Utilization and effect of telehealth for the treatment of haemangioma before and after COVID

Many patients treated at Stanford for haemangiomas must travel from the rural Central Valley or Central Coast to receive care. Because of COVID-19, there was an increased use of telehealth which shifted the management of haemangiomas. Our study aimed to identify the implications of this change and its impact on access to care for patients who live far away. Using the Stanford Research Repository, we established two cohorts of patients seen at Stanford dermatology clinics with a haemangioma diagnosis: one from 2018 and one from 2022. We took a random sample of 50 patients from each and collected data on haemangioma treatment prescriptions, age at diagnosis, age at dermatology encounters, and distance travelled to clinic. We subdivided the 2022 cohort into in-person visits and telehealth appointments. While no patients utilized telehealth in the 2018 cohort, 69% of patients in the 2022 cohort utilized telehealth for their first Dermatology visit. In the 2022 cohort, 52% of patients utilized telehealth for at least one dermatology appointment. The average age at presentation for the 2018, 2022 in-person, 2022 telehealth groups were 121 , 208 , and 116 days, respectively. Average age at diagnosis was significantly younger for the telehealth cohort compared to the 2022 in-person cohort, and there was an increase in prescriptions for treatment in the telehealth cohort. These results show that increased telehealth utilization as a result of the pandemic has allowed patients to be seen by a dermatologist at an earlier age and receive a prescription for treatment for haemangiomas.

Subglottic Hemangioma: A Hidden Mass Presenting in an Unusual Age Group.

Subglottic hemangiomas are rare in adulthood. The presence of the lesion in the subglottic region makes it even more unusual. Moreover, these lesions do not have a typical course and involution changes as seen in the infantile forms. An elderly female initially came with a brief history of dyspnea and symptoms of upper respiratory tract infection. The patient also complained of a change of voice and noisy breathing, with a recent history of intubation following COVID-19 pneumonia and late-onset bronchial asthma. Flexible nasopharyngolaryngoscopy showed a mass below the vocal folds, which was seen to arise from the posterior subglottic region. The patient eventually underwent endoscopic excision of the lesion under general anesthesia and recovered well. Symptoms of hoarseness and stridor, along with a history of intubation, should raise a high index of suspicion for laryngeal diseases. A delay in the diagnosis of an obstructing lesion in the subglottis occurs in the presence of a confounding lung infection and overlap of clinical features with those of bronchial asthma. Surgical excision is required not only to alleviate obstructive symptoms but also to rule out malignancy.

Ocular Oncology Practice During the COVID-19 Pandemic

The COVID-19 pandemic created a worldwide shift in how physician deliver optimal medical care. Ocular oncology practices have had to adapt to new challenges including how the delivery of service is performed in order to minimize SARS-CoV-2 exposure without sacrificing quality. Understanding the individual characteristics of every practice will maximize the efforts to adapt to this new reality. Telemedicine, virtual waiting rooms, and personal protective equipment have become the new standard during these unprecedented times. During clinic and operating room, our practices have had to strive for a new level of synchrony between patient and physician availability to minimize wasted time and exposure risk. Overall, medical care should not be delayed or deferred in patients with malignant ocular tumors during the COVID-19 pandemic;however, implementing safety measures for patients and healthcare workers is crucial to successfully continue to practice ocular oncology. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022.

Recurrent intussusception with ileal perforation as a complication of Blue Rubber Bleb Nevus Syndrome in a pediatric patient

Blue rubber bleb nevus syndrome (BRBNS) is a rare congenital condition, characterized by multiple venous malformations that may involve any organ system, most commonly the skin or the gastrointestinal tract. These lesions are often responsible for chronic blood loss and secondary anemia, and in rare situations may cause severe complications such as intussusception, volvulus, and intestinal infarction. Intussusception as a complication of BRBNS, although a known complication of the disease, has rarely been reported, especially in the Philippines. In the Philippine Society for Orphan Disorders, only 2 cases of BRBNS are currently included in the organization, including the patient presented in the case report. The treatment of BRBNS that involves the gastrointestinal tract depends on the extent of intestinal involvement and severity of the disease. The treatment aims to preserve the GI tract as much as possible due to the high recurrence in the disease. In this case report, we present a 13 year-old male with BRBNS with previous history of intussusception, successfully managed conservatively;however, upon recurrence, underwent exploratory laparotomy wherein a subcentimeter perforation in the antimesenteric border of the proximal ileum was noted, together with a gangrenous intussuscipiens, and multiple mulberry-like formations on the antimesenteric border of the small bowels. Histopathological findings of the resected bowels showed multiple cavernous hemangiomas consistent with BRBNS. The postoperative course of the patient was unremarkable.Copyright © 2023 The Authors

Sinonasal Lobular Capillary Hemangioma After Continuous Self-tests for COVID-19: A Case Report and Review of the Literature.

