Intravascular fasciitis of the forearm vein: A case report with immunohistochemical characterization

Intravascular fasciitis is a very unusual variant of nodular fasciitis. A unique case of this lesion occurring in the proximal portion of the superficial vein of the forearm in an otherwise healthy 26-year-old man is reported. The intravascular polypoid lesion grew longitudinally along the vascular lumen, was loosely attached to the intimal layer, and was partly anchored beyond the internal elastic lamina into the medial smooth muscle layer. However, extravascular involvement was absent. The histological features were identical to those observed in ordinary cellular nodular fasciitis. Because of its myofibroblastic phenotype exhibited by highly proliferative spindle cells, certain intimomedial myofibroblasts are thought to be the indigenous source of this unique fibroproliferative lesion. Unless the diagnosis of intravascular fasciitis is considered and appropriate differential markers examined, it may be confused with other intravascular lesions, such as intravascular leiomyoma, intravenous pyogenic granuloma, organized thrombus and, even, fibromuscular dysplasia if it arises in the arteries. A simple excision is considered curable. Even so, two recurrent cases have been documented to date.     

Ossifying fasciitis

A case of ossifying fasciitis occurring in the left femoral region of a 57-year-old male is reported. The patient complained of pain in his left lower extremity which was the site of previous catheterization. During a left femoropopliteal by-pass, a firm and cylindric mass measuring 5 x 3 x 2.5 cm in size was found and extracted from the left groin. Histologically, a reactional lymph node and an irregularly shaped lesion extended into the perinodal fat tissue which is composed of proliferating fibroblasts with occasional mitotic activity. Within this fibroblastic proliferation, immature woven bone composed of osteoid with calcification and chondroid differentiation were seen. Metaplastic bone is an uncommon finding in cases of nodular fasciitis, parosteal fasciitis, cranial fasciitis and florid reactive periostitis. Ossifying fasciitis is known as an uncommon variant of nodular fasciitis. It is an uncommon post-traumatic benign lesion of subcutaneous tissue with an unclear etiology of ossification which is neither related with a bony structure nor contains any muscle tissue. This lesion has been reported only once previously, in the femoral region after a trauma history of catheterization.     

Molecular characterization of methicillin-resistant Staphylococcus aureus from a fatal case of necrotizing fasciitis in an extremely low-birth-weight infant

Necrotizing fasciitis due to methicillin-resistant Staphylococcus aureus (MRSA) is an uncommon but life-threatening infection, and has mainly been reported as occurring in adults and the elderly. Recently, infant cases involving Panton–Valentine leukocidin (PVL)-positive community-acquired MRSA have been noted. Here, a case of fatal necrotizing fasciitis with sepsis and disseminated intravascular coagulation in an extremely low-birthweight infant is described. The causative agent was the hospital-acquired MRSA New York/Japan clone carrying the spa variant gene and nine staphylococcal enterotoxin (SE) genes. These data suggest that a high-level combination of SEs and other virulence factors, but not PVL, could contribute to the pathogenesis of fatal necrotizing fasciitis.     

Nodular fasciitis of the male breast: a case report

A case of nodular fasciitis is reported that involved the breast parenchyma of a 40-year-old man. The differential diagnosis of nodular fasciitis in the male breast mainly includes fibromatosis and myofibroblastoma. However, other benign and malignant spindle cell lesions of the breast, such as pseudoangiomatous stromal hyperplasia and especially spindle cell metaplastic carcinoma and fibrosarcoma, may enter the differential. The classic histomorphologic features and immunohistochemical findings are helpful in arriving at the correct diagnosis. The patient underwent a total excision of the lesion and is free of disease after 14 months. To our knowledge, this is the first reported case of a lesion of this type in the male breast.     

Intraarticular nodular fasciitis causing limitation of knee extension: A case report

We report a patient with intraarticular nodular fasciitis who developed mechanical symptoms in the knee, limiting knee extension. A 24 year-old man presented with mechanical restriction of extension and pain at maximum extension. MRI revealed an intraarticular mass within the knee joint. The mass was excised arthroscopically. Histological examination of the excised tissue led to a diagnosis of nodular fasciitis. Pain and limitation of motion of the knee disappeared from one day after surgery. No recurrence was found after 1 year. Intraarticular nodular fasciitis is rare, and although this lesion within the knee has been reported previously, it has not been associated with mechanical symptoms. This case indicates that intra-articular fasciitis should be considered in the differential diagnosis of a patient presenting with mechanical limitation of knee extension and a mass lesion inside the knee joint.     

