Introduction
Axillary web syndrome (AWS) is characterized by painful palpable rope-like soft tissue density usually emanating from the axilla. According to our knowledge, our case is one of 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 AWS following lymphangitis, which was misdiagnosed as herpes zoster.
Case
A 52-year-old woman was referred to our clinic for the evaluation of left arm pain. The patient was diagnosed as herpes zoster in local clinic due to red skin rash along medial side of left arm with burning sensation. She had no relevant medical history when sudden hyperalgesia on left arm with tightness developed. Laboratory tests showed negative findings. In duplex sonography, hyperechoic cording lesion running through axilla to mid-upper arm was detected. The patient was diagnosed of AWS by exclusion. After a few weeks of rehabilitation, her symptoms improved.
Discussion
The pathophysiology of AWS has been on debate, while lymphatic pathogenesis takes the highest proportion. In fact, recent studies presented atypical case of AWS without any preceding surgical procedure, however, most those had predisposing factors leading to 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. However, the preceding event of lymphangitis was assumed to stir up derangement in the lymphatic system. There are two unusual presentations of our case that deserves attention, first; clinical manifestations were similar to shingles, second; AWS developed consequently after the attack of lymphangitis. 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.
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Photo at the onset of symptoms when the subjective sensation of an axillary cord began. A reddish cord is running through the medial upper arm with extension into the antecubital fossa.
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 linear cord, B: Axillary cord, coronal view with diameter of 0.15cm.
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