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CASE REPORT
Year : 2015  |  Volume : 60  |  Issue : 4  |  Page : 400-402
A tale of two tails: Not just skin deep


1 Department of Pediatric Medicine, North Bengal Medical College, Kolkata, West Bengal, India
2 Department of Dermatology, Venereology, and Leprosy, RG Kar Medical College, Kolkata, West Bengal, India

Date of Web Publication10-Jul-2015

Correspondence Address:
Dr. Sudip Kumar Ghosh
Department of Dermatology, Venereology and Leprosy, RG Kar Medical College, Kolkata, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.160496

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   Abstract 

The dorsal cutaneous appendage or the so called human tail is a rare congenital anomaly protruding from the lumbo-sacro-coccygeal area. These caudal appendages are divided into true-tails and pseudo-tails. We report here two cases of congenital pseudo-tail with underlying spina bifida and lipo-meningocele. In this article we seek to emphasize that, as the skin and nervous systems are intimately linked by their similar ectodermal origin, a dorsal appendage may be regarded as a cutaneous marker of the underlying spinal dysraphism.


Keywords: Human tail, lipo-meningocele, spinal dysraphism


How to cite this article:
Dutta A, Ghosh SK, Mandal AK. A tale of two tails: Not just skin deep. Indian J Dermatol 2015;60:400-2

How to cite this URL:
Dutta A, Ghosh SK, Mandal AK. A tale of two tails: Not just skin deep. Indian J Dermatol [serial online] 2015 [cited 2019 Jul 21];60:400-2. Available from: http://www.e-ijd.org/text.asp?2015/60/4/400/160496

What was known?
The dorsal cutaneous appendage or the so called human tail is a rare congenital anomaly protruding from the lumbo-sacro-coccygeal area.



   Introduction Top


The tail is the portion at the posterior end of an animal's body. Generally, the term represents a distinctive, flexible appendage to the body. The dorsal cutaneous appendage or the so called human tail is a very rare congenital anomaly projecting from the lumbo-sacro-coccygeal area. [1],[2],[3],[4] This inquisitive condition has been considered to be a proof of man's descent from or relation to other primitive animals. At times, the 'tail' may be a center of many superstitions also. [3] A baby with a 'tail' brings about extreme psychological stress to the parents as well as to the family members. [1]

We describe here a report of two new born babies who presented with tail-like structures with underlying lipomeningocele on their back.


   Case Reports Top


Case 1

A 6-day-old newborn boy was admitted with a tail-like structure on the top of a swelling on his back. The baby was born by normal delivery at term and there was no history of consanguinity of his parents. The perinatal period was uneventful. Examination revealed a term baby weighing 2.7 kg with normal vital signs. His head circumference was within normal limit. On the lower back, we found a soft non-tender swelling, measuring 4 cm × 5 cm, with an umbilication in the center. A tail-like soft appendage (1.5 cm long) was projected from the left lower quadrant of the swelling [Figure 1]. Detailed neurological examination and examination of the other systems were normal.
Figure 1: (a and b) A mass with a dimple on middle and a tail-like appendage

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Magnetic resonance imaging (MRI) of the lumbo-sacral spine revealed spina bifida at the level of first sacral vertebra, evidence of lipo-myelomeningocele, and tethering of spinal cord [Figure 2]. Echocardiography and ultrasonography of the brain and abdomen were normal.
Figure 2: MRI (T2W) of the lumbo-sacral spine showing features of (a) tethering of spinal cord (marked by arrow) and (b) lipomeningocele (marked by arrow)

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Case 2

A 7-day-old, term new born boy, weighing 2.6 kg, was brought to us for the evaluation of a tail-like structure on his lower back. He was delivered by lower uterine segment caesarian section of a 24-year-old primigravida. The baby had good reflexes and activities and was appropriate for his gestational age.

Examination of the lower back revealed a soft, non-tender, elongated structure (measuring 3 cm × 1.5 cm), covered with normal skin, resembling a 'tail' [Figure 3]a and b]. On palpation, there was a gap in the lower lumbar vertebrae underneath the 'tail'. The overlying skin showed no breach in the continuity.
Figure 3: (a) A tail-like cutaneous appendage on back. (b) Close-up showing a tail-like structure. (c) Computed tomography showing spina bifida (marked by arrow) along with lipo-meningocele. (d) Magnetic resonance imaging showing tethering (marked by arrow) of the spinal cord

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Systemic examination was essentially normal. Computed tomographic (CT) scan of the lesion revealed spina bifida at fourth and fifth lumbar vertebral level and underlying lipomeningocele [Figure 3]c]. MRI of the lesion also showed spina bifida at the same level and a lipomeningocele. It also revealed tethering of spinal cord at the level of 5 th lumbar vertebra [Figure 3]d]. Ultrasonography of the abdomen and brain was normal. Echocardiography and skeletal survey of other bony parts were normal.

In both the cases the mothers had no suggestive history of any drug exposure during pregnancy or any systemic illness. There was no family history of any congenital anomaly. No voluntary movement of the structures was noted.

Based on the clinical features and imaging, a diagnosis of congenital pseudo-tail with underlying spina bifida and lipomeningocele was made in both the cases. No other congenital anomaly was present. The babies were referred to pediatric surgery and neurosurgery departments for appropriate surgical management.


