Umbilical cherry.

A four and half-year-old female child presented to dermatology outpatient department with complain of a single red color fleshy mass in the umbilicus since birth. There was no history of increase in size of the lesion or urinary complaint or dribbling of urine from the umbilical lesion during micturition. There was no history suggestive of abdominal pain or diarrhea. There was history of intermittent bleeding from the lesion. History was suggestive of first-degree burn over back after accidental spillage of hot water at the age of two years, followed by development of post-burn keloid.

Examination revealed a single cherry-colored papule in the umbilicus with normal surrounding skin [Figure 1]. Ultrasound of abdomen showed Meckel's diverticulum with a fibrotic strand connecting the anterior abdominal wall. Excision biopsy of the lesion was done by pediatric surgeon.

Figure 1

A single erythematous cherry like papule in the umbilicus

Question

What is your diagnosis?

Answer

Persistent vitellointestinal duct

Discussion

Adam and Eve were the only individuals immune from nagging problems related to umbilicus and its adjuvant structures. Persistent vitellointestinal duct (omphalomesenteric fistula) is a rare congenital developmental anomaly of embryonic omphalomesenteric duct.[1] It results from faulty closure of vitelline duct and can manifest as (1) a persistent vitelline duct (appearing as a draining fistula at the umbilicus); (2) a fibrous band that connects the ileum to the inner surface of the umbilicus; (3) a patent vitelline sinus beneath the umbilicus; (4) an obliterated bowel portion; (5) a vitelline duct cyst; and, most commonly (97%) Meckel's diverticulum, which is a blind-ending true diverticulum that contains all of the layers normally found in the ileum and whose apex lies free in the peritoneal cavity.[2]

Vitellointestinal duct anomalies can either present as an asymptomatic fleshy lesion (as in our case) or as swelling in the umbilical region. Most of the times, parents do not pay much attention to such an innocuous-looking lesion or may sometimes present to a dermatologist with a chronic discharging umbilicus. Differentials for fleshy mass in umbilical region includes umbilical granuloma, raspberry tumor, patent urachus, and umbilical hernia and rarely lobular capillary hemangioma.[3] Vitelline duct anomalies can act as a leading point for intussusception and resulting in strangulation and infarction of small bowel leading to high surgical morbidity. Because of these risks, it would appear wiser to explore the abdomen early in all babies who show intestinal mucosa at the umbilicus. Hence, it is important for a dermatologist to diagnose such conditions with reasonable accuracy and refer them to appropriate specialties for surgical intervention. To make a good diagnosis, a detailed history taking is imperative and should include the following points as mentioned in Table 1.

Table 1

Important points during history taking

Specific investigations include a thorough abdominal ultrasound with special attention paid to ileal region and an upper GI endoscopy. All suspicious lesions at the umbilical region pointing towards vitelline duct anomaly should be explored surgically and decision regarding excision can be made by operating surgeon depending upon the nature and extent of severity.