Wednesday, December 24, 2014

Congenital Gluteal Lesion

The patient is an 18 year-old boy with a congenital lesion in the gluteal cleft.
His mother says it has been slowly enlargely.  He is in excellent health and the lesion is asymptomatic.  The patient is an athlete, plays basketball.

O/E:  There is a 1 cm in diameter flesh-colored tumor just in the gluteal cleft.  No other cutaneous findings.

Clinical Photo:

Investigations:  None at this time

Diagnosis:  Soft tissue tumor of gluteal cleft.  Fibroma vs. lipoma

Question:  Midline lesions of the lubbosacral area may be a sign of spinal dysraphism.  Usually, the findings are more impressive than this.  It is unclear if a banal lesion such as this requires a work-up.  What are your thoughts.  If the reference below is to be believed, this patient's risk of OSD is low and workup may be of questionable value.

Skin markers of occult spinal dysraphism in children: a review of 54 cases.
Guggisberg D et. al.  Arch Dermatol. 2004 Sep;140(9):1109-15.  Free Full Text.
OBJECTIVES: To verify the diagnostic value of lumbosacral midline cutaneous lesions in asymptomatic children to detect occult spinal dysraphism (OSD) and to propose a practical approach for clinical investigations with respect to the type of cutaneous lesions observed.
DESIGN:Retrospective study of 54 children referred to the Department of Pediatric Dermatology between 1990 and 1999 for congenital midline lumbosacral cutaneous lesions.
SETTING:The private or institutional practices of participating dermatologists and pediatricians.
MAIN OUTCOME MEASURES:Evaluation of the diagnostic value of midline cutaneous lesions for the detec-tion of OSD. Association of skin examination findings with spinal anomalies detected by magnetic resonance imaging or ultrasound.
RESULTS: Occult spinal dysraphism was detected in 3 of 36 patients with an isolated congenital midline lesion and 11 of 18 patients with a combination of 2 or more different skin lesions.
CONCLUSIONS: A combination of 2 or more congenital midline skin lesions is the strongest marker of OSD. Careful dermatologic examination is needed to detect suggestive markers and request a spinal magnetic resonance image, which is the most sensitive radiologic approach to detect an OSD.