Supracubital perineurioma misdiagnosed as carpal tunnel syndrome: case report
© Saft et al; licensee BioMed Central Ltd. 2004
Received: 10 September 2004
Accepted: 21 November 2004
Published: 21 November 2004
Perineuriomas have been defined as tumorous lesions of the peripheral nerves which derive from perineurial cell proliferation and may be associated with abnormalities on chromosome 22.
Three years after a painful cubital vein procaine injection, a 33 year-old man developed a median nerve lesion, initially diagnosed as carpal tunnel syndrome. Symptoms progressed despite appropriate surgery. Clinical and electrophysiological re-evaluation revealed a fusiform mass at the distal upper arm, confirmed by MRI. Immunohistochemical studies classified the tumor as a mixed perineurioma and neuroma.
Perineurioma mixed with neuroma may potentially caused by the previous trauma or cytotoxic effects of procaine.
In the past years, there has been much confusion concerning the definition of the entity of rare focal lesions of the peripheral nerves since terms such as perineurioma, localized hypertrophic neuropathy, or hypertrophic neuritis have been used as synonyms [1–5]. According to the revised World Health Organization classification of tumors of the nervous system, however, perineuriomas have been defined as tumorous lesions of the peripheral nerves which derive from perineurial cell proliferation. They show strong immunoreactivity for the epithelial membrane antigen and may be associated with abnormalities on chromosome 22 [6–9].
In contrast, localized hypertrophic neuropathy has been defined as a distinct entity which is comprised of Schwann cell-onion-bulb formations, immunohistochemically stains strongly for protein S100, and is epithelial membrane antigen negative [9–11]. Localized hypertrophic neuropathy may be caused by a non-neoplastic undefined stimulus [12, 13].
Three years after a cubital procaine-HCL 0.05% injection had caused acute severe local pain radiating to his forearm and wrist, a 33-year old man complained about pain in his right hand. Two months later, he also suffered from numbness in the distribution of the right median nerve and wasting of thenar muscles. Furthermore a muscular atrophy in his right forearm was noted. Nerve conduction studies showed an increased distal latency in the median nerve, a very low thenar compound muscle action potential on median nerve stimulation, a reduced sensory conduction velocity of 39 m/s in the median nerve on thumb stimulation and no sensory nerve action potential on stimulation of the 2nd and 3rd fingers. Electromyography of the right biceps brachii muscle was normal. In the fibrillations, an increased duration and amplitude of motor unit potentials and reduced recruitment pattern were found in the right abductor pollicis brevis muscle. Forearm muscles were not investigated. A carpal tunnel syndrome was diagnosed and treated by surgery.
Ten months later the patient was admitted to our department because of persistence of his symptoms. Nerve conduction studies showed no response over the thenar muscle on median nerve stimulation at the wrist and elbow. Fibrillations and sparse motor unit potentials with increased duration and amplitude (up to 10 mV) were found in flexor digitorum superficialis muscle, in contrast to the normal Electromyography-findings of the right flexor carpi ulnaris. On median nerve stimulation at the elbow a low compound muscle action potential with an increased distal latency was recorded over flexor digitorum superficialis muscle in the right side (right: amplitude 1 mV, latency 9.0 ms, left: amplitude 7 mV, latency 3.2 ms). No sensory nerve action potential was recorded at the wrist on stimulation of the 1st, 2nd or 3rd finger. Somatosensory evoked potentials of the left median and right radial and ulnar nerve were normal. No potential was recorded at Erb's point in the supraclavicular fossa, at the sixth and second cervical vertebra and the contralateral cortex on median nerve stimulation on the right.
The tumour was diagnosed as perineurioma and additional neuroma by histopathology. On clinical follow-up four years later a partial recovery of forearm muscle strength could be noted and the patient was free from pain.
Carpal tunnel syndrome was falsely diagnosed in this case because of the increased distal latency in the median nerve, although during the first investigation an atrophy of the forearm muscle had already been noticed. Measurement of the median nerve latency to the atrophic flexor digitorum superficialis muscle would have disclosed the site of the lesion at that time.
Morphological and immunohistochemical studies classified the lesion as a mixed tumorous lesion with perineurioma and components of neuroma.
Neuromas are benign non-neoplastic lesions of the peripheral nerves which develop after disconnection of a nerve or a single fascicle. The history of severe pain with radiation to forearm and wrist immediately after procaine injection indicates that mechanical trauma by the needle and/or toxic effects of the local anesthetic may have caused nerve damage .
