Case Report
Vascular Changes in Severe Carpal Tunnel Syndrome: A Differential Diagnosis of Vasculitis
Alteraciones vasculares en síndrome del túnel carpiano severo: un diagnóstico diferencial de vasculitis
Roser Areny-Micasa,
, Rebeca Silva-Donosoa, Viviana Urtubia-Manríqueza, Jorge Saavedra-Muñozb, Lidia Hernández-Reyesc, Marta Aliste-Silvad
Corresponding author
a Unidad de Reumatología, Servicio de Medicina, Hospital Félix Bulnes, Universidad Mayor, Santiago, Chile
b Unidad de Reumatología, Servicio de Medicina, Hospital San Juan de Dios, Santiago, Chile
c Unidad de Reumatología, Servicio de Medicina, Hospital Salvador, Universidad de Chile, Santiago, Chile
d Unidad de Reumatología, Servicio de Medicina, Hospital José Joaquín Aguirre, Universidad de Chile, Santiago, Chile
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array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Unidad de Reumatología, Servicio de Medicina, Hospital Félix Bulnes, Universidad Mayor, Santiago, Chile" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Unidad de Reumatología, Servicio de Medicina, Hospital San Juan de Dios, Santiago, Chile" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Unidad de Reumatología, Servicio de Medicina, Hospital Salvador, Universidad de Chile, Santiago, Chile" "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Unidad de Reumatología, Servicio de Medicina, Hospital José Joaquín Aguirre, Universidad de Chile, Santiago, Chile" "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Alteraciones vasculares en síndrome del túnel carpiano severo: un diagnóstico diferencial de vasculitis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1280 "Ancho" => 1583 "Tamanyo" => 124682 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Longitudinal image of the right median nerve. (Image obtained with a General Electrics LOGIC e ultrasound, with a lineal 8–12<span class="elsevierStyleHsp" style=""></span>mHz transducer, using a frequency of 12<span class="elsevierStyleHsp" style=""></span>mHz.) B: large bone; N: median nerve; T: hand flexor tendons; *: compression zone.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Clinical manifestations of carpal tunnel syndrome (CTS) are known as subjective signs (paresthesia, proprioceptive alterations, paresis) and objective (alterations in sensitivity and motor function, positive Tinel and Phallen tests, and atrophy of the thenar eminence). Most of the patients are managed with medical or surgical treatment in relation to their clinical manifestations, the results of the electromyography in their progression. In some cases, presentation may be atypical and secondary atrophy may be present after severe compromise, which obliges the clinician to exclude other diagnoses.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Clinical Case</span><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of an 84-year-old woman with a history of controlled hypertension and 2 months with skin lesions on both hands, classified as a type of vasculitis associated with cyanosis on the first, second and third fingers, and severe pain that led to emergency hospitalization for suspected systemic vasculitis. Upon directed interrogation, there was no evidence of connective tissue disease or drug use. She received enalapril to treat high blood pressure. Physical examination highlighted periungual lesions, indicative of vasculitis, but their distribution was dermatomal, associated with severe hypoesthesia in the same territory and significant atrophy of the thenar region, bilaterally (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). The rest of the examination was normal, in particular, no skin lesions at other sites were seen and her blood pressure was normal. Laboratory studies were performed: blood count, erythrocyte sedimentation rate and renal function as well as complete urine testing were