Sinonasal lobular capillary hemangiomas (LCH) are rare benign vascular lesions commonly arising from the nasal septum. Nasopharyngeal, nasal mid-turbinate, and anterior nasal swabbing is the preferred method of screening for coronavirus disease-2019 (COVID-19). Herein, we present a case of a sinonasal LCH in a child after continuous self-tests for COVID-19, with an anterior nasal swab. The child presented with a well-defined red mass in the anterior part of the nasal septum, which was removed endoscopically. Histopathology revealed a LCH. This is the first report of a complication other than epistaxis with the use of an anterior nasal swab. Our literature review identified 32 studies reporting complications of COVID-19 screening. Cerebrospinal fluid leaks and foreign body retention are the most common ones. A proper specimen collection technique and a quick patient history with an emphasis on risk factors are the best practices to prevent complications from COVID-19 screening.

Hemangioma of the umbilical cord: A case report on a rare entity.

Several hundred cases of placental hemangiomas have been reported in the literature. However, the umbilical cord is extremely uncommon as a site of occurrence. We present a case of postnatal discovery of giant hemangioma of the umbilical cord (HUM) in a Coronavirus Disease 2019 (COVID 19) positive mother. To our knowledge, this is the first reported case of HUM synchronous to a maternal infection with COVID 19. We aim, through this case and a review of the literature, to study the clinicopathological characteristics of this singular entity. Our patient, a 37-year-old woman, presented to the Department Of Obstetrics And Gynecology for respiratory distress and loss of fetal movements. Ultrasound examination concluded to intrauterine fetal desmise. After stabilization of the patient, a cesarean section was performed. A macerated fetus was extracted. Placenta showed a giant mass attached to the cord. It was submitted for pathological examination. Gross examination showed that the umbilical cord was inserted eccentrically with a fusiform dilation. Near its placental end, three cohesive solid angiomatous nodules were noted. Microscopic examination revealed lobules of dilated blood-filled capillaries set in a myxoid stroma. The diagnosis of HUM have been established. HUM arise from endothelial cells of the umbilical vessels. Their etiology, physio-pathology and pathways of tumorigenesis are not yet well defined. Further studies are needed to explore the pathways of tumorigenesis and to determin the implication of COVID-19 in HUM.

Diagnosis of infantile subglottic hemangioma and the effect of oral propranolol.

OBJECTIVES: To investigate the clinical characteristics of infantile subglottic hemangioma (SGH), and to observe the safety and efficacy of propranolol in the treatment of SGH. METHODS: The data of 21 children diagnosed with SGH and treated with propranolol in our hospital from March 2013 to January 2021 were retrospectively analyzed and followed up. RESULTS: Among the 21 cases, there were 7 males and 14 females. SGH was found 11 left-sided, 9 right-sided and 1 bilateral-sided. The clinical manifestations included stridor (13/21), respiratory distress (6/21), barking cough (5/21), feeding difficulty (4/21), three concave sign (4/21), cyanosis (2/21) and hoarseness (1/21). 8 patients had multiple cutaneous hemangiomas. The age of presentation ranged from 1 to 8 months, with a median of 1.1 months. 18 cases (85.7 %) had a history of misdiagnosis, 14 bronchitis/pneumonia, 5 laryngomalacia, 2 laryngeal obstruction and 1 asthma. The median ages at diagnosis were 3 months, with a range of 1.2-28 months. The treatment duration ranged from 6 to 25.6 months, with an average of (14.3 ± 4.9) months. Age at termination of treatment ranged from 9 to 38 months, with a median of 18.6 months, and only 2 cases were beyond 2 years old at that time. No adverse side effects from propranolol therapy occurred and all 21 cases were cured. CONCLUSIONS: We advocate a strong index of suspicion for SGH presenting with respiratory symptoms under 2 years old who has poor effect or repeated condition after routine treatment. Laryngoscopy combined with contrast-enhanced CT can confirm the diagnosis of SGH. Oral propranolol is safe and effective, and that early diagnosis and intervention of propranolol without further delay are crucial to the successful management. We advocate continue propranolol treatment beyond 18 months of age, furthermore, 2 years old may be the best time for therapy termination.

