CASE REPORT
Patient
Identity :
1. Name: Mr.I
2.
Age:
33 years old
3.
Gender:
Male
4.
Religion:
Islam
5.
Address:
Gempol
6.
Medical
Record : 046748
7.
Date
of entry: 06 May 2013
8. Check-out date: 10 May 2013
Anamnesis (Autoanamnesa)
- The main complaint: There is a lump in the right arm
- Additional Complaints: -
- Disease History :
Patients came to surgery Arjawinangun Hospital
with a bump on a complaint right arm
were admitted since a few weeks ago .The lump more and
more enlarged, and no pain. The
lump settled, and can be driven. Denied
a history of trauma.
Previously History of Disease: -
Other Disease History:
a. Diabetes Mellitus (-) d. Heart Disease (-)
b. Hypertension
(-) e. Lung Disease (-)
c. Asthma
(-) f. Liver disease (-)
Family history of disease
In no patient families who suffer from such diseases.
PHYSICAL
EXAMINATION
General Status:
General condition : Good Looks
Awareness : Compos
mentis
Vital Signs :
BP : 110/80 mmHg
P : 80 x / min
RR : 20 x / min
T : 36.2 ° C
Weight : + / - 58 kg
Head:
Form :
Normocephal
Hair :
Black, not easy to pull.
Eyes
Lid : edema
- / -
Conjunctiva : anemis - / -
Sclera :
jaundice - / -
Arcus senilis : - / -
Pupil : Round,
isokor
Light reflex : + / +
Cataracts : - / -
Ear
Shape : Symmetrical
Liang : Field
Mucosa :
Not hyperemia
Cerumen : No
Membrane Timpani :
intact
Nose
Shape :
Symmetrical
Septal deviation :
No
Secretions :
No
Concha :
Not hyperemia
Mouth
Lips :
lip mucosa moist, not cyanosis
Tongue :
Not Dirty
Tonsils : T1-T1
calm
Pharyngeal mucosa :
Not hyperemia
Neck
LND : no
enlargement
Thyroid gland : no
enlargement
JVP : not
examined
Thoracic
1. Lungs
Inspection : respiratory
movement of both hemithorax symmetric
Palpation : vocal
and tactile fremitus right = left
Percussion :
Sonor all lung fields
Auscultation : breath
sounds vesikler, rh - / -, wh - / -
2. Heart
Inspection : Ictus
cordis is not visible
Palpation :
Ictus cordis palpable between the ribs on the left midclavicular line
V
Percussion : Limit
the heart within normal limits
Auscultation : I-II
heart sound pure, murmur (-), gallop (-)
Abdomen
Inspection : Flat,
symmetrical
Palpation :
Supple, tenderness (-), off pain (-)
Percussion :
across the field abdomen Tymphani
Auscultation : Bowel
(+) within normal limits
Extremity
- Top
Akral :
Warm
Cyanosis : Not
cyanosis
Perfusion : Good
- Bottom
Akral :
Warm
Cyanosis : Not
cyanosis
Perfusion : Good
Local Status
Region : Brachialis
dextra
Inspection : looks a
lump
Palpation : palpable lumps,
mobile, and there is no tenderness
Examination Support
Laboratory (CBC): -
Radiology (Photo Thorax): -
Different Diagnosis
1. Hemangioma
2. Soft Tissue Tumors: lipoma
Diagnosis
Hemangioma
Management
Operative
Prognosis
Quo ad Vitam: dubia ad bonam
Quo ad Functionam: dubia ad bonam
Quo ad sanationam: dubia ad bonam
HEMANGIOMA
1. Definition, Etiology, and Pathophysiology
Hemangioma
is a benign tumor of blood vessels that proliferate cells vascular endothelium followed by
continuous involution led to disorder is the result of anomalous development of the
vascular plexus. Hemangiomas are common in infants of 1.1% to 2.6% and the children are 10% to 12%. These lesions are more common in
females than males with a ratio of 3:1. Hemangioma
lesions are not present at birth.
