Letter - Clinical
Case for diagnosis. Bilateral ulcerations on the distal phalanges of the second and third fingers - Ulcerative carpal tunnel syndrome
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Ulcerações bilaterais nas falanges distais dos segundos e terceiros quirodáctilos" "tienePdf" => "pt" "tieneTextoCompleto" => "pt" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "531" "paginaFinal" => "533" ] ] "contieneTextoCompleto" => array:1 [ "pt" => true ] "contienePdf" => array:1 [ "pt" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figura 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1679 "Ancho" => 2925 "Tamanyo" => 300432 ] ] "descripcion" => array:1 [ "pt" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ressonância nuclear magnética do punho direito. (A) Corte sagital com espessamento do nervo mediano (setas). (B) Corte axial com espessamento do nervo mediano no túnel do carpo (setas). 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Cicatricial alopecia on the vertex - Folliculitis decalvans and lichen planopilaris phenotypic spectrum" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "533" "paginaFinal" => "536" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1247 "Ancho" => 1675 "Tamanyo" => 487886 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cicatricial alopecia, with follicular pustules at the periphery, erythema and perifollicular desquamation, in addition to areas with polytrichia.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Anna Carolina Miola, Paulo Muller Ramos, Hélio Amante Miot" "autores" => array:3 [ 0 => array:2 [ "nombre" => "Anna Carolina" "apellidos" => "Miola" ] 1 => array:2 [ "nombre" => "Paulo Muller" "apellidos" => "Ramos" ] 2 => array:2 [ "nombre" => "Hélio Amante" "apellidos" => "Miot" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "pt" => array:9 [ "pii" => "S2666275223000541" "doi" => "10.1016/j.abdp.2023.03.004" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "pt" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2666275223000541?idApp=UINPBA00008Z" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0365059623000478?idApp=UINPBA00008Z" "url" => "/03650596/0000009800000004/v1_202307031010/S0365059623000478/v1_202307031010/en/main.assets" ] "itemAnterior" => array:18 [ "pii" => "S0365059623000442" "issn" => "03650596" "doi" => "10.1016/j.abd.2021.08.015" "estado" => "S300" "fechaPublicacion" => "2023-07-01" "aid" => "725" "copyright" => "Sociedade Brasileira de Dermatologia" "documento" => "article" "crossmark" => 1 "subdocumento" => "crp" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter - Clinical</span>" "titulo" => "Amelanotic nodular melanoma in Marjolin ulcer on the plantar region" "tienePdf" => "en" "tieneTextoCompleto" => "en" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "529" "paginaFinal" => "531" ] ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1149 "Ancho" => 2508 "Tamanyo" => 457100 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0070" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(a) Ulcerated lesion with cell proliferation occupying the superficial and deep dermis. 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Bilateral ulcerations on the distal phalanges of the second and third fingers - Ulcerative carpal tunnel syndrome" "tieneTextoCompleto" => true "saludo" => "Dear Editor," "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "531" "paginaFinal" => "533" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Hiram Larangeira de Almeida Jr., Fernanda Pinto Garcia, Laura de Moraes Gomes, Antônia Larangeira de Almeida" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Hiram Larangeira de" "apellidos" => "Almeida Jr." "email" => array:1 [ 0 => "hiramalmeidajr@hotmail.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernanda Pinto" "apellidos" => "Garcia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Laura de Moraes" "apellidos" => "Gomes" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Antônia Larangeira de" "apellidos" => "Almeida" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Department of Dermatology, Universidade Católica de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Dermatology, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Hospital Erasto Gaertner, Curitiba, RS, Brazil" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Radiology, Universidade Federal de Pelotas, Pelotas, RS, Brazil" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1709 "Ancho" => 2508 "Tamanyo" => 265447 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical aspect. (A) Right hand - subungual ulceration on the index finger, ulcer with a callus border on the distal phalanx of the middle finger, and atrophy of the thenar region. (B) Left hand - ulceration on the distal phalanx of the index finger and decrease in the size of the phalanx; there is also a healed area on the distal phalanx of the middle finger.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">A 60-year-old female, hypertensive, type 2 diabetic patient with dyslipidemia, who worked in gastronomy, reported bilateral paresthesia in the thumb, index and middle fingers associated with nocturnal pain, which had started three years before. Two years before, she started to present ulcerated, bleeding, painless skin lesions on the second and third fingers, whereas on the third finger of the left hand, she had a healed lesion (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>A and B). The patient did not have any other skin lesions or other signs suggestive of leprosy, such as neural thickening, or loss of strength in other muscle groups. She also had hypoesthesia in these fingers, reporting no pain from professional injuries.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0010" class="elsevierStylePara elsevierViewall">Neurological examination showed that Tinel’s sign was present, as well as pain on wrist flexion. Electroneuromyography showed severe sensorimotor axonal neuropathy of the median nerve, which affected its distal segment, with an absence of potential in the nerve conduction test. X-rays of the hands showed osteolysis of the distal phalanx of the index fingers. A wrist magnetic resonance imaging showed bilateral thickening of the median nerve in the retinaculum (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>A and B), with normal thickness outside this region (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>C), whereas the ulnar nerves showed a normal appearance.