Parosteal fasciitis of the clavicle

A rare case of parosteal fasciitis arising from the periosteum of the left clavicle in a 27-year-old woman is reported. Magnetic resonance imaging demonstrated the lesion surrounding the periosteum of the clavicle. The lesion was iso-intense with muscle on T(1)-weighted images and hyperintense on T(2)-weighted images. At surgery, the lesion was discovered to be densely adherent with the periosteum, and excised along with the periosteum. Histopathological examination revealed the proliferation of myofibroblasts in a vague storiform or short fascicular pattern. A large amount of extravasated erythrocytes, and a few lymphocytes were present in the matrix. There were some foci of abundant myxoid materials. Immunohistochemical study showed the cells to be positive for vimentin, alpha-smooth muscle actin and HHF35, but negative for desmin. There was no local recurrence at a 6 months postoperative follow up.     

Unusual “Flesh-Eating” Strain of Escherichia coli

We report an exceptional case of life-threatening Escherichia coli-induced necrotizing fasciitis. A combined host-pathogen genetic analysis explained the phenotype: the host displayed a susceptibility to intravascular coagulation, and the strain was capable of producing a necrotic toxin (cytotoxic necrotizing factor 1), showing how E. coli can be a dermonecrotic pathogen.     

Multiple metachronus proliferative fasciitis occurring in different anatomic regions: a case report and review of the literature

Proliferative fasciitis is a benign lesion that usually has a self-limited course and rarely recurs after excision. In the literature, the multifocal occurrence of PF in different anatomic sites has not been reported so far. In this report, we describe the clinical case of a 30-year-old woman with two metachronous proliferative fasciitis occurring firstly in the orbit and, after 18 months, in the forearm; we also review the available literature on this topic, outlining guidelines for therapy and the follow-up of these patients.     

Fasciitis ossificans of the breast

We report a rare case of fasciitis ossificans of the breast. A nodule of the breast was incidentally found in a 77-year-old woman without a history of trauma. The painless lesion was located 3 cm from the nipple in the lower outer quadrant of the left breast. Excisional biopsy was performed, and there has been no evidence of recurrence or metastasis for 2 years. The 1.8 cm diameter nodule was well demarcated from the adjacent tissue and located 2.5 cm beneath the skin. Histologically, the lesion was composed of uniform woven bone trabeculae with rimming of osteoblasts and fibrous stroma. At the periphery, spindle cells actively proliferated in edematous stroma, demonstrating uniform nuclei without increased chromatin, pleomorphism, or evident nucleoli. We counted 2 mitotic figures per 10 high-power fields, but no atypical forms were observed. Spindle cells were immunoreactive for vimentin and alpha-smooth muscle actin, suggesting myofibroblastic differentiation. Fasciitis ossificans is histologically identical to myositis ossificans, but tends to present no zonation phenomenon. We considered this lesion as fasciitis ossificans since it was situated at the superficial layer of the mammary gland. To avoid an unnecessarily aggressive treatment, fasciitis ossificans, a benign bone-forming nodule, needs to be considered in the differential diagnosis of breast hard tumor.     

Nodular fasciitis of the vulva: a challenging histopathologic diagnosis supported by the detection of USP6 gene rearrangement

Nodular fasciitis involving the vulva on physical examination can mimic a Bartholin gland lesion, and histologically can have overlapping features with more ominous mesenchymal pathologies. We describe a case in which a 52‐year‐old perimenopausal woman presents with a vulvar mass. After an initial biopsy and later excision, the myofibroblastic lesion was noted to have areas of differing cellularity, with compact nodule formations at the periphery. Immunohistochemical staining showed lesional cells to be positive for desmin, estrogen receptor, progesterone receptor, and smooth muscle actin, and negative for CD34, ALK‐1, myogenin, caldesmon, S100, and wide spectrum (Oscar) cytokeratin. Desmin is generally negative in this lesion type, but the positivity in this case was considered to be secondary to the origin of the myofibroblastic cells of the vulva. The morphologic pattern and immunophenotype favored a diagnosis of nodular fasciitis, however, the degree of hypercellularity and desmin positivity warranted further analysis. The diagnosis was supported with fluorescence in situ hybridization that demonstrated USP6 gene rearrangement. This highlights the necessity in certain challenging cases for ancillary molecular and/or cytogenetic analysis.     