They manifest in the first month of life,
suggesting a rapid proliferation phase
and an perfect slowly towards involusion. Lesions, Until now hemangioma etiology remains unclear,
there are many hypotheses that expressed about the etiology of
hemangiomas. However, the process
of angiogenesis plays a role important. Cytokines, such as basic fibroblast growth
factor (bFGF) and vascular endothelial growth factor (VEGF) has been shown to be associated
with the process of angiogenesis. Increased
levels of factor. The angiogenesis and
or reduced levels of angiogenesis inhibitors such as gamma interferon (ÎŽ-IF), tumor necrosis
factor-beta (TNF-β) and transforming growth factor-beta (TGF-β) is suspected to be the cause
of hemangioma. There are several hypotheses put forward regarding the
pathophysiology of hemangioma,of them stated that this process begins with a
proliferation of cells endothelium
is not regular and the travel time to be organized by forming lobe-shaped blood vessels with lumen
containing blood cells Hypothesis
of Takahashi stated that in the last trimester of pregnancy, in the immature fetal endothelium is
formed along with the immature pericyte also
have the ability to perform limited
proliferation begins at the age of 8 months to
The first 18 months after birth the life span at age thus formed
hemangioma.
During the
proliferative activity of endothelium occurs influx of a number of mast cells
and tissue inhibitors of
metalloproteinases (TIMP or tissue growth inhibitor). Proliferation endothelium return to normal after
stopping proliferation or involution phase. Largely hemangioma will undergo spontaneous
involution at the age of 5-7 years or until the age of 10-12 years.
2.
Classification and Clinical Features
Several classifications have been used to classify the various forms of hemangiomas, but not entirely
explained in detail. In 1982
Mulliken and Glowacki introduced
a classification scheme based on physical examination hemangioma, nature clinic and provider of lesions. They divide the tumor vasoformatif into two categories, namely hemangiomas and malformations vascular.
In general, the
experts classified hemangiomas into three types: (1) capillary hemangioma, which is composed of
capillary hemangiomas in children (nevus vasculosus, strawberry nevus), pyogenic granuloma,
and cherry-spot. (2) hemangioma cavernosum
(3) mixed hemangioma. Vascular malformations further divided
into arterial malformations, venous, capillary, and malformations
limfatic. Neville et al,
classifies a hemangioma capillary hemangioma, hemangioma juvenile, cavernous hemangioma and hemangioma
arterivenosa. Capillary hemangioma is most often found, because the color
is also called strawberry hemangiomas.
Juvenile
hemangioma is more often found in the parotid region, cavernous hemangioma generally larger in diameter and involve deeper
structures. Hemangioma arterivenosa is a situation where
there is an abnormal connection between the arteries and vena. A simple classification made by
Watson and McCarty by 1308 type of tumor blood vessels are capillary
hemangioma, hemangioma cavernous, hemangioma hipertrophic / angioblastic, recemose
hemangioma, diffuse systemic hemangioma, hemangioma metastasis (spread), vinosus nevus or
port-wine stain, and hemorrhagic telangiectasia hereditary. Lesions in almost all cases of
hemangioma occurs when the newborn and increases
in the first year. According to
Watson and McCarthy report, 85% of 1308 lesions has been formed at the end of the
first year infant age. The most
commonly affected areas are the lesions head
and neck which is about 56% of cases, while the rest can occur in six to seven skin surface tubuh.The clinical
features vary according to the type hemangioma. Capillary hemangioma (Strawberry
nevus) appears as patches of bright red, tense and lobular-shaped,demarcated,
which can occur in various places on the body. Unlike the capillary hemangioma, hemangioma lesions in the corpora cavernosa not
demarcated can be erythematous macular or nodes that are red to purple. When pressed deflated and will quickly swell again if released.
The clinical features
of hemangiomas mixture is a combination of capillary types and
species cavernosa. Tumor lesions in the form of soft, bluish red
color on development can provide an overview keratotic and
verukosa. Largely found in the lower extremities and usually unilateral.
