Figure 1
Ultrasonography
A small hypoechoic soft tissue lesion (arrow) noted in plantar surface of distal phalanx. No significant vascularity could be demonstrated within the lesion.
Glomus tumour of pulp of 3rd toe
SectionMusculoskeletal system
Case TypeClinical Cases
AuthorsChary Duraikannu
Connected authors
21 years, male
Clinical History
21-year-old male patient with severe pain and tenderness and cold hypersensitivity in base of distal phalanx of right 3rd toe for 4 years. On examination no obvious swelling was seen and the overlying skin was normal.
Imaging Findings
Ultrasonography showed a small hypoechoic lesion in plantar aspect of distal phalanx. No significant vascularity could be demonstrated within the lesion.
MRI showed a small globular lesion noted abutting the plantar surface of distal phalanx of 3rd toe measuring 5 x 4 mm. The lesion had T1 hypointense and PD hyperintense signal.
Dynamic contrast study showed intense enhancement of the lesion in arterial phase. Arterial feeders noted from the corresponding digital arteries. The adjacent bone showed no erosion or marrow oedema.
MRI showed a small globular lesion noted abutting the plantar surface of distal phalanx of 3rd toe measuring 5 x 4 mm. The lesion had T1 hypointense and PD hyperintense signal.
Dynamic contrast study showed intense enhancement of the lesion in arterial phase. Arterial feeders noted from the corresponding digital arteries. The adjacent bone showed no erosion or marrow oedema.
Discussion
Glomus tumours are benign tumours arising from glomus bodies of fingers and toes. These glomus bodies are specialized neuromyoarterial receptors containing arteriovenous anastomosis regulating the body temperature. Glomus tumour was first described clinically in 1812 by Wood [1, 2]. These tumours predominantly occur in the subungual region of fingers. Glomus tumour involving pulp region is rare, about 10% [2, 3, 4]. Even rarer is the occurrence in pulp of the toe.
The average age of occurrence is 30 -50 yrs with female predominance [1, 4]. Although most cases can be diagnosed clinically, some of them may not be detected for years. The typical clinical triad of symptoms are pain, tenderness and cold hypersensitivity [1-4].
Glomus tumour can occur either sporadically or multifocally if associated with neurofibromatosis. Several cases of neurofibromatosis 1 with multifocal glomus tumour have been reported [5, 6, 7].
Imaging plays an important role in establishing the diagnosis. Radiographs may show erosion of the adjacent phalanx. The lesion appears hypoechoic in ultrasonography with significant vascularity on Doppler. In MRI the glomus tumour shows T1 hypointense and T2 hyperintense signal intensity. On dynamic MR contrast angiogram, the lesion shows intense enhancement in arterial phase with tumour blush. Treatment is complete surgical resection by transungual or lateral incision depending on the tumour location [2]. The typical clinical presentation and imaging findings together help to make an accurate diagnosis.
The average age of occurrence is 30 -50 yrs with female predominance [1, 4]. Although most cases can be diagnosed clinically, some of them may not be detected for years. The typical clinical triad of symptoms are pain, tenderness and cold hypersensitivity [1-4].
Glomus tumour can occur either sporadically or multifocally if associated with neurofibromatosis. Several cases of neurofibromatosis 1 with multifocal glomus tumour have been reported [5, 6, 7].
Imaging plays an important role in establishing the diagnosis. Radiographs may show erosion of the adjacent phalanx. The lesion appears hypoechoic in ultrasonography with significant vascularity on Doppler. In MRI the glomus tumour shows T1 hypointense and T2 hyperintense signal intensity. On dynamic MR contrast angiogram, the lesion shows intense enhancement in arterial phase with tumour blush. Treatment is complete surgical resection by transungual or lateral incision depending on the tumour location [2]. The typical clinical presentation and imaging findings together help to make an accurate diagnosis.
