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Isolated Plantar Vein Thrombosis Resembling a Corn with a Bruise

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Isolated Plantar Vein Thrombosis Resembling a Corn with a Bruise JE Hahm, et al pISSN 1013-9087ㆍeISSN 2005-3894 Ann Dermatol Vol. 31, No. 1, 2019 https://doi.org/10.5021/ad.2019.31.1.66 CASE REPORT Isolated Plantar Vein Thrombosis Resembling a Corn with a Bruise Ji Eun Hahm, Kang Su Kim, Jae Won Ha, Chul Woo Kim, Sang Seok Kim Department of Dermatology, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea Plantar vein thrombosis, rarely-reported disease, is usually or callus, plantar fibromatosis, or plantar verruca1. Among accompanied by pain and tenderness in the plantar region laborers, they may develop from excess pressure on the and should be differentiated from other dermatological con- bony prominences of the feet, repetitive uneven friction ditions causing plantar pain, such as hemorrhagic corn/cal- from footwear, or gait abnormalities. Plantar vein throm- lus, plantar epidermal cyst, verruca, or plantar fibromatosis. bosis is a rare condition causing plantar pain. The exact A 52-year-old man presented with a violaceous tender sub- cause of plantar vein thrombosis is yet unclear, but predis- cutaneous nodule overlying a hyperkeratotic plaque on his posing conditions, such as prior trauma, surgery, paraneo- sole. Initially, he thought it was a corn and applied keratolytic plastic syndromes, or coagulation disorders have been agents, which failed to work. Sonography revealed a well-de- described. To date, there is no established treatment ex- marcated mass with increased peripheral vascularity. His cept surgical excision, but reportedly, nonsteroidal anti-in- pain was relieved after a complete wide excision, which con- flammatory drug or heparin with elastic bandage is known firmed the mass to be plantar vein thrombosis after histo- to be effective for symptomatic control2-5. To the best of pathological examination. (Ann Dermatol 31(1) 66∼69, our knowledge, this is the typical case of an isolated plan- 2019) tar vein thrombosis resembling a corn or verruca with a bruise, which showed improvement after surgical ex- -Keywords- cision, in a man working as a freight car driver. We re- Corn, Plantar vein thrombosis, Venous thrombosis ceived the patient’s consent form about publishing all photographic materials. INTRODUCTION CASE REPORT Plantar pain caused by dermatological condition is often A 52-year-old man working as a freight car driver pre- associated with plantar epidermal cyst, hemorrhagic corn sented to our clinic with a tender nodule on his right sole toward the heel, which developed 4 years ago and got bigger. He thought it was a corn and applied some kerato- Received May 2, 2017, Revised November 27, 2017, Accepted for lytic agents, with which it failed to improve. Physical ex- publication December 31, 2017 amination revealed a walnut-sized, firm, fixed subcuta- Corresponding author: Chul Woo Kim, Department of Dermatology, Kangdong Sacred Heart Hospital, College of Medicine, Hallym University, neous nodule with an overlying fine violaceous hyper- 150 Seongan-ro, Gangdong-gu, Seoul 05355, Korea. Tel: 82-2-2224-2285, keratotic plaque on the heel side of the right plantar area Fax: 82-2-474-7913, E-mail: [email protected] (Fig. 1A). Clinically, he was diagnosed as having a corn or ORCID: https://orcid.org/0000-0002-0970-0439 verruca associated with a neighboring bruise. Sonography This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons. was performed to rule out the presence of an underlying org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, subcutaneous tumor, and revealed a 1.9×1.2 cm sized, distribution, and reproduction in any medium, provided the original work well-demarcated, lobulated heterogeneous hypoechoic is properly cited. mass surrounded by a thin anechoic area with increased Copyright © The Korean Dermatological Association and The Korean Society for Investigative Dermatology peripheral vascularity (Fig. 2). The radiologist suggested an 66 Ann Dermatol Corn-Like Isolated Plantar Vein Thrombosis Fig. 1. (A) A bruise-like violaceous nodule 2.5 cm in diameter, on the heel side of the right sole. (B) A dark reddish rubbery, lobulated nodule in the subcutaneous layer. Fig. 2. A 1.9×1.2 cm sized, well- marginated, lobulated, heteroge- neous hypoechoic mass surrounded by a thin anechoic area with in- creased peripheral vascularity. Fig. 3. (A) Several variable thick and plicated walled small muscular vessels in the dermis and its abutting thrombus consisting of aggregated erythrocytes and eosinophilic fibrin in the lumen of a dilated vein in the subcutaneous layer (H&E, ×10). (B) Granular bluish deposit (hemo- siderin) within and around mural walls of muscular vessels (Iron stain, ×20). inflamed epidermal cyst. Surgical excision was performed blocked by a thrombus consisting of aggregated eryth- for complete removal of the superficial corn and the sub- rocytes and eosinophilic fibrin (Fig. 3A). The violaceous cutaneous tumor, to relieve his plantar tenderness. A dark bruise-like