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甲下神经瘤竟然可以伪装成绿指甲综合征?

2022-01-11 MedSci原创 MedSci原创

创伤性神经瘤是一种罕见的良性肿瘤,但是当它长在指甲下面却给我们的诊断带来了非常大的难度。

创伤性神经瘤是一种罕见的良性肿瘤,经常在创伤或手术后出现,最常见于面部、颈部和四肢。它们被认为是由于周围神经损伤后的无组织的神经增殖,并且通常是疼痛的。迄今为止,报告了2例甲下神经瘤;1例表现为疼痛的甲下结节,另一例表现为甲营养不良由于指甲板固有地为甲下位置提供保护,临床医生很少怀疑甲下神经瘤,特别是在缺乏明显外伤史的情况下。在这里,我们描述了一例甲下神经瘤,表现为持续性甲剥离并发绿指甲综合征。

一名 53 岁的女性,因右侧拇指呈绿色 1 年而就诊。检查发现右侧拇指指甲有剥离和远端指甲的深绿色绿甲图 1 )。既往治疗包括口服氟康唑、口服特比萘芬、口服环丙沙星1周、泡、外用庆大霉素软膏、外用依氟康唑溶液,无改善。

指甲的细菌培养显示铜绿假单胞菌大量生长. 真菌培养阴性。患者开始口服环丙沙星,计划治疗 5 周;然而,由于担心手腕手术后的肌腱炎,她提前停药。随后,该患者每两周用稀释的消毒剂浸泡指甲,并每天两次口服强力霉素100 mg,持续 2 个月,症状部分改善。此时的真菌培养显示念珠菌属适度生长,真菌聚合酶链反应 检测到近平滑念珠菌。在接下来的 2 年中,该患者接受了几个周期的脉冲伊曲康唑治疗200 毫克,每天两次,每月 1 周,持续 3 个月,但改善甚微。

鉴于指甲绿色变色的不完全消退和持续的甲剥离,对远端甲床进行了穿刺活检,包括甲床最近的溶解区域。撕下指甲板的远端半部进行活检。撕脱后,没有明显可识别的病变的证据。组织病理学评估显示纤维化的甲皮组织内有显着的成熟神经组织和粘液变化,与神经瘤一致图 2)。活检两个月后,患者的绿色变色完全消退,最远端部分残留少量甲剥离。建议观察。

图一:右拇指远端甲剥离和绿色变色符合绿指甲综合征

图2:甲下神经瘤的组织病理学。有一个纤维化真皮边缘和一个带有粘蛋白的突出的成熟神经样结构。

 

创伤性神经瘤是周围感觉神经组织的良性肿瘤,继发于手掌、上下肢和舌头等部位的损伤。他们的病因可能是由于神经末梢的无组织修复造成的创伤性神经瘤也可能由慢性刺激和摩擦引起。迄今为止,仅报告了 2 例创伤性甲下神经瘤。在这两种情况下,由于明显疼痛的甲下结节或带状甲营养不良,怀疑甲下生长。在我们的患者中,甲下神经瘤的占位效应导致慢性远端甲剥离,从而导致持续性绿指甲综合征和念珠菌性甲真菌病的发展

绿甲综合征,最常由绿脓杆菌引起,是一种传染性指甲疾病,可导致绿甲、剥离和慢性甲沟炎

在持续性绿甲综合征的情况下,应考虑甲剥离的全部潜在潜在原因。检查甲下病变可能具有挑战性,尤其是当指甲板有上覆变色时。因此,在难治性病例中可以考虑进行指甲单位活检。创伤性神经瘤的潜在治疗选择包括手术切除、皮质类固醇注射、神经松解或期待治疗。在这种情况下,建议进行观察,因为绿指甲综合征在指甲活检后得到解决。然而,如果将来甲剥离不能完全解决,患者将面临绿指甲综合征复发的风险。

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    2022-08-06 ycmayy
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    2022-01-26 ms558296600876652

    受益匪浅

    0

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