, and topical treatments (eg, silver nitrate). However, lesions occurring during pregnancy usually regress postpartum and may not require treatment. (Choice A) Bacillary angiomatosis is a Bartonella infection seen primarily in patients with advanced HIV. It presents as multiple small, reddish or purple papules that evolve into friable nodular lesions. Constitutional symptoms (eg, fever, malaise, night sweats) are typically present. Bacillary angiomatosis (Choice B) Basal cell carcinoma presents as a slowly growing, ulcerating nodule with pearly borders and telangiectatic vessels. It usually occurs in older individuals (age >55) and is uncommon in pregnancy. Basal cell carcinoma (Choice C) Kaposi sarcoma is caused by human herpesvirus 8 and is most common in patients with advanced HIV. In the skin, it typically presents as red or purple vascular papules. Kaposi sarcoma (Choice D) Keratoacanthoma is a rapidly growing, volcano-like nodule with a central keratotic plug. It is most common in hair-bearing skin in middle-aged and older adults and does not have a moist or friable surface. Keratoacanthoma Educational objective: Pyogenic granulomas are small vascular tumors composed of abnormal capillaries and granulation tissue. They typically present as friable, dome-shaped nodules on the hands, trunk, or oral mucosa/gingiva. Pyogenic granulomas are common in pregnancy and usually regress postpartum. References: Pyogenic granuloma (lobular capillary hemangioma). (http://www.ncbi.nlm.nih.gov/pubmed/32310537)

A 29-Year-Old Woman, Gravida 1 Para 0, at 20 Weeks