Lithopedion in a Patient with Hypertensive Cerebrovascular Accident

IBIMA Publishing International Journal of Case Reports in Medicine http://www.ibimapublishing.com/journals/IJCRM/ijcrm.html Vol. 2014 (2014), Article ID 575308, 5pages DOI: 10.5171/2014.575308

Case Report Lithopedion in a Patient with Hypertensive Cerebrovascular Accident

C.M Nkabinde 1 and M.H Motswaledi 2

1Department of Radiology, University of Limpopo, Medunsa Campus

2Department of Dermatology, University of Limpopo, Medunsa Campus

Correspondence should be addressed to: M.H Motswaledi; [email protected]

Received date: 6 November 2013; Accepted date: 10 February 2014; Published date: 18 December 2014

Academic Editor: Edward Araújo Júnior

Abstract

The word lithopedion is a descriptive term derived from the Greek words litho (meaning stone), and pedion (meaning child). This is a rare condition with less than 300 cases reported in 400 years of medical literature. Lithopedion is a name given to an extra-uterine pregnancy that evolves to foetal death and calcification. This rare phenomenon, that was first described in the 10 th century by Albucasis, a surgeon of the Arabic era of medicine, is a sequelae of a form of ectopic pregnancy. Most cases of lithopedion are discovered incidentally on abdominal x-ray, at surgery, or autopsy. We report a case of lithopedion in a woman who presented with a hypertensive cerebrovascular accident.

Keywords: Cerebrovascular accident; hypertension; abdominal pregnancy; lithopedion; lithokelyphopedion.

Introduction pregnancy is 1:11 000 pregnancies, and lithopedion occurs in 1,5% to 1,8% of these A lithopedion as an extra-uterine cases¹. The incidence of lithopedion varies pregnancy in which the fetus died and widely with geographical location, degree calcified¹. This rare phenomenon, that was of antenatal attendance, level of medical first described in the 10 th century by care, and socio-economic status³. By the Albucasis, a surgeon of the Arabic era of end of the 20 th century, there were less medicine, is a sequelae of a form of ectopic than 300 cases of lithopedia reported in pregnancy². 400 years of medical literature¹.

Lithopedia have been described in women, Case Report ranging in age, from 23 to 100 years old, with a duration of lithopedion retention A 51year old African female presented to estimated for periods ranging from 4 to 60 the Accident and Emergency department years¹. The incidence of abdominal with acute onset of expressive aphasia. The ______

Cite this Article as: C.M Nkabinde and M.H Motswaledi (2014)," Lithopedion in a Patient with Hypertensive Cerebrovascular Accident ", International Journal of Case Reports in Medicine , Vol. 2014 (2014), Article ID 575308, DOI: 10.5171/2014.575308

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patient has a history of hypertension and with brain metastasis. The pre and post previous cerebrovascular accident. contrast computerised brain scan, revealed extensive brain involution, with multiple On examination, she was fully conscious hypodense areas with volume loss. There and had a facial nerve palsy, and was also effacement of sulci and gyri and hemiplegia on the right side. Examination hypodensity on the left parieto-occipital of the abdomen revealed a bony-hard mass area, in keeping with a recent ischaemic extending to the level of the umbilicus. infarct involving the left middle cerebral The initial assessment was that she artery territory. possibly has a malignant ovarian tumour

No mass lesions in the grey/white matter hyperflexed, calcified foetus in the interface, no vasogenic oedema or abdomen. Thin calcified membranes were haemorrhage were noted. The abdominal noted. x-ray demonstrated a fully formed,

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C.M Nkabinde and M.H Motswaledi (2014), International Journal of Case Reports in Medicine, DOI: 10.5171/2014. 575308

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Computerized tomography (CT) of the further showed a normal and empty uterus, abdomen confirmed the x-ray findings, and which was separate from the foetus.

Coronal reconstructed contrast enhanced a fully formed foetus with matured computerized tomography (CECT) showed skeleton intra-abdominally.

