Intramuscular hemangioma causing periosteal reaction and cortical hypertrophy misdiagnosed as osteoid osteoma

Abstract

Introduction: Intramuscular hemangioma in the periosteal region is rare. Although comprising less than 1% of all hemangiomas, they represent the most common type of intramuscular tumors. When located adjacent to bone, a periosteal reaction can occur. The deep localization of the hemangioma poses the diagnosis difficult. Only 8% to 19% of cases were diagnosed before surgery according to the literature review.

Presentation of case: We present a case of forty-one-year-old female diagnosed with intramuscular hemangioma, mimicking osteoid osteoma, adjacent to the periosteal region of tibia diaphysis treated by surgical excision.

Discussion: When intramuscular hemangioma occurs nearby a bone structure, it can cause cortical, medullary and periosteal bone changes that are frequently misdiagnosed by plain radiography. Due to their infrequency, deep location, and atypical presentation, these lesions are seldom diagnosed at presentation. The hemangioma of the periosteal region can be locally destructive due to compression exerted on neighboring structures. It does not regress spontaneously, and surgical excision is frequently needed.

Conclusion: Intramuscular hemangioma of periosteal region occurs most commonly adjacent to long bones of the lower limb. They can cause hypertrophic periosteal reactions mimicking a periosteal or parosteal tumor. Although osteoid osteoma was considered in the differential diagnosis, MRI with enhancement should be performed to exclude intramuscular hemangioma. This may avoid unnecessary aggressive en-bloc tumor excisions resulting in bone weakness and prolonged rehabilitation. This case report has been written in line with the SCARE criteria (Agha et al., 2016 [1]).

Keywords: Intramuscular hemangioma; Osteoid osteoma; Periosteal reaction.

Fig 1

Plain radiograph showing periosteal reaction with cortical hypertrophy of the posterior mid-diaphyseal segment of the right tibia (white arrow).

Fig. 2

Axial CT scan revealed a cortically based sclerotic lesion emanating from the posterior aspect of the tibial diaphysis (white arrow). A poorly defined high density heterogeneous mass was seen immediately posterior to the cortically based lesion, within the adjacent musculature, likely representing a phlebolith (red circle).

Fig. 3

A large friable soft lobulated dark-red mass was located on the surface of the hypertrophic tibia bone and interpolated within the soleus muscle fibers. Photographs showed the tumorous mass before (A) and after (B) surgical excision. (C) Plain radiograph showing en-bloc excision of the hypertrophic cortex of the posterior mid-diaphyseal segment of the right tibia.

Fig. 4

Microscopically (hematoxylin-eosin, magnification 100×), red blood cells are visible within multiple dilated vascular channels (A) with interpositions of fibrous stroma and surrounded by skeletal muscle. The lining endothelial cells are stained for factor VIII (B). No nidus was found.