Is He Pregnant...?


If you think that this man in the picture has a pot belly due to all that junk what he ate then you are mistaken. Sanju Bhagat, a 36 year old farmer's stomach was so swollen at one point that it seemed he was pregnant . He felt self-conscious and embarrassed his entire life since he was teased of being pregnant. But his swollen tummy resulted into severe pain one fine night of June 1999 and he was rushed to the hospital. And what doctors found was not less than a shock to him as well all those who witnessed the operation.

Doctors thought that Bhagat had a large tumor inside his stomach but were amazed when they found lots of bones, limbs, part of genitalia, some part of hair, jaws etc. This was just not what they were expecting. Inside his stomach was a half-formed creature which had developed feet and hands and had long fingernails.

It was then the doctors realized that creature found in Bhagat's stomach was no one but his own twin. He had one of the world's most bizarre medical conditions- fetus in fetu. This abnormality is extremely rare and occurs when a fetus gets trapped in its own twin and survives as a parasite and leaches its twin's blood supply.

As for now Bhagat is very relieved after the operation and is happy that he would be able to lead a normal life without those nasty comments. And doctors still wonder about this medical miracle.



ABSTRACT

Fetus in fetu is a rare condition in which a fetiform calcified mass often is present in the abdomen of its host, a newborn or an infant. We report on a case of a 19-month-old girl whose plain abdominal radiograph, ultrasonography, and computed tomography scan revealed a mass in which the contents favor a fetus in fetu rather than a teratoma. The noncalcified vertebral column invisible on the radiographs was identified by the pathologist; therefore, the nonvisualization of the vertebral axis on radiography or on computed tomography scan does not exclude the diagnosis of fetus in fetu.
Key words: fetus in fetu, spine of fetus, teratoma, twin, intraabdominal mass, parasitic twin.

The term fetus in fetu is used to point out an unequal division of totipotential cells of a blastocyst where the result is the inclusion of a small cellular mass in the more mature embryo. This is a form of monozygotic diamniotic twin pregnancy where the parasitic twin installs and grows in the body of its partner.1 This is a rare malformation that has some similarities with the retroperitoneal teratoma, but it is different from the latter by its fetiform aspect and the metameric segmentation of its spinal axis. The presence of a capsule covering this formation and a vascular pedicle is frequently encountered.2

In reality, one may find cases whose vertebral column is insufficiently calcified and therefore invisible on the plain radiograph. It may also be nonexistent but, because of the organogenetic differentiation, one may link this fetiform mass to the diagnosis of fetus in fetu.



CASE REPORT


A 19-month-old girl was hospitalized because of an abdominal mass of some months' duration. She was the only child in her family where there was neither twin pregnancy nor fetal malformation. Her body weight was 10 kg. Except for the presence of a mass in the upper right abdomen, the clinical examination and laboratory findings were normal. The plain film of the abdomen showed left-sided calcifications adjacent to the spine at the fourth and fifth lumbar vertebrae and the first sacral vertebra (Fig 1). These calcifications had the appearance of limb bones rather than vertebral bodies. Abdominal ultrasonography showed a hypoechoic mass with hyperechoic structures inside that extended from the lower border of the liver to the hypogastric region. An abdominal computed tomography (CT) scan (Figs 2, 3, and 4) showed a thick-walled mass that measured approximately 90 × 65 mm including solid, cystic, and calcified components. The calcifications resembled cranial bones and long bones, but a vertebral axis was not visualized. The mass was displacing the transverse colon downward and the small bowel downward and posteriorly.

Fig. 1. Plain film of the abdomen. Calcified mass (arrows) at the left border of lumbosacral vertebrae L4, L5, and S1.
Fig. 2. Axial CT at the L2 level. In front of the vertebral column, there is a well-defined mass with 2 cystic formations. In the larger formation, which is anterior and on the left side, there are long and hyperdense opacities corresponding to fetal limbs.
Fig. 3. Axial CT at the L3 level. In front of the vertebral column, there is a cystic mass containing fluid and some calcified opacities that correspond to fetal bones.



Fig. 4. Axial CT at the L3-L4 levels. In the midline of the abdomen, there is a round hyperdense opacity that corresponds to the fetal skull.


Based on these imaging findings, a diagnosis of fetus in fetu was thus made preoperatively.

The surgeon discovered a well-encapsulated retroperitoneal mass behind the transverse mesocolon. This mass had a pedicle that was connected to the superior mesenteric artery. Excision of the capsule revealed a yellowish fluid and an incompletely developed fetus covered by vernix caseosa.

The postoperative course was uneventful and the patient was discharged on the eighth postoperative day.

A radiograph of the specimen showed cranial bones and long bones but no vertebral column. On the macroscopic pathologic examination, the mass measured 20 × 8 × 5 cm and was composed of a head with hair, a trunk, and rudimentary limbs corresponding to an incompletely developed fetus. A soft vertebral axis was found behind the intestinal loops, colon, and liver. (Figs 5 and 6). Microscopically, there were hepatic cells, biliary tract cells, splenic tissue, and pulmonary tissue. Most of these cells were in blastic stage and not well-differentiated. The bony tissue was essentially composed of osteoblasts with little bone marrow. The nervous tissue was mostly formed by glial cells and not well-differentiated neurons.



Fig. 5. The postoperative specimen shows a fairly well-developed fetus lying on its back. The head is on the right side (thick black arrow), the buttocks on the left side (2 small arrows). The left arm, left leg, and feet are clearly seen (small separated arrows). The intestines are visible on the anterior abdominal wall, which is open (white curved arrow).


Fig. 6. The postoperative specimen shows the fetus in prone position: the head on the left side (thick arrow) and the buttocks on the right side (small black arrows). The right shoulder and arm can be visualized (small white arrows) as a minor formation.

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