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><span id="sec1005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect1005">What’s your diagnosis?</span><p id="par0015" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a)</span><p id="par0020" class="elsevierStylePara elsevierViewall">Leprosy</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b)</span><p id="par0025" class="elsevierStylePara elsevierViewall">Diabetic neuropathy</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">c)</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ulcerative carpal tunnel syndrome</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">d)</span><p id="par0035" class="elsevierStylePara elsevierViewall">Dermatitis artefacta</p></li></ul></p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">Carpal tunnel syndrome (CTS) is a focal mononeuropathy caused by compression of the median nerve as it goes through the osteofibrous carpal tunnel. In the case reported herein, the nerve measured 18.7 mm<span class="elsevierStyleSup">2</span> in the left retinaculum and 22.1 mm<span class="elsevierStyleSup">2</span> in the right one, with normal size being up to 15 mm<span class="elsevierStyleSup">2</span>; measurements above 19 mm<span class="elsevierStyleSup">2</span> are considered a severe form of the disease.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">The idiopathic form of CTS occurs more often in women aged between 40 and 60 years, and in half of the cases it is bilateral,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> similar to the case described herein.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Secondary forms are caused by trauma, such as dislocation of the carpal bones, or by joint alterations in the wrist, such as osteoarthritis or inflammatory arthritis.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Cutaneous involvement in CTS is rare, having been described as an ulcerative-mutilating form in 1979 by Bouvier,<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> with some reports in the dermatological literature,<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> which are generally described as ulcerative or ulcerative-mutilating forms.</p><p id="par0060" class="elsevierStylePara elsevierViewall">There is a Portuguese report of nine cases in a retrospective study,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> confirmed by electromyography. All of them started with paresthesia in the second and third fingers and one case had nocturnal pain. All radiographed cases (one-third) had osteolysis of the distal phalanges. Seven cases (77%) had ulcerations on the second and third fingers, also similar to the case described herein, and two cases had ulceration in only one finger.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The lesions observed in this patient are characteristic of peripheral neuropathy, with a clear background and callused edges and without pain, probably aggravated by the patient’s professional activity. CTS should be suspected whenever there is involvement restricted to the second and third fingers, and the thumb is usually spared, as it has combined innervation of the radial nerve.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">It is relevant in dermatology to know about this disease, given the important differential diagnosis with leprosy (although it cannot be completely ruled out), so these cases can be referred for orthopedic evaluation and treatment, which can be conservative or surgical, with retinaculotomy, which gave good results in this patient..<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Financial support</span><p id="par0075" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Authors’ contributions</span><p id="par0080" class="elsevierStylePara elsevierViewall">Hiram Larangeira de Almeida Jr.: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0085" class="elsevierStylePara elsevierViewall">Fernanda Pinto Garcia: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0090" class="elsevierStylePara elsevierViewall">Laura de Moraes Gomes: Approval of the final version of the manuscript; drafting and editing of the manuscript; collection, analysis and interpretation of data; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0095" class="elsevierStylePara elsevierViewall">Antônia Larangeira de Almeida: Approval of the final version of the manuscript; design and planning of the study; drafting and editing of the manuscript; collection, analysis and interpretation of data; critical review of the literature; critical review of the manuscript.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Conflicts of interest</span><p id="par0100" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:2 [ "identificador" => "sec1005" "titulo" => "What’s your diagnosis?" ] 1 => array:2 [ "identificador" => "sec0005" "titulo" => "Discussion" ] 2 => array:2 [ "identificador" => "sec0010" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0015" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2021-12-21" "fechaAceptado" => "2022-03-20" "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Study conducted at the Liga de Dermatologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil.</p>" ] ] "multimedia" => array:2 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1709 "Ancho" => 2508 "Tamanyo" => 265447 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Clinical aspect. (A) Right hand - subungual ulceration on the index finger, ulcer with a callus border on the distal phalanx of the middle finger, and atrophy of the thenar region. (B) Left hand - ulceration on the distal phalanx of the index finger and decrease in the size of the phalanx; there is also a healed area on the distal phalanx of the middle finger.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1679 "Ancho" => 2925 "Tamanyo" => 300432 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Magnetic resonance imaging of the right wrist. (A) Sagittal view showing thickening of the median nerve (arrows). (B) Axial view showing thickening of the median nerve in the carpal tunnel (arrows). (C) Nerve showing normal thickness outside the carpal tunnel (arrow).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MRI criteria for diagnosis and predicting severity of carpal tunnel syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.W.H. Ng" 1 => "J.F. Griffith" 2 => "C.S.L. Tong" 3 => "E.K.C. Law" 4 => "W.L. Tse" 5 => "C.W.Y. 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