A Rare Case of Arteriovenous Hemangioma Clinically Mimicking Pigmented Nevus

Arteriovenous hemangioma (AH) is a rare benign vascular skin lesion, which typically appears in the skin of the face and extremities and most commonly occurring on the head and neck region with appearances as single, raised, red, or violaceous papules; sometime tan papule. A case of AH clinically mimicking pigmented nevus in 19year-old woman was reported. This is the first case in Dermatology Department of Dr. M. Djamil Padang Hospital. She complained about a black pimple on the right lower arm since one month. Physical examination: there is a solitare black papule, with 0,3x0,4 mm, round shape, fine scales, well defined, regular border with irreguler surface. Histopathology findings: the lesions consist of thicked-walled and very dilated thin-walled vessels that full-filled with erythrocytes and are lined by an endothelial layer that suitable for AH. Arteriovenous hemangioma is a tumor of middle-age to elderly adults with a peak incidence in the fourth and fifth decades of life. In this case, the patient was young adult and clinically the lesion mimicking pigmented nevus.


INTRODUCTION
Arteriovenous hemangioma (AH), also known as cirsoid aneurysm or acral arteriovenous tumor, represents a benign vascular skin lesion, which typically appears in the skin of the face and extremities. 1,2It is a tumor of middle-age to elderly adults with a peak incidence in the fourth and fifth Winkelmann have confirmed the benign nature of these vascular tumors and have emphasized the acral pattern of distribution by the assignment of the name acral arteriovenous tumor. 1,2teriovenous hemangioma maybe cutaneous or mucosal.These lesions grow slowly and achieve only a small size with range from 1mm to 3 cm, with an average of 4 to 6 mm in months to many years.Most are asymptomatic, but a minority of patient complain enlargement, pain, or pruritus. 1The lesions most commonly present as single, raised, red, or violaceous papules; sometime tan papule on the head or neck.Microscopically, AH lesions are wellcircumscribed but uncapsulated.They are composed of an intimate admixture of thick-walled and thin-walled blood vessels distributed within the superficial and middle dermis. 1 Muscular walled vessels in haphazard cluster in the dermis.More vessels have features of veins than of arteries (and lack internal elastic lamina with an elastic stain). 3zinger and Weiss divide arteriovenous hemangioma into two types, "deep" and "superficial".
The so-called "deep" type, is asscociated with varying The pathologic nature and etiology of Ahs remain a matter of speculation, and both congenital and acquired Ahs have been reported. 5However,  The third possibility was pyogenic granuloma (PG), also known by its correct histopathologic description lobular capillary hemangioma.It is one of the most common vascular tumors of infants, children, and can also occur in adults, particularly in young adults and also pregnant women.Pyogenic granuloma usually presents as a solitary, red, rapidly growing papule or nodule, often with a subtle collarette of scale.Typical locations include the cheek or forehead but virtually any body site may be affected.They often develop an eroded surface, with subsequent bleeding which can be profuse, resulting in the moniker the band-aid disease.show endothelial or mast cell hyperplasia.Based on these criteria, however, superficial AH may have the features of both entities. 5ere was no case of superficial AH with lesion clinically mimicking pigmented nevus has been reported.This is the first case of AH in our department.
In this case, we did biopsy excision with concideration that the lesion was small, occurring of discoloration and bleeding of the lesion that tend to be a carcinoma and to exclude the differential diagnosis.The choice of treatment of AH is surgical exicision, and recurrences have never been reported.The prognosis this lesion was bonam. 6 decades of life.Biberstein and Jessner reported the first case of AH in 1956 as "cirsoid aneurysm".The entity then lay relatively dormant in the literature until 1974 when Girard et al. characterized the salient clinical and histologically similar lesions that they termed arteriovenous hemangioma.Subsequent Laporan Kasus http://jurnal.fk.unand.ac.idJurnal Kesehatan Andalas.2015; 4(2) reports by Carapeto et al. and Connely and degrees of shunting, and is regarded as a malformation.It is generally affect young adult and adolescent.Although called "deep", lesions can occur close to the skin and they may pulsate or writhe due to afferent arterial blood flow if large shunts are present.These lesions are referred as cirsoid or arteriovenous aneurysms.The superficial form includes lesions classified as arteriovenous haemangioma or acral arteriovenous tumor by Capareto et al. and generallyaffected middle age to elderly adult.2.4 hamartomatous proliferation either of the subpapilary vascular plexus or of the Sucquet-Hoyer canal of the true glomous is proposed as a possible histogenetic mechanism.Treatment of choice is complete surgical excision. 6CASE REPORT A 19-year-old woman came to Dermato-Venereology out-patient Department of Dr. M. Djamil Hospital on December 28 th 2011 with chief complaint there was a black pimple on the right lower arm since one month ago.Initially, about 2 years ago, there was a tiny reddish pimple arised on her right lower arm.The size of the pimple only as pinhead size.The pimple was painless, sometimes itchy, not easy to bleed although she scratched it, and not become large since appeared.In last two months, she often touched the pimple and scratched it because itchy.Since one month ago, she felt the pimple become larger and easily bleed after she scratched it and the color turned into black.On physical examination we found a solitare black papule, with 0,3x0,4 mm in diameter, round shape, fine scales, the regular border with irreguler surface.Then, we diagnosed this patient with pigmented naevus at the beginning with differential diagnosis pigmented basal cell carcinoma (T1 N0 M0) and pyogenic granuloma.To exclude those differential diagnosis, we did histopathology examination by skin biopsy and the result showed mild acanthosis dan hyperkeratosis on epidermis and superficial dermis containing thicked-walled and very dilated thin-walled vessels that full-filled with erythrocytes and are lined by an endothelial layer.There are also seen bleeding area and mild lymphocytes perivasculer.This features supported to AH.

Figure 1 .
Figure 1.Black pimple on the right lower arm

Figure 2 .
Figure 2. Histopathology examination: showed thickedwalled and very dilated thin-walled vessels that full-filled with erythrocytes and are lined by an endothelial layer (yellow arrow)