normal, she had negative rheumatoid factor, negative antinuclear antibodies, ENA and negative C and P ANCA. The patient complained of abnormal sensitivity and nocturnal paresthesias and lack of strength in her hands for some time, so she had been seen by other physicians, leading to a diagnosis of CTS, undergoing an upper extremity electromyography a year earlier. This showed a severe entrapment of both median nerves at the carpal tunnel, with complete denervation of the thenar eminence. Ultrasonography was performed, showing the entrance to the tunnel at the pisiform, a right median nerve with a 17<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span> area (normal<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>±10<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a> (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>), with the central presence of a median artery remnant (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The left median nerve was also thickened, with an area at the pisiform level of 18<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleSup">2</span>. Both nerves appeared trapped in the carpal tunnel in longitudinal sections (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0015" class="elsevierStylePara elsevierViewall">Skin lesions are localized on the median nerve territory because, as reported in the literature, in severe CTS there may be perivascular sympathetic nervous system compromise in that distribution.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–5</span></a> This patient also presented a remnant of the median artery, an uncommon anatomical variant<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> generally associated to a bifid median nerve, leading to a greater repercussion on the compression of structures in the tunnel, affecting tissue vascularization even further. Thrombotic phenomena and occlusion of the remnant artery may be triggered for CTS.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> The case presented had a unilateral remnant artery; we may suppose that if it had occurred bilaterally it may have occluded and increased symptoms. Severe hypoesthesia adds the possibility of presenting associated traumatic lesions.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> It is important to perform the diagnosis because a surgical option, through the liberation of the nerve at the retinaculum, could revert the lesions, impeding the appearance of severe complications. This clinical presentation with atrophy in severe, long-term CTS is currently infrequent because most of the patients have rapid access to specialized care.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conclusions</span><p id="par0020" class="elsevierStylePara elsevierViewall">Faced with a patient with possible systemic vasculitis but with limited hands, the clinician must make a differential diagnosis with severe CTS and secondary atrophy because the treatment is very different and the use of steroids and immunosuppresants will not benefit these patients.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:2 [ "identificador" => "xres125649" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec112942" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres125650" "titulo" => "Resumen" ] 3 => array:2 [ "identificador" => "xpalclavsec112943" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical Case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conclusions" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-02-03" "fechaAceptado" => "2011-04-20" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec112942" "palabras" => array:2 [ 0 => "Carpal tunnel syndrome" 1 => "Vasculitis" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec112943" "palabras" => array:2 [ 0 => "Síndrome del túnel carpiano" 1 => "Vasculitis" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Carpal tunnel syndrome may present with skin lesions. This may lead to a differential diagnosis with vasculitis. Sympathetic nervous system perivascular involvement and recurrent injuries secondary to sensory loss are probably part of the mechanism of injury. In this case, we also comment on the pathogenic role of persistent median artery associated with a bifid median nerve.