Differential Diagnosis List
Glomus tumour
Haemangioma
Neurofibroma
Melanoma
Lipoma
Final Diagnosis
Glomus tumour
References
[1] Tsuchie H, Okada K, Nagasawa H, Minagawa H, Shimada Y (2009) Glomus tumor of the toe with symptoms similar to those of Morton’s disease. J Orthop Sci 14(6):826-9 (PMID: 19997833)
[2] Shin DK, Kim MS, Kim SW, Kim SH (2010) A painful glomus tumor on the pulp of the distal phalanx. J Korean Neurosurg Soc 48(2):185-7 (PMID: 20856673)
[3] Bhaskaranand K, Navadgi BC (2002) Glomus tumour of the hand. J Hand Surg Br 27(3):229-31 (PMID: 12074607)
[4] Carroll RE, Berman AT (1972) Glomus tumors of the hand: review of the literature and report on twenty-eight cases. J Bone Joint Surg Am 54(4):691-703 (PMID: 4341268)
[5] Okada O, Demitsu T, Manabe M, Yoneda K (1999) A case of multiple subungual glomus tumors associated with neurofibromatosis type 1. J Dermatol 26(8):535-7 (PMID: 10487011)
[6] Sawada S, Honda M, Kamide R, Niimura M (1995) Three cases of subungual glomus tumors with von Recklinghausen neurofibromatosis. J Am Acad Dermatol 32(2 Pt 1):277-8 (PMID: 7829715)
[7] De Smet L, Sciot R, Legius E (2002) Multifocal glomus tumours of the fingers in two patients with neurofibromatosis type 1. J Med Genet 39(8):e45 (PMID: 12161612)
Case information
| URL: | https://www.eurorad.org/case/10589 |
| DOI: | 10.1594/EURORAD/CASE.10589 |
| ISSN: | 1563-4086 |
Figure 2
coronal and sagittal T1
A globular T1 hypointense lesion (arrows) noted abutting the plantar surface of distal phalanx of right 3rd toe. The adjacent bone appears normal.
Figure 3
coronal and sagittal proton density FS
A globular PD hyperintense lesion (arrows) noted abutting the plantar surface of distal phalanx of right 3rd toe. Incidentally subcutaneous oedema noted in plantar aspect of 2nd toe.
Figure 4
MR contrast angiography
Sequential contrast MR angiography shows enhancement of the lesion
Figure 5
T1 fat sat contrast - coronal and sagittal
T1 fat sat contrast images show a small enhancing lesion (arrows) abutting the plantar surface of distal phalanx of 3rd toe.
Ultrasonography
A small hypoechoic soft tissue lesion (arrow) noted in plantar surface of distal phalanx. No significant vascularity could be demonstrated within the lesion.
Chary D, VRR Diagnostics, Radiology, Chennai, India
Chary D, VRR Diagnostics, Radiology, Chennai, India
coronal and sagittal T1
A globular T1 hypointense lesion (arrows) noted abutting the plantar surface of distal phalanx of right 3rd toe. The adjacent bone appears normal.
Chary D, VRR Diagnostics, Radiology, Chennai, India
Chary D, VRR Diagnostics, Radiology, Chennai, India
coronal and sagittal proton density FS
A globular PD hyperintense lesion (arrows) noted abutting the plantar surface of distal phalanx of right 3rd toe. Incidentally subcutaneous oedema noted in plantar aspect of 2nd toe.
Chary D, VRR diagnostic, Radiology, Chennai, India.
Chary D, VRR diagnostic, Radiology, Chennai, India.
MR contrast angiography
Sequential contrast MR angiography shows enhancement of the lesion
Chary D, Radiology, VRR Diagnostics, Chennai, India
Chary D, Radiology, VRR Diagnostics, Chennai, India
T1 fat sat contrast - coronal and sagittal
T1 fat sat contrast images show a small enhancing lesion (arrows) abutting the plantar surface of distal phalanx of 3rd toe.
Chary D, Radiology. VRR Diagnostics, Chennai, India
Chary D, Radiology. VRR Diagnostics, Chennai, India