A 41 year old patient presented with an enlarging painful mass at the subungual region of the right hallux. MRI exam was performed and the findings are presented.
A 41 year old female patient with a recent history of enlarging painful mass at the subungual region of the right hallux was referred to the radiology department by his GP. She was afebrile and no history of trauma in the region was referred. There was no history of diabetes. MRI exam was performed and demonstrated a mass located in the subungual region of the right hallux. On T1 weighted images (Fig. 1) the mass was hipointense to the muscular tissues. After admission of contrast medium the tumor was strongly enhancing (Fig. 2). On T2 fat-suppressed – weighted images (Fig ures 3, 4) the mass revealed an intense high MR signal. The patient underwent surgical excision of the tumor and the cytological examination (Fig. 5) revealed glomus tumor.
Glomus tumors represent 1-5% of soft-tissue tumors in the extremities. In pathologic examination, glomus tumors are hamartomas developed from the neuromyoarterial glomus bodies that regulate blood flow in the skin.
The normal glomus body is an arteriovenous shunt that has an important role in thermoregulation and is present throughout the body in the deepest layer of the dermis, the reticular dermis. Each glomus body is an encapsulated oval organ of 300μm in length. It is located in the subungual region, digits and palms. Glomus bodies are highly concentrated in tips of the digits, particulary beneath the nails. The nail beds of fingers and toes contain 93–501 glomus bodies per square centimeter.
At clinical examination, glomus tumors are in majority non palpable lesions, frequently found in women. They usually provoke a compression to the nail matrix and thus, the principal symptom is pain at the region. A “classic triad” of clinical findings was described which include pain, point tenderness and cold sensitivity. The disappearance of the pain after application of a tourniquet proximally on the arm (Hildreth sign) is pathognominic of a glomus tumor. Eliciting pain by applying precise pressure with the tip of a pencil (Love test) helps locate the lesion.
Most glomus tumors are iso- or slightly hyperintense to the dermal layers of the nail bed on T1-weighted MR images and strongly hyperintense on T2-weighted images. The majority of them are surrounded by a capsule which has the appearance of a dark rim on T2-weighted and contrast material-enhanced imaging. The capsule is the result of a secondary reaction of the surrounding tissue and may be incomplete.
In some cases the signal intensity on T1WI and T2WI varies. It can be low or intermediate intense reflecting the variety of its histological components. The predominant cellular pattern of glomus tumors can be divided into 3 main forms: vascular , myxoid and solid. The solid or cellular type has a slightly high signal intensity on T2WI and injection of contrast medium helps its detection. The vascular type has a very strong enhancement. When the form of the tumor is myxoid the T2 times are very long. This scheme is theoretical because most tumors are composed of a mixture of the various types.
The differential diagnosis of glomus tumor includes mucoid cysts and angioma. Mucoid cysts are painless and at MRI imaging they present communication with the distal interphalangeal joint, longer values of T2 times and lack of contrast enhancement. The angioma may strongly mimic glomus tumor as they present the same signal intensity. Nevertheless, it is more superficial and located in the papillary dermis and the epidermis.
In our case, the tumor was located in the subungual region of the right hallux. Imaging techniques demonstrated the location of the tumor and its relation with the subsequent tissues. The cytological examination revealed the nature of the tumor and its composition of vascular, myxoid and solid components.
Glomus tumor of the subungual region of the right hallux
The patient is a 41-year-old female, presenting with a gradually enlarging painful mass located under the nail (subungual region) of the right big toe. Based on the provided MRI images, the following key features are noted:
Based on the patient’s history (no prior trauma, female, painful subungual mass) and the MRI findings (signal characteristics), the main differential diagnoses include:
Taking into account the patient’s age, clinical presentation (painful subungual mass, possible cold sensitivity), MRI features (signal and enhancement patterns), and the pathological examination revealing abundant vascular components as well as mucoid and solid elements, the most consistent diagnosis is:
Glomus tumor
Treatment Strategy:
Rehabilitation and Exercise Prescription:
This report serves as a reference analysis, based on currently available imaging and pathological data, as well as related medical literature. It does not replace in-person consultation or professional medical advice. Should you have any questions or changes in your condition, please seek immediate medical attention or consult specialized healthcare providers for further examination and treatment.
Glomus tumor of the subungual region of the right hallux