Documented growth of a de novo intracranial capillary hemangioma: a case report

Background: Intracranial capillary hemangiomas are rare, particularly in adults, and diagnosis can be challenging. The literature lacks visualization of intracranial capillary hemangioma growth over time. Here we document growth of a de novo intracranial capillary hemangioma, initially interpreted radiologically as a glioma. Methods: We report a case of a 64 year old male with history of HIV, recent Lyme disease and unconfirmed prior COVID-19 infection, who presented with exhaustion and confusion. Imaging demonstrated an intra-axial high T2/FLAIR signal lesion centred in the subcortical white matter of the posterior right temporal lobe. There was faint enhancement, and a few mildly prominent vessels were seen along its anterior aspect. Imaging 2 years prior had not shown the lesion. Stereotactic biopsy was nondiagnostic. Craniotomy and resection was carried out. Results: Pathological examination and immunohistochemistry returned the diagnosis of capillary hemangioma. We review how this case adds to proposed theories of de novo intracranial capillary hemangioma growth. Our patient's co-morbidities support possible inflammation related triggers for symptomatic progression of these uncommon lesions. Conclusions: This unusual case documents the radiological appearance and progression of a de novo intracranial capillary hemangioma. It represents the first time such growth has been visualized in an adult male.

Infantile hemangioma referral delays persist despite 2019 American Academy of Pediatrics Clinical Practice Guideline: Experience at a single quaternary pediatric institution

Infantile hemangiomas (IH) are vascular tumors that often require timely treatment to reduce morbidity.1,2 The 2019 American Academy of Pediatrics (AAP) Clinical Practice Guidelines (CPG) for the Management of IH recommend referral to dermatology prior to 4 weeks of age, enabling timely treatment initiation.1 This study examines adherence to national guidelines and aims to identify barriers to appropriate referral timing & treatment. This retrospective cohort study examined IH patients, ages 0 to 24 months, referred to Phoenix Children’s Hospital (PCH) Dermatology from 1/1/2019 to 12/31/2020, following release of AAP CPG. Patients were categorized into age appropriate (≤4wks) or late (>4wks) referral groups. Associations of referral age w/ demographics/treatments were examined. Among 791 patients identified, 46 (6%) were appropriately referred at ≤4 weeks of age, 680 (86%) were referred late at >4 weeks of age, and 65 (8%) had missing referral dates. For the group of 343 patients who were referred and treated w/ propranolol, mean age at referral, initial dermatology visit, and propranolol initiation was 3.2, 3.8, & 4.2 months, respectively. No statistical differences (p≤0.05) were detected in gender, race, insurance, language, or rates of propranolol/timolol treatment between referral groups. Despite AAP recommendations, the vast majority of infants with IH are referred to PCH Dermatology after 4 weeks of age. Late referral has led to treatment initiation after the rapid growth phase in most patients, which is problematic for those w/ high-risk hemangiomas. Patient demographics were not correlated w/ referral category suggesting that other factors, such as primary care provider referral practices and the COVID-19 pandemic, may have contributed to delayed referrals. Based on mean age at referral and treatment initiation, patients may have already experienced complications from their hemangiomas, which could result in increased healthcare utilization, costs, & morbidity. References: 1) Krowchuk DP et al. Clinical Practice Guideline for the Management of Infantile Hemangiomas: American Academy of Pediatrics. Pediatrics, Jan 2019;143(1). 2) Tollefson MM and IJ Frieden. Early growth of infantile hemangiomas: what parents;photographs tell us. Pediatrics, Aug 2012;130(2): e314-20.

