Surgeons in Ashdod remove remnants of twin from 12-year-old girl’s swollen abdomen
Girl suffered from a 10-kilogram cyst growing in her belly before doctors discovered it contained an embryo’s hair, bones, and cartilage
Renee Ghert-Zand is the health reporter and a feature writer for The Times of Israel.
In a rare medical case, surgeons at Samson Assuta Ashdod University Hospital removed a huge cyst from the abdomen of a 12-year-old girl, apparently containing the fetal remnants of a twin brother.
The Hebrew media reported on the January procedure this week, and a spokesperson for Assuta confirmed the reports to The Times of Israel on Thursday.
The reports did not provide a name for the condition, saying only that surgeons had removed a mass containing hair, bones and cartilage that they believe belonged to a male twin that entered the girl embryo in utero early in pregnancy.
At first glance, it appears to be a case of fetus-in-fetu, a condition in which parts of a fetus that does not fully develop become entrapped in its twin. The condition, sometimes referred to as a parasitic twin, occurs at a rate of 1 in 500,000 births and most commonly presents as a mass in the abdomen.
Children with a parasitic twin usually have swollen and hard bellies, like the Israeli girl. If the child has other symptoms, the situation is usually discovered at a younger age.
The unidentified girl’s abdomen was hard and swollen from age six, but she never experienced pain that would indicate that this was a case of fetus-in-fetu. Instead, other possible diagnoses were pursued, such as celiac disease. The girl was also directed to weight loss and control counseling.
When the girl’s family turned to Assuta’s pediatric endocrinology service for a second opinion, doctors ordered ultrasound and MRI imaging. These tests revealed a 10-kilogram cyst containing a huge amount of fluid and also solid matter.
“It wasn’t clear what this was, but we knew this was a foreign body and that we had to remove it,” said Dr. Vadim Kapuler, head of pediatric surgery at Assuta.
During the laparoscopic procedure done through the girl’s navel, eight liters of fluid were drained from the cyst. Then the surgical team removed the solid mass, which they were amazed to find contained hair, bones, and cartilage.
According to reports, the physicians determined following pathology tests that these were the remnants of the girl’s male twin who did not properly develop and whose tissues had become absorbed into her while in utero.
Dr. Kapuler said that this likely occurred during the first weeks of the girl’s mother’s pregnancy.
The news that the twin was male raises questions, since medical literature online states that fetus-in-fetu occurs in monochorionic, diamniotic, monozygotic twins, also known as identical twins. These twins come from a single fertilized egg that splits, making them genetically identical and of the same sex.
This raises the possibility that this may be an irregular case of vanishing twin syndrome, which is a type of miscarriage of one embryo among two or more in the womb. The affected embryo stops developing, and its tissue gets absorbed by the mother and the surviving embryo(s). A vanished embryo is detected when seen on one ultrasound and not on the next.
According to the Cleveland Clinic’s website, this absorption is harmless, and up to 36 percent of IVF pregnancies involving multiples are diagnosed with vanishing twin syndrome.
Kapuler said he had never personally encountered a case such as that of the girl he operated on, but cited its rate of occurrence as one in 4,000 as opposed to the one in 500,000 of fetus-in-fetu.
He suggested that the girl’s condition went undetected because her body adapted to the slow growth of the cyst and because it did not put pressure on or damage any of her organs.
“Had she suffered from symptoms like an intestinal blockage, a fever, or vomiting, it would have been possible to diagnose the problem earlier,” he said.
The girl recovered quicker than expected and left the hospital 10 kilograms lighter less than 48 hours after the surgery.
The Times of Israel Community.