﻿Spontaneous Parasitic myoma with the omental vessel: A Case report and literature review


 Aim: The study is the Case Report of spontaneous parasitic myoma with omental vessel, and the management at Bahrain Defense Force Hospital. Case Report: A 35years old female was diagnosed, almost 20 cm, sub serous myoma with the pedicle of 2cm from the fundus of the uterus. There was a feeding vessel from the omentum. She underwent myomectomy after the resection of pedicle and omental vessel .Post-operative period was uneventful. Conclusion: Parasitic myoma is the type of subserous uterine myoma. Generally surgical management is required for the relief of symptoms and to avoid encroachment of nearby abdominal or pelvic structures which in turn leads to further complications.


Introduction
Parasitic myomas are the rare type of subserous uterine myomas 1,2 . whenever the subserous myomas getting attachment to the surrounding structures ,they derive the feeding vessel from them and detach from the uterine blood supply and the uterine pedicle often dissipate 3,4 . Parasitic broids frequently attached to omentum 3 .The other structures of attachment includes urethra ,bladder, Gastrointestional tract ,intraperitoneal and retroperotoneal myomas 5,6 . Mostly etiology is not well understood 2,7 .One of the possibility is post laparoscopic removal of uterine myomas 1,8,9 .Commonly they may not be symptomatic .Mostly diagnosis is incidental. However symptoms are in relation with the size, location, numbers and the attached structure 8 .The common symptoms include abdominal distension ,abdominal pain, pelvic pain and pressure symptoms 2,10 . Diagnosis could be assisted by imaging such as ultrasonogram ,Computed tomography (CT scan)and Magnetic Resonance Imaging (MRI) 3,8 .Management is generally surgical resection of feeding blood vessel and removal of parasitic myoma 10 .

Case Report
We report an infrequent case of spontaneous Parasitic Fibroid in a young unmarried Female.

Discussion
Kelly and Cullen described parasitic leiomyomas as early as 1909 11 .Their presentation is varied. These unique broids were classi ed by Nezhat and Kho into three categories. The rst category spontaneously develops from pedunculated broids which detach from the uterus and grow by gaining blood supply from adjacent organs. The second type develops due to reduction in blood ow to the uterus and the third category develops following uterine surgeries 12 . Our case is a spontaneous broid in an unmarried lady which is of the second type. The third type of broid is suggested to be a complication of morcellator usage in laparascopic surgeries, which occurs due to tissue growth spread in the pelvic cavity concluded Ladke AB and colleagues 13 . As a solution they suggested the usage of endobag morcellation Genetic and hormonal factors may be responsible for parasitic broids where a history of morcellation is absent suggested AlTalib A and group 14 .A case report by Alnagar A et al revealed a different presentation of the parasitic broid where it was attached to the jejunum and the patient presented with small intestinal obstruction 7 .This brings out the complexity in presentation of these unusual leiomyomas.
A similar case to ours was reported by Mushtaq R et al where a parasitic broid along with tortuous omental vessels were identi ed 15 . Our patient's main concern was the abdominal distension and pressure symptoms. A literature searches on parasitic broids by Lete I et al gathered information on 274 patients. They found that the mean age was 40 years. 56% had no uterine surgery and 39% had a history of morcellation. The clinical symptom frequently encountered was abdominal pain which accounted for 49% 16 . Our patient was 35 years old and also did not have any kind of surgery. Ghamande SA and colleagues reported a case with high Ca -125 associated with parasitic leiomyoma 17 .Interestingly, Osegi N and group also published a case of a parasitic broid in a post-menopausal woman who had no history of any previous surgery 4 . Varun N and colleagues also presented a case of a parasitic broid in pregnancy 18 .A case report by Salih AM and group in 2017 concluded that these unique myomas presenting with vague symptoms are diagnosed by ultrasound and resection of the myoma is the management 1 .We used ultrasound and MRI along with clinical assessment for the diagnosis and myomectomy along with the double ligation of the omental vessel as the management.

Conclusion
Parasitic leiomyomas have a diverse presentation and causes dilemma when the condition is not kept in mind when dealing with a mass per abdomen. Hence this condition should be considered as a differential diagnosis for early management.

Declarations
Con icts of Interest: None.
Written consent: has been obtained from the patient.