Introduction: Axillary web syndrome (AWS) is characterized by painful palpable rope-like soft tissue density usually emanating from the axilla. AWS is widely known to occur after axillary lymph node dissection for breast cancer, or rarely, after physical exertion or imflammatory insult. According to our knowledge, our case is one the few rare cases of AWS without any preceding triggers such as cancer history, surgery or physical exertion. Herein, we report a rare case of idiopathic AWS which was misdiagnosed as herpes zoster.
Case: A 52-year-old woman was referred to our clinic for the evaluation of left arm pain. She had no underlying disease except dermographism and nut allergies. In breast sonography held 8 months ago for screening test, no abnormal findings were shown. No preceding event including trauma, infection, vigorous physical activities or travel was present. Three weeks prior to her visit, sudden burning sensation and hyperalgesia on her left medial arm developed with subjective tightness on axillary area. She was misdiagnosed as shingles at local clinic. For further evaluation, laboratory tests were performed showing normal range of complete blood counts and d-dimer value, making lymphangitis or deep vein thrombosis less likely. In duplex sonography, hyperechoic cording lesion running through axilla to mid-upper arm on subcutaneous level was detected, without evidence of venous thrombus. The patient went through multiple rehabilitative therapies including manual therapy to release the cord and home exercise education. The evolution was favorable after a few weeks. Based on the clinical characteristics and absence of any other underlying diseases that could explain the patient’s manifestations, the patient was diagnosed of idiopathic AWS, by exclusion.
Discussion: The pathophysiology of AWS has been on debate, while lymphatic pathogenesis has been most reported. In fact, recent studies presented atypical case of AWS without surgical procedure, however most non-surgery related AWS cases had predisposing factors triggering acute or chronic inflammation in lymphovascular system. In our case, the patient did not have any history of cancer, surgery, or physical exertion, which in sharp contrast to the mechanism suggested in previous studies. There are two unusual presentations of our case that deserves attention, first; clinical manifestations were similar to shingles, second; AWS developed idiopathically. When a patient presents atypical arm pain and skin lesion, clinicians should be aware that only with thorough physical exam of upper extremity, accurate final diagnosis would be achieved. Furthermore, misuse of empirical medicines would be prevented, and early intervention could be feasible by keeping in mind that AWS can develop idiopathically. In addition, our case drives assumption that lymphovascular system could be interrupted by unstudied factors. More research is warranted on the exact mechanism of AWS. |
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Axillary web syndrome of the left upper extremity. Multiple cords are visible in mid axilla and medial upper extremity with extension into the antecubital fossa. On palpation, the cord felt fibrous
Duplex ultrasonography of left upper extremity. Hyperechoic cording lesion with diameter of 1.5mm, running through axilla to mid-upper arm is detected on subcutaneous level. A: Axillary cord, sagittal view showing trilaminar appearance, B: Axillary cord, coronal view with diameter of 0.15cm.
Duplex ultrasonography of left upper extremity. Hyperechoic cording lesion with diameter of 1.5mm, running through axilla to mid-upper arm is detected on subcutaneous level. A: Axillary cord, sagittal view showing trilaminar appearance, B: Axillary cord, coronal view with diameter of 0.15cm.
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