Case Studies With Pyogenic Granulomas

Here are two case reports of a pyogenic granuloma on the foot. In these cases, a family physician and an emergency room physician sent the respective patients to my office as a result of their unusual presentations. 

Pyogenic granulomas are rapidly growing, red, exophytic nodules. They are a benign vascular growth of the skin and mucous membranes, and usually present as a solitary red papule.^1,2 Pyogenic granulomas are characteristic for growing rapidly and becoming pedunculated, which may be alarming to the patient and even the physician. Histologically, pyogenic granulomas are composed of numerous newly formed capillaries that may lead to bleeding from the lesion. They commonly occur during pregnancy and in response to trauma.

The first case is of a 67-year-old male who had presented to his primary care physician with a lesion on his left great toe that had, according to the patient, appeared overnight and was extremely painful. The lesion enlarged over several days and was severely painful with the patient describing the lesion as bleeding frequently. The patient’s primary care physician (PCP) sent him to me for a quick exam as the lesion was very painful and disrupting the patient’s ability to ambulate.

On clinical exam, I was unable to evaluate the lesion before anesthetizing it given the level of pain. The lesion was a 1 cm by 0.5 cm mass to the medial aspect of the left great toe. The inferior portion of the lesion was necrotic and the superior half was purpuric in color with a vascular-like appearance. I easily removed the mass after anesthesia by cutting the stalk, which was a few mm in size, with a 15 blade. I obtained hemostasis and bandaged the toe without the need for cauterization of sutures. Within seven days, the patient had full relief with no need for further treatment.

The second case is of a 58-year-old male with a lesion on his left foot, which he had described as a “blister” that had emerged over a two-week period. The area became extremely painful and began hemorrhaging, which prompted him to go to the emergency room. The ER physician had a difficult time evaluating the patient given the level of pain and the amount of bleeding so the physician sent the patient directly to my office for evaluation. When the patient presented to my office, the mass was actively bleeding with pulsatile blood flow.

I obtained hemostasis and anesthetized the area surrounding the lesion. The examination revealed a 3 cm mass with a stalk leading to the plantar arch of the foot. I then excised the mass at the level of the stalk and placed three nylon 4.0 sutures to control the bleeding. I subsequently discharged the patient with a prescription for five days of ciprofloxacin 500 mg given the severity of the bleeding that the patient said had occurred over the past several days and his level of activity without healing the wound.

References

1. Kober MM, Alapati U, Khachemoune A. Red, exophytic nodule of the plantar foot. J Am Podiatr Med Assoc. 2015; 105(2):195–97.

2. Lee DR, Lee JY, Ahn JY, Park MY. A case of acquired digital fibrokeratoma accompanied by pyogenic granuloma. Dermatology Online Journal. 2009; 15(1):8.