Visual Diagnosis in Emergency Medicine| Volume 54, ISSUE 5, e109-e110, May 2018

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Woman with a Bleeding Friable Lesion in the Right Hand

      A 52-year-old female presented to emergency department (ED) with a 1-month history of a recurrent painless bleeding lesion in her right hand. She recalled a bird biting her right hand while she was feeding birds in a park 1 week before the onset of symptoms. She was admitted with her right hand covered with blood (Figure 1A). After washing her hand, a bright red papule, without pulsation, surrounded by a collar of epidermis was observed (Figure 1B). An ultrasound image, requested in another ED 10 days prior, revealed a well-vascularized 7-mm deep nodular lesion (Figure 2A and 2B). Saucerization excision of the lesion was performed, and histopathology showed a lobular proliferation of small blood vessels, which erupted through a breach in the epidermis to produce a globular pedunculated tumor (Figure 3A and 3B).
      Figure thumbnail gr1
      Figure 1(A) Right hand covered with blood at presentation to the emergency department. (B) A bright red papule surrounded by a collar of epidermis.
      Figure thumbnail gr2
      Figure 2(A) Sonographic features of a friable vascular palmar lesion. (B) Color Doppler sonography showed intense vascularization in the interior of the lesion.
      Figure thumbnail gr3
      Figure 3(A) Lobular proliferation of capillaries with epidermal collarette at the periphery (yellow arrows). Presence of erythrocytes in the lumen of vascular channels and in interstices, and intense inflammatory infiltrate (hematoxylin and eosin stain; 50×). (B) Lobules of dilated (green arrows) and congested (black arrows) capillaries in an edematous stroma (hematoxylin and eosin stain; 400×).
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