In perineuriomas, the underlying etiology still remains unclear. It has been recently suggested that perineuriomas are clonal neoplasms which may be associated with abnormalities on chromosome 22 . In our case, however, hyperplastic reaction to the preceding nerve damage by trauma or toxic effect may have contributed to the pathogenesis of perineurioma and neuroma-like components, similar to mechanisms supposed to cause localized hypertrophic neuropathy [10, 13]. Strong immunoreactivity for epithelial membrane antigen and virtually negative staining for S-100 unequivocally characterized the patient's tumor as a perineurioma and excluded localized hypertrophic neuropathy.
Perineurioma and localized hypertrophic neuropathy are characterized clinically by slowly progressive motor mononeuropathy without significant pain or numbness [2, 10, 15]. Neuromas, however, are painful. Pain and numbness in our patient were possibly caused by the neuroma-like component of the tumor.
We gratefully acknowledge the patient for his participation and consent for the publication of study.
- Erlandson RA: The enigmatic perineurial cell and its participation in tumors and in tumorlike entities. Ultrastruct Pathol. 1991, 15: 335-351.View ArticlePubMedGoogle Scholar
- Heilbrun ME, Tsuruda JS, Townsend JJ, Heilbrun MP: Intraneural perineurioma of the common peroneal nerve. Case report and review of the literature. J Neurosurg. 2001, 94: 811-815.View ArticlePubMedGoogle Scholar
- Mitsumoto H, Estes ML, Wilbourn AJ, Culver JE: Perineurial cell hypertrophic mononeuropathy manifesting as carpal tunnel syndrome. Muscle Nerve. 1992, 15: 1364-1368.View ArticlePubMedGoogle Scholar
- Sciacco M, Scarpini E, Baron PL, Doronzo R, Moggio M, Passerini D, Scarlato G: Sural nerve immunoreactivity for nerve growth factor receptor in a case of localized hypertrophic neuropathy. Acta Neuropathol (Berl). 1992, 83: 547-553. 10.1007/BF00310035.View ArticleGoogle Scholar
- Stanton C, Perentes E, Phillips L, VandenBerg SR: The immunohistochemical demonstration of early perineurial change in the development of localized hypertrophic neuropathy. Hum Pathol. 1988, 19: 1455-1457.View ArticlePubMedGoogle Scholar
- Emory TS, Scheithauer BW, Hirose T, Wood M, Onofrio BM, Jenkins RB: Intraneural perineurioma. A clonal neoplasm associated with abnormalities of chromosome 22. Am J Clin Pathol. 1995, 103: 696-704.View ArticlePubMedGoogle Scholar
- Giannini C, Scheithauer BW, Jenkins RB, Erlandson RA, Perry A, Borell TJ, Hoda RS, Woodruff JM: Soft-tissue perineurioma. Evidence for an abnormality of chromosome 22, criteria for diagnosis, and review of the literature. Am J Surg Pathol. 1997, 21: 164-173. 10.1097/00000478-199702000-00005.View ArticlePubMedGoogle Scholar
- Kleihues P, Louis DN, Scheithauer BW, Rorke LB, Reifenberger G, Burger PC, Cavenee WK: The WHO classification of tumors of the nervous system. J Neuropathol Exp Neurol. 2002, 61: 215-225.View ArticlePubMedGoogle Scholar
- Tsang WY, Chan JK, Chow LT, Tse CC: Perineurioma: an uncommon soft tissue neoplasm distinct from localized hypertrophic neuropathy and neurofibroma. Am J Surg Pathol. 1992, 16: 756-763.View ArticlePubMedGoogle Scholar
- Lantos PL, Louis DN, Rosenblum MK, Kleihues P: Tumours of the nervous system. In Greenfield's Neuropathology. Edited by: Graham DI, Lantos PL. 2002, Arnold, 2: 904-905. 8Google Scholar
- Thomas PK, Landon NN, King RHM: Diseases of the peripheral nerves. In Greenfield's Neuropathology. Edited by: Graham DI, Lantos PL. 1997, Arnold, 2: 410-412. 605, 7Google Scholar
- Johnson PC, Kline DG: Localized hypertrophic neuropathy: possible focal perineurial barrier defect. Acta Neuropathol (Berl). 1989, 77: 514-518.View ArticleGoogle Scholar
- Phillips LH, Persing JA, Vandenberg SR: Electrophysiological findings in localized hypertrophic mononeuropathy. Muscle Nerve. 1991, 14: 335-341.View ArticlePubMedGoogle Scholar
- Powell HC, Kalichman MW, Garrett RS, Myers RR: Selective vulnerability of unmyelinated fiber Schwann cells in nerves exposed to local anesthetics. Lab Invest. 1988, 59: 271-280.PubMedGoogle Scholar
- Mitsumoto H, Wilbourn AJ, Goren H: Perineurioma as the cause of localized hypertrophic neuropathy. Muscle Nerve. 1980, 3: 403-412.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2377/4/19/prepub