</p>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El síndrome del túnel carpiano puede manifestarse con lesiones cutáneas. Estas pueden plantear el diagnóstico diferencial con una vasculitis. El compromiso del sistema nervioso simpático perivascular y los traumatismos a repetición secundarios a la hipoestesia son probablemente parte del mecanismo de daño. En este caso, se plantea además el papel patogénico de una arteria mediana remanente asociada a nervio mediano bífido.</p>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please, cite this article as: Areny-Micas R, et al. Alteraciones vasculares en síndrome del túnel carpiano severo: un diagnóstico diferencial de vasculitis. Reumatol Clin. 2012;<span class="elsevierStyleBold">8(1)</span>:36–38.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1133 "Ancho" => 850 "Tamanyo" => 96320 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Right hand palm and a detail of the right index finger.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 768 "Ancho" => 950 "Tamanyo" => 68470 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Transverse image of the right median nerve at the entrance of the carpal tunnel, with measurement of the nerve area with an ellipse (0.17<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">2</span>), at the pisiform level P (B: large bone). (Image obtained with a General Electrics LOGIC e ultrasound, with a lineal 8–12<span class="elsevierStyleHsp" style=""></span>mHz transducer, using a frequency of 12<span class="elsevierStyleHsp" style=""></span>mHz and maximal enlargement.)</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Fig. 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1280 "Ancho" => 1583 "Tamanyo" => 127451 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Transversal image of the median nerve in the carpal tunnel: median artery remnant. (Image obtained with a General Electrics LOGIC e ultrasound, with a lineal 8–12<span class="elsevierStyleHsp" style=""></span>mHz transducer, using power Doppler with a frequency of 5.0<span class="elsevierStyleHsp" style=""></span>MHz, gain of 12, PRF DE 1.2<span class="elsevierStyleHsp" style=""></span>h<span class="elsevierStyleHsp" style=""></span>Hz and a wall filter of 180<span class="elsevierStyleHsp" style=""></span>Hz.)</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Fig. 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1280 "Ancho" => 1583 "Tamanyo" => 124682 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Longitudinal image of the right median nerve. (Image obtained with a General Electrics LOGIC e ultrasound, with a lineal 8–12<span class="elsevierStyleHsp" style=""></span>mHz transducer, using a frequency of 12<span class="elsevierStyleHsp" style=""></span>mHz.) B: large bone; N: median nerve; T: hand flexor tendons; *: compression zone.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diagnostic utility of ultrasonography versus nerve conduction studies in mild carpal tunnel syndrome" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. Mondelli" 1 => "G. Filippou" 2 => "A. Gallo" 3 => "B. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 13 | 10 | 23 |
| 2024 October | 98 | 47 | 145 |
| 2024 September | 98 | 30 | 128 |
| 2024 August | 118 | 41 | 159 |
| 2024 July | 91 | 38 | 129 |
| 2024 June | 94 | 45 | 139 |
| 2024 May | 84 | 38 | 122 |
| 2024 April | 77 | 45 | 122 |
| 2024 March | 95 | 34 | 129 |
| 2024 February | 75 | 38 | 113 |
| 2024 January | 84 | 22 | 106 |