Incidental Finding of a Tracheal Lipoma

Introduction: Primary tracheal tumors are rare with an incidence of 0.2/100,000 persons, accounting for 0.6% of all pulmonary tumors. Only 10-20% of these tumors are benign with the most common being recurrent respiratory papillomatosis. Other benign tracheobronchial tumors include hamartoma, fibroma, lipoma and hemangioma among others. Due to the slow growing nature of these tumors, patients may present with progressive exertional dyspnea, cough and recurrent pneumonia, though rarely these tumors are identified incidentally in asymptomatic patients. This case describes a patient with an who underwent successful resection with flexible bronchoscopy and snare electrocautery. Case Report: A 66-year-old male with a history of former tobacco use was admitted to the medical intensive care unit (ICU) in 11/2020 with COVID-19 pneumonia, and incidentally found to have a tracheal tumor noted on CT imaging. His ICU course was complicated by submassive pulmonary embolism, pneumothorax requiring chest tube, and acute hypoxemic respiratory failure requiring heated high-flow nasal cannula. He was successfully discharged to home after 4 weeks and evaluated in the ambulatory clinic for follow-up 2 months later. Review of his imaging from an outside facility demonstrated a 1-cm polypoid lesion arising from the right tracheal wall (Figure 1A). Pulmonary function testing demonstrated a moderate restrictive defect with normal flow-volume loops. He was referred to interventional pulmonology for further evaluation and management. Flexible bronchoscopy revealed a 50% partially obstructing polypoid mass 6-cm distal to the vocal cords (Figure 1B). The mass was excised using snare electrocautery with subsequent cryotherapy for destruction of abnormal tissue at the base of the lesion and argon plasma coagulation for hemostasis. Pathology revealed tracheal lipoma. Repeat flexible bronchoscopy 12 weeks later revealed no evidence of recurrence at the site of the previously resected tracheal lipoma (Figure 1C). Discussion: Among benign tracheobronchial tumors, lipoma is an extremely rare diagnosis representing only 3-9% of cases. Airway lipomas very rarely involve the trachea and are infrequently found incidentally in asymptomatic patients. Epidemiological risk factors are thought to include male gender, obesity, middle age, and smoking. Flexible tracheobronchoscopy remains the gold standard for diagnosis, also allowing for excisional treatment with electrocautery, cryotherapy, or laser therapy. Given the rare incidence of these tumors, follow-up evaluation is recommended, though to-date there are no reports of local recurrence after bronchoscopic treatment. This case highlights the importance for diagnostic evaluation of incidental tracheobronchial tumors given the rare incidence of benign diagnoses.

21st ESPD Annual Meeting

The proceedings contain 169 papers. The topics discussed include: GNAQ/11 mosaicism causes aberrant calcium signaling and drives systemic hypocalcemia;pediatric obesity and skin disease (PicoSkin-study): cutaneous findings and associated quality of life in 86 children and adolescents with obesity;what gives them the shivers? two new cases of infantile transient smooth muscle contraction of the skin;dermatologic manifestations of multisystem inflammatory syndrome in children during the COVID-19 pandemic;clinical characteristics and management of cutaneous lymphangioma circumscriptum;different shades of grey! infantile black hairy tongue- a case series and review of the literature;descriptive series of cases of pediatric linear morphea in a tertiary hospital in Barcelona;the prevalence of itch in German schoolchildren: a population-based study;neurocognitive functioning, physical health, and mental health of school-aged children treated with propranolol or atenolol for infantile hemangioma;and efficacy and safety of tralokinumab in adolescents with moderate-to-severe atopic dermatitis: results of the phase 3 ECZTRA 6 trial.

A case report of mediastinal cavernous hemangioma.

When faced with a hypervascular mediastinal tumor, mediastinal hemangioma should be taken into consideration. Although it is uncommon, considering this important diagnosis may avoid a possible extensive surgery that is not necessary.