Intravascular myopericytoma: an interesting case of a long-standing large, painful subcutaneous tumor

Myopericytoma is a benign neoplasm consisting of cells that appear to have a distinct differentiation towards presumed perivascular myoid cells. Amongst myopericytoma, an intravascular variant appears to have been reported only rarely. A 67-year-old man presented with a 15-year history of a painful, slow growing 3 × 3.5 cm sized mass in the subcutis of his right lateral thigh. Histopathological studies showed a subcutaneous mass entirely within the lumen of a vein. The tumor was composed of spindle-shaped myoid-appearing cells in a concentric arrangement, intimately associated with thin-walled vascular channels. Tumor cells were diffusely positive for smooth muscle actin, focally positive for CD34, and negative for desmin and CD31. From these findings, we diagnosed this lesion as intravascular myopericytoma. Unlike previous reports, our case showed a relatively large painful subcutaneous mass, although this tumor has an intravascular nature.     

Nodular fasciitis of the hand: a potential diagnostic pitfall in fine-needle aspiration cytopathology

Fine-needle aspiration biopsy (FNAB) is applied very uncommonly to soft tissue masses and even more infrequently to lesions of the hand. Nodular fasciitis, an uncommon pseudosarcomatous lesion of soft tissue, rarely occurs in the hand and, because of this, is not often considered in the differential diagnosis of hand masses. We report 3 cases (2 men and 1 woman; mean age, 44.3 years) of soft tissue masses of the hand, which, after clinical and radiologic evaluation, were strongly suspected by an experienced orthopedic oncologist as harboring a soft tissue sarcoma. Each patient underwent FNAB, which showed markedly hypercellular smears with overlapping, relatively isomorphic spindle cells that were mistaken cytologically as possible sarcoma in 2 cases; 1 case was considered probable nodular fasciitis. All lesions eventually were diagnosed as nodular fasciitis after thorough histologic and immunohistologic evaluation. Nodular fasciitis remains a difficult diagnosis by FNAB, particularly when it occurs in locations such as the hand.     

Fibroma of the tendon sheath. Description of a case

One case of fibroma of tendon sheath is described. This tumor is a distinct entity with a characteristic location and histological appearance. The lesion must be distinguished from giant cell tumor of tendon sheath, nodular fasciitis and fibrous histiocytoma. Recurrence rate is 24%. Local excision is the treatment of choice for primary and recurrent lesions.     

Flow cytometric study of nodular fasciitis, proliferative fasciitis, and proliferative myositis.

DNA ploidy was assessed retrospectively, using flow cytometry, in 13 nodular fasciitis (NF) lesions, three proliferative myositis (PM) lesions, one proliferative fasciitis lesion, and 12 other benign fibrous lesions (BFLs). All were diploid. In view of the large amounts of cellular debris, cell cycle analysis was possible in only seven NF lesions, three PM lesions, and six BFLs. The mean percentage of S phase did not differ markedly between the combination of NF and PM lesions (6.6%) and BFLs (7.1%); the mean percentage of G2 + M phase (5.4%) of the NF/PM lesion combination was twice as large as that of the BFLs (2.5%). No correlation was detected between the cell cycle analysis and the mitotic count, the predominant histologic type in NF lesions, or the predominant stroma in PM lesions.     