macule around the nodule was turned out der- erythematous rubbery nodule, 2 cm in diameter, was mal deposits of hemosiderin (Fig. 3B). Based on these found in the subcutaneous layer (Fig. 1B). There was mini- findings, he was diagnosed as having an isolated plantar mal intraoperative bleeding. Histopathological examina- vein thrombosis. Sutures were removed 2 weeks later, and tion revealed several variable thick and plicated walled he had no recurrence during 6-month follow up. small muscular vessels and hemosiderin deposition within and around them in focal areas of the dermis. The sub- cutaneous layer showed a large vessel whose lumen was Vol. 31, No. 1, 2019 67 JE Hahm, et al DISCUSSION T1-weighted images and high signal intensity on T2- weighted/fluid-sensitive sequences13. Finally, biopsy, pref- Plantar vein thrombosis was first reported in 1997 by erentially excisional one, can help confirm the diagnosis. Legrand et al.6 in a patient developing this condition after We removed the thrombosed vein surgically with minimal a saphenectomy. The exact etiology is yet unknown, but intraoperative bleeding and the patient had a 6-month fol- reportedly, it has been associated with trauma or athletic low up without recurrence. Therefore, surgical excision activity2, postsurgical immobilization5,6, coagulation dis- should be considered as a treatment option for plantar orders such as anticardiolipin syndrome4 or prothrombin vein thrombosis. G20210A mutation3 and paraneoplastic syndromes in a In conclusion, plantar vein thrombosis is one of the rare patient with bone metastasis2. Our case was not asso- dermatologic diseases causing plantar pain. This is the ciated with prior surgery, malignancy, or coagulation dis- case that looked like a corn associated with a bruise, per- orders and might have been caused by repetitive trauma haps due to its long-standing nature and hemosiderin because as a freight car driver, he was known to have car- deposition. When dermatologists encounter patients with ried heavy loads. painful plantar subcutaneous mass, multiple disorders Long-standing subcutaneous venous thrombosis might should be considered in the differential diagnosis. cause both tender subcutaneous mass and surface hyper- Radiological studies or skin biopsy can be a useful tool for keratosis of the epidermis, which makes diagnosis more the diagnosis. difficult. It should be differentiated from other dermato- logical conditions causing plantar pain such as hemor- CONFLICTS OF INTEREST rhagic corn or callus, plantar epidermal cyst, plantar fi- bromatosis, and plantar verruca1. A corn or callus is the The authors have nothing to disclose. localized focus of hyperkeratosis, arising on the plantar portion from foot deformity or pressure, and the accom- ORCID panying pain is usually relieved by paring it or applying keratolytic agent7. Plantar warts appear as horny plugs sur- Ji Eun Hahm, https://orcid.org/0000-0001-7863-2452 rounded by a ring of hyperkeratotic skin with slight ele- Kang Su Kim, https://orcid.org/0000-0002-2996-9814 vation7. They also revealed homogeneous black to red Jae Won Ha, https://orcid.org/0000-0003-2097-7241 dots and globules with papilliform surfaces more prom- Chul Woo Kim, https://orcid.org/0000-0002-0970-0439 inently seen via dermoscopy8. In the case of plantar epi- Sang Seok Kim, https://orcid.org/0000-0001-9717-9710 dermoid cyst, there is a tiny blackhead plugging the cen- tral punctum of the cyst and sometimes foul smelling REFERENCES cheesy debris drains from it9. Typically, plantar fi- bromatosis presents along the central or medial aspect of 1. Wallace GF. Dermatologic causes of heel pain. Clin Podiatr the plantar fascia as a firm, fixed, rather deep subcuta- Med Surg 2010;27:407-416. 10 neous nodule . 2. Bernathova M, Bein E, Bendix N, Bodner G. Sonographic To make a proper diagnosis, radiological studies of the le- diagnosis of plantar vein thrombosis: report of 3 cases. J sion may be essential. Plantar vein thrombosis can be di- Ultrasound Med 2005;24:101-103. agnosed with Doppler sonography or magnetic resonance 3. Siegal DS, Wu JS, Brennan DD, Challies T, Hochman MG. Plantar vein thrombosis: a rare cause of plantar foot pain. imaging (MRI). On Doppler sonography, it characteristi- Skeletal Radiol 2008;37:267-269. cally appears as hypoechoic, dilated, noncompressible 2 4. Long A, Bura-Riviere A, Sapoval M. [Plantar venous thrombosis vessels with no luminal blood flow . However, being op- and anticardiolipin antibody syndrome. Case report]. J Mal erator dependent, a diagnosis might be missed, and MRI is Vasc 2004;29:39-40. French. preferred for evaluating persistent foot pain11. The typical 5. Cavezzi A. Isolated thrombosis of plantar veins. Case MRI finding is intraluminal filling defect in plantar veins in report. Minerva Cardioangiol 1999;47:309-313. association with perivenular enhancement12. On the other 6. Legrand MS, Papon X, Leftheriotis G, Saumet JL. [Isolated hand, plantar fibromatosis shows ill-defined, infiltrative plantar venous thrombosis. Report of a case]. J Mal Vasc 1997;22:364-365.
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