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C.M Nkabinde and M.H Motswaledi (2014), International Journal of Case Reports in Medicine, DOI: 10.5171/2014. 575308

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The final diagnosis was a hypertensive tubal abortion. There is subsequent re- cerebrovascular accident and lithopedion. implantation of the embryo onto the bowel, Her previous gynaecologic history could omentum or mesentery 4,5 . not be obtained because of her expressive The risk factors for ectopic pregnancies in aphasia. It was therefore, not possible to general are infertility, previous pelvic estimate how long has she retained the infection, congenital anomalies, lithopedion. She was put on endometriosis, previous ectopic pregnancy antihypertensive medication and later and tubal surgery 5. surgery was performed whereby a calcified foetus was removed. Ovular membranes The mortality risk from abdominal were found to be attached to the omentum, pregnancy is higher than that of tubal necessitating omentectomy. Surgery was pregnancy, and intra-uterine pregnancy³. uneventful with good recovery. In these patients the mortality is usually Discussion due to intra-abdominal bleeding, which leads to anaemia. Other causes of death A lithopedion is a dead fetus which are infections, disseminated intravascular underwent intra-abdominal calcification coagulopathy, pulmonary embolism and and not spontaneous resorption⁴. fistulae caused by penetration of fetal bones³. There is a report in the literature on a lithopedion presenting as an ovarian A lithopedion can develop following extra- neoplasm⁴. uterine pregnancy, fetal death after the first trimester, failure to diagnose extra- Most cases of lithopedia are discovered uterine pregnancy early, and conditions 1,2 incidentally at surgery, autopsy, or on x- favourable for calcification . ray². In 1881 Kuechenmeister classified retained 1,2 Abdominal pregnancies are rare, and abdominal pregnancy into 3 classes . usually are secondary to tubal rupture or ______

C.M Nkabinde and M.H Motswaledi (2014), International Journal of Case Reports in Medicine, DOI: 10.5171/2014. 575308

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Lithokelyphos in which only the fetal clinical diagnosis is virtually impossible but membranes are calcified. radiological investigations like X-Rays, CT- Lithokeyliphopedion in which both the Scan and MRI will clinch the diagnosis. membranes and fetus are calcified. Discovery of such a condition calls for True lithopedion in which the fetus is holistic patient management, considering calcified, but calcification of the the psycho-social impact on the patient and membranes is absent or minimal. family.

Complications of lithopedion are caecal In our patient we believe the lithopaedion volvulus, intestinal obstruction, abscess was not diagnosed earlier because it was formation, perforation of the urinary not symptomatic and she never sought bladder and rectum as well as extrusion of medical attention for it. It was an fetal parts through the abdominal wall⁴. incidental finding in a patient who presented with a hypertensive An x-ray of the abdomen is enough to cerebrovascular accident. confirm the diagnosis. Computerised tomography (CT scan), and magnetic References resonance imaging (MRI) clearly demonstrate the pathology, and assist with 1. Passini JR, Roxana K, Angela PM, et al. the diagnosis of associated complications Calcified abdominal pregnancy with prior to surgery¹. The CT scan clearly eighteen years of evolution: Case Report. shows the empty uterus and adnexae free Sao Paulo Med J/Rev Paul Med of ovular membranes, as in our case. 2000;118(6):192-194

The differential diagnosis to be considered, 2. Lachman N, Satyapal KS, Kalideen JM, especially if the foetus is not clearly defined et al. Lithopedion: A Case Report. Clin Anat are teratomas, ovarian tumours, calcified 2001;14:52-54 uterine fibroids, inflammatory masses, urinary tract and bladder tumours¹. In a 3. Kun KY, Wong PY, Ho MW, et al. foetus with well formed skeleton, Abdominal pregnancy presenting as a radiological investigations will reveal the missed abortion at 16 weeks’ gestation. diagnosis of a lithopaedion¹. HKMJ 2000 Dec;6(4):425-427

Some cases of retained abdominal 4. Kim SM, Park S, Lee TS. Old pregnancy may remain stable without Abdominal Pregnancy Presenting as an surgical intervention, while others may Ovarian Neoplasm . J Korean Med Sci need early surgical intervention after 2002 ;17:274-275 thorough consideration of the morbidity and the risk of complications if not treated 5. Cotter A, Izquierdo L, Heredia F. accordingly⁴. Abdominal pregnancy [monograph on the internet] The Fetus.net,2000 [2000-10-22- Conclusion 11] Available from: http://www.thefetus.net/page.php?id=103 Intra-abdominal pregnancy may be fatal, 2 with significant maternal and perinatal mortality 5. 6. Woodbury JW, Jarrett JC. Abdominal A finding of lithopedion implies an absence lithopedion retained for thirteen years: of adequate medical attention or some Case Report with review. Am J Obst & Gynec rather serious mistakes in medical 1960;80:590-595 judgement 2,6 .

The case can never over-emphasize the importance of good history taking, systematic and thorough patient examination at all levels of healthcare. A

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C.M Nkabinde and M.H Motswaledi (2014), International Journal of Case Reports in Medicine, DOI: 10.5171/2014. 575308