| 2023 December | 75 | 34 | 109 |
| 2023 November | 76 | 33 | 109 |
| 2023 October | 82 | 37 | 119 |
| 2023 September | 123 | 42 | 165 |
| 2023 August | 72 | 19 | 91 |
| 2023 July | 89 | 29 | 118 |
| 2023 June | 67 | 29 | 96 |
| 2023 May | 89 | 19 | 108 |
| 2023 April | 70 | 16 | 86 |
| 2023 March | 95 | 19 | 114 |
| 2023 February | 90 | 33 | 123 |
| 2023 January | 94 | 32 | 126 |
| 2022 December | 76 | 39 | 115 |
| 2022 November | 100 | 39 | 139 |
| 2022 October | 104 | 57 | 161 |
| 2022 September | 89 | 26 | 115 |
| 2022 August | 57 | 40 | 97 |
| 2022 July | 63 | 46 | 109 |
| 2022 June | 60 | 34 | 94 |
| 2022 May | 75 | 44 | 119 |
| 2022 April | 76 | 50 | 126 |
| 2022 March | 70 | 56 | 126 |
| 2022 February | 84 | 61 | 145 |
| 2022 January | 95 | 46 | 141 |
| 2021 December | 60 | 38 | 98 |
| 2021 November | 61 | 39 | 100 |
| 2021 October | 76 | 51 | 127 |
| 2021 September | 66 | 41 | 107 |
| 2021 August | 60 | 43 | 103 |
| 2021 July | 52 | 35 | 87 |
| 2021 June | 53 | 38 | 91 |
| 2021 May | 79 | 49 | 128 |
| 2021 April | 174 | 87 | 261 |
| 2021 March | 94 | 40 | 134 |
| 2021 February | 64 | 26 | 90 |
| 2021 January | 68 | 25 | 93 |
| 2020 December | 62 | 27 | 89 |
| 2020 November | 67 | 19 | 86 |
| 2020 October | 50 | 17 | 67 |
| 2020 September | 49 | 32 | 81 |
| 2020 August | 31 | 22 | 53 |
| 2020 July | 28 | 31 | 59 |
| 2020 June | 37 | 20 | 57 |
| 2020 May | 48 | 17 | 65 |
| 2020 April | 40 | 13 | 53 |
| 2020 March | 15 | 9 | 24 |
| 2020 February | 2 | 0 | 2 |
| 2020 January | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 July | 1 | 0 | 1 |
| 2019 June | 1 | 0 | 1 |
| 2019 March | 1 | 0 | 1 |
| 2019 January | 1 | 0 | 1 |
| 2018 May | 5 | 0 | 5 |
| 2018 April | 83 | 8 | 91 |
| 2018 March | 97 | 6 | 103 |
| 2018 February | 84 | 3 | 87 |
| 2018 January | 65 | 8 | 73 |
| 2017 December | 61 | 5 | 66 |
| 2017 November | 84 | 4 | 88 |
| 2017 October | 43 | 4 | 47 |
| 2017 September | 52 | 4 | 56 |
| 2017 August | 71 | 8 | 79 |
| 2017 July | 62 | 17 | 79 |
| 2017 June | 88 | 17 | 105 |
| 2017 May | 91 | 9 | 100 |
| 2017 April | 74 | 6 | 80 |
| 2017 March | 79 | 9 | 88 |
| 2017 February | 60 | 8 | 68 |
| 2017 January | 64 | 8 | 72 |
| 2016 December | 94 | 16 | 110 |
| 2016 November | 69 | 5 | 74 |
| 2016 October | 123 | 10 | 133 |
| 2016 September | 122 | 9 | 131 |
| 2016 August | 89 | 1 | 90 |
| 2016 July | 61 | 11 | 72 |
| 2016 June | 1 | 0 | 1 |
| 2016 May | 0 | 8 | 8 |
| 2016 April | 1 | 11 | 12 |
| 2016 March | 2 | 12 | 14 |
| 2016 January | 1 | 0 | 1 |
| 2015 December | 2 | 0 | 2 |
| 2015 November | 1 | 0 | 1 |
| 2015 September | 1 | 21 | 22 |
| 2015 August | 4 | 10 | 14 |
| 2015 July | 28 | 7 | 35 |
| 2015 June | 44 | 10 | 54 |
| 2015 May | 68 | 8 | 76 |
| 2015 April | 53 | 13 | 66 |
| 2015 March | 47 | 7 | 54 |
| 2015 February | 55 | 8 | 63 |
| 2015 January | 66 | 8 | 74 |
| 2014 December | 60 | 8 | 68 |
| 2014 November | 78 | 8 | 86 |
| 2014 October | 56 | 11 | 67 |
| 2014 September | 41 | 7 | 48 |
| 2014 August | 47 | 7 | 54 |
| 2014 July | 49 | 13 | 62 |
| 2014 June | 63 | 9 | 72 |
| 2014 May | 65 | 14 | 79 |
| 2014 April | 43 | 4 | 47 |
| 2014 March | 66 | 16 | 82 |
| 2014 February | 51 | 9 | 60 |
| 2014 January | 51 | 15 | 66 |
| 2013 December | 44 | 4 | 48 |
| 2013 November | 47 | 20 | 67 |
| 2013 October | 53 | 10 | 63 |
| 2013 September | 57 | 13 | 70 |
| 2013 August | 48 | 13 | 61 |
| 2013 July | 44 | 11 | 55 |
| 2013 June | 52 | 10 | 62 |
| 2013 May | 53 | 10 | 63 |
| 2013 April | 42 | 6 | 48 |
| 2013 March | 44 | 12 | 56 |
| 2013 February | 38 | 9 | 47 |
| 2013 January | 31 | 8 | 39 |
| 2012 December | 55 | 13 | 68 |
| 2012 November | 22 | 15 | 37 |
| 2012 October | 14 | 7 | 21 |
| 2012 September | 11 | 4 | 15 |
| 2012 July | 3 | 0 | 3 |
| 2012 June | 8 | 0 | 8 |
| 2012 May | 6 | 0 | 6 |
| 2012 April | 3 | 0 | 3 |
| 2012 March | 11 | 0 | 11 |
| 2012 February | 11 | 0 | 11 |
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