3.
Oral
Manifestations and Differential Diagnosis
Hemangiomas that occur in
the soft tissues of the mouth with the same shape hemangioma of the skin. Lesions are usually shaped lesions appear flat or bulging of the mucosa, dark red or bluish red
and not demarcated.
Areas that are often affected are the lips,
tongue, buccal mucosa, and palate. Hemangioma
tumor often followed by trauma and infection
continues ulcerated and the second. In
the oral cavity, bones and muscles can also be affected by the hemangioma, as mucosa and skin. Intraosseous hemangioma incidence
varies the 0,5 - 1,0% of the entire intraosseous
neoplasm. Facial bones most often
affected are the mandible, maxilla,and nasal bones. Intraosseous lesions more often on the
mandible than the maxilla ie 2:1. Intramuscular hemangioma in the oral cavity is
most often the masseter muscle, with
approximately 5% of the whole incident hemangioma intramuskular Determination
diagnosis of hemangioma seen from patient history and clinical examination appropriate. In clinical diagnosis of hemangioma is not difficult, especially on the
typical lesions. The differential
diagnosis of hemangioma is the other skin tumor that is limfangioma, higroma, lipoma, neurofibroma,
congenital vascular malformations, venous stars, and hereditary Hemorrhagic telangiectasias
(Osler-Weber-Rendu Syndrome) .
4.
Treatment
Hemangioma
There are various types of hemangioma
therapy with the advantages and disadvantages of each. In general, treatment of hemangiomas
can be divided into conservative therapy (observation) where naturally hemangioma lesions
will undergo changes in the months first,
then reaches a maximum and then a large spontaneous regression occurs around
age 12 months. Regression of lesions continue to hold
until the age of five years. In
addition to the treatment conservative,
hemangioma lesions can also be done actively namely surgery, radiation, the use
of corticosteroids, and, elektrokoagulasi.Treatment with surgery has evolved,
some of which is excision, laser,
cryo surgery, and sclerotherapy. Excision
is rarely done because hemangiomas
tend to bleed. Excision is done
by combination with sclerotherapy
to reduce bleeding. The use of lasers has been widely used to treat hemangiomas. There are several laser types such as: yellow light
lasers, Nd: YAG laser, argon laser, laser Carbondioxide.
Using Argon laser surgery has been known to give better results Indications to do surgery are:
1. There is a sign - a sign of growing too fast, for example, in
some weeks the lesions became 3-4 times larger.
2. Hemangioma is large with thrombocytopenia.
3. No spontaneous regression, for example, did not occur diminution after
6-7 years.
Treatment with radiation in the year - last year was a lot left out
because irradiation resulted in less well in children - children whose
bone growth is still active, complications
of treatment in the form of malignancy that occurs in the long term,
and cause fibrosis of the skin that is healthy to be difficult when we
need an act.
Treatment with surgical cryo is cold applications using liquid
nitrogen.
Whereas treatment with corticosteroids is done for this type of hemangioma
strawberry, cavernosa, and mix. Corticosteroids used is prednisone,
which
resulted in hemangioma held regression.
References
1.
R, Syamsuhidajat, Wim de Jong;
Buku Ajar Ilmu Bedah : Jakarta EGC, 1997, hal 300
2.
Schwartz. Principles of
Surgery. Ed. 7th. The McGraw-Hills Company, 1999
3. Dunphy
Englebert J, MD, Way W Lawrence, MD, Current Surgical Diagnosis &
Treatment.
4. Marchuk,
DA, 2001, Pathogenesis of Hemangioma, Journal Clinical Investigations, volume 107,USA
5. Stringel,
G, 1980, Hemangiomas and Lymphangiomas, dalam Ashcraft, KW, Pediatric Surgery, edisi 3, W.B. Saunders
Company, Philadelphia, New York
6.
www.nlm.nih.gov/medlineplus/ency/article
7. www.webmd.com/skin-problems-and-treatments