Multiple, Eruptive and Generalised Lobular Capillary Haemangiomas- A Rare Morphological Variant

Lobular Capillary Haemangioma or Pyogenic Granuloma (PG) is a common benign, vascular proliferative lesion, usually occurring at sites of preceding trauma. It is known to occur more commonly in children and young females. The most common presentation is a solitary lesion. Multiple, eruptive PG have been reported after antecedent burns, trauma and following retinoid therapy and as satellite lesions after treatment of a primary lesion. A 14-year-old female, without any co-morbidities presented with spontaneous onset of multiple, eruptive and generalised skin coloured papules and nodules over face, neck, upper chest and upper back. The lesions were eruptive in nature, involved the back, face and upper trunk over duration of 4 months. There was intermittent bleeding from the lesions after trivial trauma. Clinical diagnosis of lobular capillary haemangioma was confirmed by histopathology which showed lobules of variably dilated network of blood filled capillaries in the papillary dermis surrounded by typical epithelial collarette. The lesions were removed by Radiofrequency (RF) in subsequent sittings. This case report features an interesting and unusual morphological presentation of generalised eruptive lobular capillary haemangioma, which occurred de novo in a young female without any associated skin or systemic disease.

Spinal intramedullary cavernous angioma patient in a pain clinic - A case report.

BACKGROUND: Spinal intramedullary cavernous angioma is a rare form of spinal cord tumor that is associated with myelopathy and significant morbidity and surgical treatment is almost always required. CASE: We report a case of spinal intramedullary cavernous angioma in a pain clinic with initial symptoms of unilateral interdigital space sensory change. Morton's neuroma and piriformis syndrome were clinically suspected, however, symptoms acutely aggravated, and paraplegia developed following the patient's COVID-19 vaccination. Vaccine-associated side effects were ruled out and spinal intramedullary cavernous angioma was confirmed through magnetic resonance image. The patient underwent surgery for complete mass excision. CONCLUSIONS: Recent reports of COVID-19 vaccine-associated side effects have raised sensitive concerns to both health care providers and the public, that in some cases when the symptoms coincide with vaccination history, it may delay time-sensitive diagnosis and treatment and spend unnecessary costs.

Differential diagnosis of malformations of lymphatic vessels in dermatological practice

Lymphangiomas (LG) are uncommon, rare congenital anomalies or acquired lymphatic dilations of a benign flow that can involve the skin [1, 2]. There are main groups of lymphangiomas: 1) a superficial variant, characterized by grouped vesicles (circumscriptum lymphangioma), 2) a deeper variant in the form of a cavernous lymphangioma. The prevalence of LG may be focal or diffuse. Secondary acquired LG with a rarer frequency are known [3, 4]. LG can be one of the manifestations of a symptom complex, for example, Gorham-Stout syndrome, which is characterized by progressive osteolysis [5]. The rare occurrence of LG, clinical diversity, undulating course of congenital forms, the possibility of an acquired nature of the disease causes a high risk of diagnostic errors in establishing the final diagnosis. At the Department of Dermatovenereology, Cosmetology and Additional Professional Education of Smolensk State Medical University for the period from 2018 to 2021, 5 patients (age from 5 to 17 years) with LG were observed. Of these: in four children, the disease existed from birth, in one girl it had an acquired character and developed after covid infection [4]. Gender characteristics: 4 girls (5, 6, 12 and 17 years old) and 1 boy (9 years old). All patients are urban residents. The time to establish the final diagnosis from the moment of seeking medical help ranged from 15 months to 12 (!) years, the average value being 6.5 years. The range of diagnoses of LG 'masks': herpetic infection, molluscum contagiosum, atopic dermatitis, contact dermatitis, epidermolysis bullosa. A frequent change in diagnoses was established in the same patient. Clinical case 1. The boy is 12 years old. The debut of skin lesions from birth and progression to 3 years of age, then spontaneous regression within 4 years (without signs of dermatosis). From 7 years to the present, there has been an increase in the number of rashes. Localization: the skin of the lateral surface of the trunk. Features of the rash: flesh-colored and/or reddish- purple bubbles. A pathognomonic symptom of 'frog calves' is found. The frequent autodestructive effect on the rash provokes its subsequent progression. Family history: his father is a liquidator of the atomic catastrophe in Chernobyl. Previous diagnoses: molluscum contagiosum, herpes zoster. Clinical case 2. The girl is 17 years old. The debut of the disease from birth. Lack of progression up to 5 years of age (up to 5 years of age did not apply to dermatologists). At the age of 5, she began to engage in rhythmic gymnastics (she continues to practice professionally at the present time) and noted an active increase in the number and size of the elements of the rash. She repeatedly consulted dermatologists: diagnoses of molluscum contagiosum (laser removal), herpetic infection (courses of antiherpetic therapy without effect) were assumed. The diagnosis was established 12 years after the moment of seeking medical help. Unilateral location of the rash along the inner surface of the right upper limb with transition to the axillary region;on the right lateral surface of the body, the right inguinal-femoral fold and the inner surface of the right thigh. Focuses of a rash in the form of different sizes of vesicular elements with a tendency to lymphorrhea and oozing, areas of maceration around. Single elements with a hemorrhagic component. The patient notes an increase in the inflammatory response and vesicle lymphorrhea after each workout. Dermatoscopy: yellow-pink lacunae alternating with single dark red lacunae. Histological examination: multiple dilated lymphatic vessels in the papillary and reticular dermis. Clinical case 3. Girl 6 years old. Sick from birth. The diagnosis of LG of the genitals was established at the age of 1, 5 years. Due to the localization of the rash in the external genital area, the girl's parents (at the age of 1 month) consulted an obstetrician-gynecologist, who suggested a hemangioma and referred to a dermatologist. The disease is of a family nature her grandmother (on the maternal side) and her lder brother have similar rashes on the skin of the trunk and in the mouth. The diagnosis was verified by histological examination. The pathological process is localized in the area of the labia majora and labia minora: multiple vesicular rashes with translucent contents, easily traumatized and accompanied by itching, were found. Conclusions: LG is a multidisciplinary problem, which is caused by mimicry of manifestations, varied localization and prevalence of the rash. To verify the diagnosis, the following algorithm should be followed: 1) the debut more often at birth or in the first months of life (with the exception of acquired forms of LG);2) the nature of evolution: a stable state or slow progression in the absence of traumatic factors;3) clinical features: the formation of grouped deep vesicles that resemble 'frog eggs'. The color of the bubbles is transparent or red-purple due to the hemorrhagic component. LG lesions may have hemangioma components. It should be remembered about the frequent localization of LG on the mucous membrane of the cheeks, tongue and floor of the oral cavity, which can manifest itself as bleeding from the elements of the rash when chewing or when providing dental care;4) biopsy reveals dilated lymphatic vessels in the upper layers of the dermis.

