Endometriosis con infiltración aislada del nervio ciático, una forma de presentación atípica: reporte de un caso clínico / Isolated infiltrative endometriosis of the sciatic nerve, an atypical presentation: clinical case report

INTRODUCCIÓN: La endometriosis afecta hasta un 10-15% de las mujeres jóvenes. Se define como tejido endometrial funcional fuera de la cavidad uterina y su presentación clásica es la dismenorrea. La variedad profunda afecta a un 1-2% y las localizaciones más frecuentes son el peritoneo pélvico, ovarios, ligamentos útero-sacros y septum recto-vaginal; sin embargo, puede presentarse de forma muy infrecuente como implantes aislados localizados en relación al nervio ciático. El diagnóstico habitualmente es complejo y tardío, dado que los síntomas son inespecíficos y el examen físico puede ser indistinguible de otras etiologías. El estudio imagenológico de elección para la endometriosis profunda es la resonancia magnética (RM) de pelvis ya que una adecuada localización pre-quirúrgica de las lesiones es fundamental. CASO CLÍNICO: Paciente de sexo femenino de 46 años, con tres años de dolor pélvico, dismenorrea y dispareunia. El síntoma cardinal fue dolor ciático progresivo, con déficit motor y alteraciones sensitivas, los cuales se exacerbaban durante la menstruación y no presentaban respuesta al tratamiento farmacológico. En la RM se identifica nódulo sólido sospechoso de endometriosis en relación al nervio ciático derecho. El caso es evaluado por un comité multidisciplinario y se realiza cirugía laparoscópica. El diagnóstico de sospecha es confirmado histológicamente. La paciente presenta buena recuperación post-quirúrgica y cese completo de los síntomas descritos. DISCUSIÓN: La endometriosis profunda presenta un reto diagnóstico y habitualmente es tardío. Este caso presenta el resultado exitoso de una buena sospecha clínica, un estudio imagenológico completo y la resolución con una técnica quirúrgica compleja.

INTRODUCTION: Endometriosis is a disease that affects 10-15% of young women. It is characterized as functional endometrial tissue outside the uterine cavity. The most common form of presentation is dysmenorrhea. Deep endometriosis affects 1-2% of the patients, and is frequently located in the pelvic peritoneum, ovaries, utero-sacral ligaments and recto-vaginal septum. The isolated endometriosis of the sciatic nerve is a very uncommon presentation of this disease. Late diagnosis is frequent, mainly because the symptoms are non-specific, and the physical examination may be indistinguishable from other etiologies. The imaging study of choice is the pelvic magnetic resonance imaging (MRI) and an accurate pre-surgical location of the lesions is critical for a successful surgical outcome. CLINICAL CASE: 46-year-old female patient with 3 years of pelvic pain, dysmenorrhea and dyspareunia. The cardinal symptom was progressive sciatic pain, with motor deficit and sensory alterations. The pain was persistent despite pharmacological treatment and exacerbated during menstruation. MRI identifies a nodule located in the pelvic portion of the right sciatic nerve, suggestive of an endometriosis implant. The case was discussed by a multidisciplinary committee and laparoscopic surgery was performed. The diagnosis was confirmed with histology. The patient recovered well from surgery with significant improvement of the previously described symptoms. DISCUSSION: The diagnosis of deep endometriosis is challenging and usually delayed. This rare disease had a successful outcome, due to an early clinical suspicion, a thorough imaging study and an effective resolution with a complex surgical technique.

Benign Solitary Schwannoma of Right Ulnar Nerve – A Case Report.

Introduction: Benign peripheral nerve schwannomas are uncommon tumours. Extra cranial schwannomas have also been reported from uncommon and unusual sites including breast, pancreas, and gastrointestinal system. Peripheral nerve schwannomas may pose a problem in clinical diagnosis, however an appropriate diagnostic work-up including thorough history and clinical examination, Ultrasonography, magnetic resonance imaging, fi ne needle aspiration cytology, nerve conduction velocity and electromyography study may all help reaching the correct preoperative diagnosis. Th e important clinical diff erential diagnoses include traumatic neuroma, neurfi bromas, lipoma, cold abscess and muscle hernia. Th e defi nitive treatment of benign peripheral nerve schwannoma is complete enucleation of the tumour mass without damaging the intact nerve fascicles followed by confi rmatory histopathological examination. When there is a doubt on histopathology, a positive Immunohistochemical staining with S100 is helpful in confi rming a diagnosis of schwannoma. Case presentation: We had 40 years female who had a slow growing swelling over the inner aspect of her right elbow for the last one year; this was followed by pain, tingling and numbness over inner one and half fi ngers of her right hand for six months. Tinnels sign was positive over the swelling. Her subsequent clinical examination and investigations including a magnetic resonance imaging was suggestive of a benign growth in her right ulnar nerve in the elbow region. Complete enucleation of the swelling was done from the right ulnar nerve in the elbow region and subsequent histopathological examination confi rmed it to be a benign cellular schwannoma. Patient recovered successfully after the surgery and paresthesia in the distribution of her right ulnar nerve also improved six weeks after surgery. At her last follow-up six months after surgery, the patient was completely asymptomatic and highly satisfi ed with the results of surgery. Conclusion: A correct preoperative diagnosis of peripheral nerve schwannomas is possible, and it can be successfully managed with complete enucleation of tumour mass with satisfactory patient outcomes.