Intravascular large B-cell lymphoma presenting with mass lesions in the central nervous system: a report of five cases

We have encountered five cases of intravascular large B-cell lymphoma (IVL) presenting with central nervous system (CNS) mass lesions during their clinical course. The age of the patients ranged from 50 to 74 years and three patients were male. All of these cases histopathologically showed typical intravascular localization of the neoplastic cells in the initial biopsy specimens obtained from sites other than the CNS. Despite multiagent chemotherapy, patients suffered from single or multiple CNS mass lesions 5-44 months after the initial diagnosis of IVL, except for one case in which IVL and the CNS mass lesion were diagnosed at the same time. The subsequent biopsy and autopsy specimens obtained from the CNS mass lesions revealed diffuse infiltration of the tumor cells with perivascular spreading, but minimal or no intravascular components. Immunohistochemical analysis of intravascular tumor cells and CNS mass lesions revealed expression of CD20, CD79a, bcl-2 and negative for CD3e and Epstein-Barr virus encoded RNA. The overall features of the CNS mass lesions were very similar to or indistinguishable from those of the primary CNS lymphomas. This implies that CNS mass lesions in the IVL cases can be correctly diagnosed only by careful attention to clinical and pathological findings. Moreover, there is the possibility that some cases previously diagnosed as primary CNS lymphomas may have include IVL cases. Further investigation is needed to explore this unusual phenomenon.     

Cytological findings in nodular fasciitis

Nodular fasciitis, proliferative fasciitis, and proliferative myositis are tumorous proliferative soft tissue changes which on histological examination are quite often erroneously diagnosed as malignant neoplasms. Reported are cytological and histological findings recorded from nodular fasciitis in a man aged 34 years. The cytomorphology of nodular fasciitis is sufficiently characteristic, so that the lesion can be differentiated with certainty from malignant processes, since the cells have no features of malignancy, and the admixture of granulocytes and histiocytes in smears suggests a proliferative inflammatory process.     

Fine needle aspiration cytology of myositis ossificans

Fine needle aspiration was performed on a large soft tissue mass of the left thigh and hip region in a 27-year-old paraplegic man. Cytologic examination revealed sheets of immature fibroblasts and scattered skeletal muscle cells in various stages of degeneration compatible with myositis ossificans. This case is probably the first needle aspiration cytology of this lesion. The danger of confusing the cytology with that of a sarcoma is emphasized.     

Pseudosarcomatous changes in inflammatory pseudopolyps of the colon

The occurrence of pseudomalignant changes in biopsy specimens from two patients with ulcerative colitis and pseudopolyposis is described. One lesion was characterized by the proliferation of large ganglion cell-like cells, similar to those observed in proliferative fasciitis. Ultrastructural and immunohistochemical findings supported a fibroblastic origin. Biopsy specimens of an inflammatory pseudopolyp from the second patient showed proliferation of oval to spindle cells that were initially interpreted as a possible neoplasm. The site of origin and reactive nature of this lesion became apparent on a subsequent polypectomy specimen. Attention is called to the occurrence of pseudosarcomatous changes in inflammatory pseudopolyps of the gastrointestinal tract that may lead to an erroneous diagnosis of malignancy.     

假肉瘤性软组织病变的细针吸取细胞学

目的：总结假肉瘤性软组织病变细针吸取细胞学（ＦＮＡＣ）特点,寻求在针吸细胞学基础上与肉瘤鉴别的要点。方法：总结１０例结节性筋膜炎,１例增生性筋膜炎,１例增生性肌炎的针吸细胞学改变及临床经过。结果：假肉瘤性软组织病变的ＦＮＡＣ特点是细胞的种类、大小较多样化及多数会出现节细胞样细胞。细胞核大,核仁明显,但核的恶性特征不明显。有６例结节性筋膜炎及１例增生性肌炎临床自行消退。结论：可凭ＦＮＡＣ特点将假肉瘤     

Fatal necrotizing fasciitis due to Streptococcus pneumoniae: a case report

Necrotizing fasciitis is known to be a highly lethal infection of deep-seated subcutaneous tissue and superficial fascia. Reports of necrotizing fasciitis due to Streptococcus pneumoniae are exceedingly rare. We report a case of necrotizing fasciitis in a 62-yr-old man with liver cirrhosis and diabetes mellitus. He presented with painful swelling of left leg and right hand. On the day of admission, compartment syndrome was aggravated and the patient underwent surgical exploration. Intra-operative findings revealed necrotizing fasciitis and cultures of two blood samples and wound aspirates showed S. pneumoniae. The patient died despite debridement and proper antimicrobial treatment. To the best of our knowledge, this is the first case of fatal necrotizing fasciitis with meningitis reported in Korea. We also review and discuss the literature on pneumococcal necrotizing fasciitis.