Infantile hemangioma. Part 2: Management.

The majority of infantile hemangiomas (IH) can be managed conservatively, but for those requiring active treatment, management has been revolutionized in the last decade by the discovery of propranolol. Patients that may require active intervention should receive specialist review, ideally before 5 weeks of age to mitigate the risk of sequelae. Propranolol can commence for most infants in the outpatient setting and the most frequently employed dosing regimen is 1 mg/kg twice daily. In the future, ß-blockers with a more-selective mechanism of action, such as atenolol, show some promise. In recalcitrant lesions, systemic corticosteroids or sirolimus may be considered. For small, superficial IHs, topical timolol maleate or pulsed dye laser may be considered. Where the IH involutes with cutaneous sequelae, a range of interventions have been reported, including surgery, laser, and embolization. IHs have a well-described clinical trajectory and are readily diagnosed and managed via telemedicine. Algorithms have been constructed to stratify those patients who can be managed remotely from those who warrant in-person review during the COVID-19 pandemic.

A case of diffuse hepatic hemangiomatosis coexistent with giant hemangioma: case report and literature review.

We report a case of hepatic hemangiomatosis coexistent with a giant hepatic hemangioma diagnosed in the context of the study for SARS-CoV-2 infection. Computed tomography showed irregular contours of the left hepatic lobe with a lesion that compromised the whole lobe, with peripheral uptake and a centripetal tendency in the late phase, compatible with bulky cavernous hemangioma, as well as another lesion with the same characteristics in segment VI. Magnetic resonance imaging of the abdomen showed multiple hepatic hemangiomas observed in both lobes involving all segments, some of them smaller than 1 cm, which were hyperintense in the T2-weighted sequences and showed progressive contrast enhancement. This case illustrates the incidental diagnosis of this condition during the study for another pathology, the radiological features that are important to differentiate from other tumoral findings, and the possible management strategies to follow.

Giant nasal granuloma gravidarum.

Nasal granuloma gravidarum usually presents as a small vascular lesion on the septum or turbinates during pregnancy. We present a case of a giant nasal granuloma gravidarum and its management.