Spontaneous Fingertip Endometriosis: A Rare Case Report.

Abstract

Here is a young unmarried girl of 18 y with bleeding from right index finger tip below nail bed, during menstruation for the last 3 months. She had attained menarche at the age of 13 y. She had regular menstrual cycles, where duration of flow was 4 to 5 days. There was no history of any comorbid illness or surgical intervention in the past. General examination revealed no abnormalities except mild pallor. Abdomen was soft, non-tender, with no palpable mass or free fluid. Per rectal examination was done and was normal. Examination of respiratory, cardiovascular and central nervous system was normal. On examination of the right index finger, there was a lesion with reddish discoloration of size 1 cm2 with slight swelling and tenderness just below the nail bed [Table/Fig-1]. There was a bleeding point within the lesion from where there was continuous oozing of blood during periods. USG of abdomen and pelvis showed no abnormality. MRI and diagnostic laparoscopy could not be done due to financial constraints. Biopsy of the bleeding site was done. Histological features revealed endometrial glands and stroma suggestive of endometriosis [Table/Fig-2]. Complete surgical excision was done with relief of the presenting symptoms thereafter. This is a very rare site of extra pelvic endometriosis reported till date. [Table/Fig-1]: Spontaneous bleeding from fingertip during menstruation [Table/Fig-2]: Histology of finger tip tissue showing features of endometriosis Extrapelvic endometriosis accounts up to 15% of all cases of endometriosis [1]. The most common sites in extrapelvic endometriosis include sites of previous surgical scars like cesarean scars, hysterectomy scars, episiotomy wounds and laparoscopic port sites. The other sites include bowel, omentum, urinary system, lungs, pleura, nasal mucosa, lymph nodes, umbilicus and undersurface of diaphragm. Nerve involvement of conus medullaris and sciatic nerve and muscle involvement of gluteal, adductors and rectus abdominis are rare sites that have been described in the literature previously [2,3]. This case is one of such rare spontaneous extrapelvic endometriosis described till date. The pathogenesis is probably due to vascular or lymphatic dissemination of endometrial cells [4]. The diagnosis and management of extrapelvic endometriosis pose a real big challenge to clinicians. The cyclical nature of symptoms is sometimes the only clue to reach the diagnosis. As up to 50% of these affected women may have concomitant pelvic endometriosis, further pre-operative diagnostic investigation is advisable. The gold standard for definitive diagnosis is laparoscopy and biopsy, but MRI can be recommended as the best non-invasive investigation. These tests could not be performed in our case due to financial constraints. Surgical excision only, brought complete relief of symptoms in this case.