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After 30 minutes of surgery, a woman in Armenia can knit without pain for the first time in over 40 years, thanks to teamwork by a group of specialists who removed a rare glomus tumor from under her fingernail, according to a new case study.

Dr Mikhail Dziadzko

“The cause of a patient’s pain isn’t always obvious. In a puzzling case such as this one involving a glomus tumor, which is rare, a multidisciplinary collaboration by various specialists will almost always help solve the problem,” Mikhail Dziadzko, diprolene in canada MD, PhD, a pain specialist and anesthesiologist at Hospices Civils de Lyon, in Lyon, France, told Medscape Medical News in an email.

“This is an excellent example of the efficiency of multidisciplinary collaboration,” he added. “The presence of radiologists, anesthesiologists, and surgeons at the same place and time allowed for immediate decision-making. A systematic approach, multidisciplinary management and discussion, where different specialists were readily available, made this diagnosis possible.”

Dziadzko and his colleagues reported the case in an online poster at Euroanaesthesia, the annual meeting of the European Society of Anaesthesiology and Intensive Care, which was held in Milan, Italy.

A Longtime Mystery

For over 40 years, the 58-year-old right-handed woman had experienced severe shooting and burning pain in her right index finger when she knit and during cold weather. The patient also felt pins and needles in her right lower arm and shoulder. She had no history of injury to that finger.

After having received multiple misdiagnoses and treatments for various conditions, including Reynaud’s disease and neuroma, the woman visited a pain clinic in Yerevan, Armenia, in 2021, where a multidisciplinary team of Armenian and French specialists diagnosed and treated her appropriately.

Glomus tumors “are benign and uncommon mesenchymal neoplasms, presenting >2% of all soft tissue tumors, with often hand subungual location (75%),” the authors write in the abstract of the study. “Usually managed by hand and plastic surgeons, these patients may, however, present a puzzle for other specialists.”

The woman’s pain sensitivity was normal, but applying pressure to the affected nail, stroking the edge of the nail, putting ice on the affected hand, and holding the hand downward generated the same pain she felt when knitting. Raising and keeping her arm up stopped the pain almost instantly.

A small area of her nail was slightly bulbous, darker than the surrounding nail, and slightly purple.

Glomus tumor.

An x-ray showed slight scalloping of the distal phalanx under the nail. Ultrasound showed a 4 x 5 mm solitary hypoechoic, less vascularized lesion, with adjacent bone defect. These findings suggested that the woman’s decades-long pain was caused by a slow-growing glomus tumor.

A pain specialist, a bone and joint infection specialist, a microbiologist, a neurologist, a radiologist, and a hand surgeon were among those involved in her care. In a 30-minute procedure conducted under local anesthetic in a hand surgery department, an Armenian hand surgery team removed the tumor. On histology, the mass was confirmed to be a benign glomus tumor.

The patient received a short course of standard painkillers, and there were no complications. At 3 months, the woman could go outdoors in the cold and also knit, free of pain.

A Classical Presentation

Ankit Mangla, MD, a sarcoma and skin cancer specialist at the Seidman Cancer Center at University Hospitals in Cleveland, Ohio, agreed that collaborating with colleagues in various specialties helps providers in rare cases such as this one.

“The patient had a classical presentation of a glomus tumor, which is four times more common in women than in men: a middle-aged woman with a long-standing finger lesion, sensitivity to cold, and positive diagnostic tests,” Mangla, who was not involved in the study, said in an email.

“But she was not diagnosed all those years due to lack of clinical suspicion. Plastic surgeons, orthopedic oncologists, and oncologists who specialize in soft tissue and bone cancers are more aware of this condition because we see and discuss it in clinics and on tumor boards.

“This case highlights the fact that, if a disease or condition is chronic, patients must be referred to academic centers and to specialists,” he said. “Specialists are more geared towards thinking of rare diagnoses — what we call ‘zebras.’ “

Mangla explained that glomus tumors arise from glomus bodies — neuromyoarterial cells in the reticular layer of the dermis that help regulate body temperature — although what causes them to arise is unclear.

“Since the main job of glomus bodies is to regulate temperature, they are primarily located in the fingertips and nail beds. Hence, these are the most common locations of the tumors,” he added.

“Surgery is the mainstay of treatment,” he noted. “Recurrence is not common unless the tumor is not completely resected. In the very rare instance of a glomus tumor becoming malignant and metastasizing, case reports have consistently reported a very rapid and fatal course.”

The study was not funded. Dziadzko and Mangla report no relevant financial relationships.

Euroanaesthesia, the Annual Meeting of the European Society of Anaesthesiology and Intensive Care (ESAIC): Abstract 08AP01-07. Presented virtually June 5, 2022.

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