Blue Rubber-Bleb Nevus Syndrome: Report of a Case Associated with Osteoid Osteomas

Blue rubber blister nevus syndrome: A case report

BACKGROUND

Blue rubber blister nevus syndrome (BRBNS) is a congenital, rare disease characterized by venous malformations of the skin and internal organs, affecting all systems throughout the body. The pathogenesis is unknown. There is no consensus on the treatment of BRBNS. Most of the previously reported cases were mild to moderate with a good prognosis, and this case was a critically ill patient with severe gastrointestinal hemorrhage, disseminated intravascular coagulation (DIC), and severe joint fusion that was different from previously reported cases.

CASE SUMMARY

An 18-year-old man with early onset of BRBNS in early childhood is reported. He presented with recurrent melena and underwent malformed phlebectomy and partial jejunectomy and ileal resection. The patient had melena before and after surgery. After active treatment, the patient's gastrointestinal bleeding improved. This was a case of atypical BRBNS with severe gastrointestinal bleeding and severe joint fusion, which should be differentiated from other serious joint lesions and provide clinicians with better understanding of this rare disease.

CONCLUSION

This case of critical BRBNS with gastrointestinal hemorrhage, DIC and severe joint fusion provides further understanding of this rare disease.

Orbital Hemangioma in Bean Syndrome: The Lure of the Red Herring

BACKGROUND

Bean syndrome (BS) is a rare congenital low-flow angiomatosis affecting multiple organ systems. About 200 cases with heterogeneous clinical presentation have been reported worldwide. The exact etiopathology is still not known. Most reported cases have occurred sporadically, although autosomal dominant inheritance has been suggested. BS predominantly presents with characteristic multifocal mucocutaneous lesions and often leads to refractory anemia caused by occult blood loss from the alimentary tract. Apart from the mucocutaneous and gastrointestinal tract involvement, this syndrome may rarely affect the central nervous system in the form of multiple venous anomalies. Patients often approach a dermatologist or gastroenterologist for treatment and this entity is usually less known among neurosurgeons. To the best of our knowledge, only 3 cases of sinus pericranii and 12 cases with orbital hemangioma as a presenting feature in BS have been reported.

CASE DESCRIPTION

Keeping neurosurgical management of this rare entity in mind, we discuss a case of a young female who presented with congenital naso-orbital swelling with a history of multiple-stage embolization and surgical excision of the orbital mass in her childhood. Now, she presented with recurrent swelling involving the right side of the forehead for cosmetic concerns and was subsequently diagnosed to have BS at 23 years of age.

CONCLUSIONS

Blue rubber bleb nevus syndrome is a lesser known entity among neurosurgeons that requires a high index of clinical suspicion for diagnosis. Red herrings, such as in our case, must prompt a search for characteristic mucocutaneous lesions and other associated lesions of blue rubber bleb nevus syndrome. A timely diagnosis may improve the quality of life and help avoid life-threatening complications.

Dynamic contrast-enhanced MR imaging in osteoid osteoma: relationships with clinical and CT characteristics

OBJECTIVE

To correlate dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) features to clinical and computed tomography (CT) morphological features of osteoid osteoma (OO).

MATERIALS AND METHODS

Our institutional review board approved this retrospective study, waiving the need for informed consent. We included the 102 patients treated with interstitial laser ablation for histologically documented OO at our institution in 2008-2013. DCE-MRI variables were the time-enhancement pattern and rising slope (Slope_rise) and CT variables were the bone and segment involved (OO_bone and OO_segment, respectively), OO location relative to the native cortex (OO_cortex), nidus surface area, vessel sign, and largest neighboring-vessel diameter (Dmax_vessel). Descriptive statistics and correlations linking DCE-MRI findings to clinical and CT characteristics were computed.

RESULTS

DCE-MRI showed early arterial peak enhancement in 95 (93%) cases, with a mean Slope_rise of 9.30 ± 8.10. CT visualized a vessel sign in 84 (82%) cases with a mean Dmax_vessel of 1.10 ± 0.60 mm. By univariate analysis, Slope_rise correlated significantly with pain duration and Dmax_vessel (r = 0.30, P = 0.003; and r = 0.22, P = 0.03; respectively). Analysis of variance showed that Slope_rise correlated significantly with OO_bone (P < 0.001), with a steeper slope for OOs located in short or flat bones.

CONCLUSION

This study suggests more abundant vascularization of OOs with long-lasting pain and location on short or flat bones.

Histological study of osteoid osteoma's blood supply

The osteoid osteoma is a painful lesion with a special predilection for the femur and tibia of young patients. Although the lesion has been described as richly innervated, its vascular supply has not been critically appraised to date in the pathology literature. To this end, we have undertaken a morphological study of 16 archival cases of osteoid osteoma, focusing primarily on the patterns of vascularization, utilizing traditional histological and immunohistochemical approaches. The study demonstrated that a prominent arterial and arteriolar blood supply was a constant finding within the various zones of soft tissues, skeletal muscle, and bone surrounding the nidus. It also showed that the caliber of the vessels underwent gradual attenuation throughout their centripetal course toward the nidus, where the vessels lost their muscularis as they merged into the capillary network of the nidus. Immunostaining with antibodies to neurofilament and S100 proteins revealed a pattern of innervation that was overall less exuberant than that described in some reports and that was virtually absent from the nidus. Taken together with data reported in the radiological literature, our findings lead us to wonder whether the osteoid osteoma may represent a response to the local stimulation of bony tissue by a primarily aberrant vasculature, a hypothesis that warrants further elucidation using state-of-the-art imaging approaches.