Multiple leiomyoma

Introduction

Painful tumour of the skin is one of the fascinating titles in dermatology. Presence of pain and tenderness in a patient with dermal nodules helps the physician to narrow down his diagnostic armamentarium. Leiomyoma is one such painful tumour of the skin. But it is not a constant finding, particularly in clinical practice. Here we describe a case of asymptomatic multiple leiomyomas in an adult male.

Case Report

A 23 - year - old man presented with multiple asymptomatic raised skin lesions at various sites for the past 1 7 years. At the age of 6, patient noticed skin-coloured nodules, which were asymptomatic over the thenar eminence of right palm and dorsal aspect of right middle finger. Lesions remained same till the age of 15 years after which they started to spread and involved the dorsal aspects of right thumb and middle fingers, right palm, lateral aspects of right elbow, pinna of the right ear, right side of face, left ankle and dorsum of foot. There was no history of pain, bleeding or oozing, sudden flare up of lesions or family history of similar skin lesions. General physical examination was within normal limits.

Dermatological examination showed multiple skin-coloured nodules of various sizes over the above described sites. Lesions were firm, smooth non tender without any change in surface or in surrounding skin [Figure - 1] and [Figure - 2]. They were freely mobile except the one in pinna of the right ear. Routine haematological and biochemical investigations were normal. Excision biopsy of one of the nodules in hematoxylin and eosin section showed poorly demarcated tumour mass in dermis composed of interlacing bundles of smooth muscle fibres with centrally located thin elongated eel- like nuclei with blunt edges [Figure - 3]. Patient was advised plastic excision of tumour masses which he refused to undergo.

Discussion

Based on clinical presentation the following differential diagnoses such as dermatofibroma, neurofibroma and xanthomas were entertained. But biopsy proved the lesion as leiomyoma. Lack of pain and tenderness, which is usually found in leiomyoma led to initial confusion in diagnosis.

Leiomyoma is a benign tumour of smooth muscle derived from the arrector pill muscle, from media of blood vessels or from smooth muscle of scrotum, labia majora or nipples.[2] Piloleiomyonlas are commonest which may be solitary or muitiple. Genital and angioleiom yomas are usually solitary. Onset of disease is usually early in ′life in 2nd or 3rd decade in contrast to the present case where it was noticed in the first decade itself. Characteristically they occur over the face, anterior trunk and extensor surface of extremities[3] as also seen in our case. Leiomyomas are usually painful either occur spontaneously or may be paroxysmal in nature with stabbing, burning or pinching qualities. Electron microscopic study supports the concept that direct tumour impingement on cutaneous nerves produces pain.[4] The absence of pain in the present case could be possibly due to absence of such impingement. A cold stimulus applied to lesions can produce contraction and pain. But genital leiomyomas are mostly asymptomatic.[3] Treatment is surgical excision when it is solitary or few in number. Recurrence is common. Calcium channel blockers have been found effective in relieving pain, particularly when patient is having large number of lesions which is amenable to surgery.[5]