   Discussion Top


Human embryos have a tail measuring roughly one-sixth of the size of the embryo itself. [5] It is a normal feature during the embryonic development. Embryonic tail regresses by fusion and a remnant is left as coccyx. The developmental tail is thus a human vestigial structure.

The caudal appendages are unusual malformations and are divided into true-tails and pseudo-tails. [2] It is very important to make distinction between true and pseudo-tail as the treatment and prognosis is significantly different.

A true human tail is considered as a boneless, midline protrusion, capable of spontaneous or reflex movement. The true human tail lacks vertebrae and is typically attached to the skin of the sacrococcygeal region. [3] In contrast, pseudo-tail may be one of the complex sacrococcygeal malformations. The pseudo-tail masquerades a vestigial tail and is covered by skin. However, it may consists of coccygeal vertebra, lipoma, teratoma, glioma, chondromegaly, meningocele, or parasitic fetus. [6] On the other hand, occult spinal dysraphism may be associated with cutaneous signs in more than 50% cases. [7] Pseudo-tails are encountered more commonly in girls than in boys; true-tails are seen in the reverse frequency. [6]

Advanced imaging technology in the modern era has revealed its relation to the underlying anomalies like spinal dysraphism and tethered spinal cord, among others. [4]

The associations of central nervous system anomalies in children with spinal dysraphism underlying human tails have also been described. The most common co-existing intracranial findings were hydrocephalus, corpus callosum abnormalities, heterotopic gray matter, and  Arnold- Chiari malformation More Details More Details. In view of the fact that neural tube closure defect is not a single developmental abnormality, some authors believe that spinal MRI is not sufficient in the evaluation of human tail. They emphasized upon imaging studies of the entire neuraxis in every case of spinal dysraphism. [8] There are only a few reports of the prenatal sonographic diagnosis of the human tail. In most cases, the tail disappeared shortly after detection. However, at birth, dermal abnormalities such as deep dimples, scarred tissue, and pilonidal sinus, may be found. More rarely, the tail persists in the newborn. [9]

Microscopic examination of all true human tail showed skin covering a core of adipose tissue, collagen fibers, and skeletal muscle fibers. No bone or cartilage has been documented. [2] An associated lipoma, lipomeningocele, capillary hemangioma, or juvenile hemangioendothelioma, glial fibers, and calcification have also been reported in relations to dorsal appendages. [5]

Management of these appendages should include a detailed history and clinical examination plus thorough radiological evaluation. Treatment is essentially surgical. Excision of the tail and microsurgical procedures for any intraspinal component are the usual procedures of choice. [3] Since the clinical differentiation between the true-tail and pseudo-tail is almost always doubtful, and in spite of a normal neurological examination, normal plain x-ray of spine, and clinical classification of true-tail, subfascial exploration may reveal tethered cord or lipomeningomyelocele.

Therefore, whatever may be the type of tail, each individual case requires complete preoperative investigation, and surgical exploration of the intraspinal content should be done microsurgically to avoid any damage or neurological deficit. [7]

Long term follow up for early detection of probable post-surgical complications, especially in cases with spinal cord involvement, is mandatory.

To conclude, as the skin and nervous systems are closely related by their similar ectodermal origin, [4] a dorsal appendage may be regarded as a cutaneous marker of the underlying spinal dysraphism.



 
   References Top

1.
Mukhopadhyay B, Shukla RM, Mukhopadhyay M, Mandal KC, Haldar P, Benare A. Spectrum of human tails: A report of six cases. J Indian Assoc Pediatr Surg 2012;17:23-5.  Back to cited text no. 1
[PUBMED]  Medknow Journal  
2.
Kabra NS, Srinivasan G, Udani RH. True tail in a neonate. Indian Pediatr 1999;36:712-3.  Back to cited text no. 2
    
3.
Cai C, Shi O, Shen C. Surgical treatment of patient with human tail and multiple abnormalities of the spinal cord and column. Adv Orthop 2011;2011:153797.  Back to cited text no. 3
    
4.
Sarmast AH, Showkat HI, Mir SF, Ahmad SR, Bhat AR, Kirmani AR. Human born with a tail: A case report. S Afr J CH 2013;7:38-9.  Back to cited text no. 4
    
5.
Kansal R, Agrawal N, Khare S, Khare A, Jain S, Singhal BM. Newborn with tail - A genetic throwback. P J S R 2010;3:15-7.  Back to cited text no. 5
    
6.
Hori A. Developmental anomalies of the spinal cord. Neuropathology 1998;18:433-43.  Back to cited text no. 6
    
7.
Singh DK, Kumar B, Sinha VD, Bagaria HR. The human tail: Rare lesion with occult spinal dysraphism--a case report. J Pediatr Surg 2008;43:e41-3.  Back to cited text no. 7
    
8.
Alexiou GA, Sfakianos G, Prodromou N. Human tail and spinal dysraphism. J Pediatr Surg 2009;44:477-8.  Back to cited text no. 8
[PUBMED]    
9.
Efrat Z, Perri T, Meizner I, Chen R, Ben-Rafael Z, Dekel A. Early sonographic detection of a 'human tail': A case report. Ultrasound Obstet Gynecol 2001;18:534-5.  Back to cited text no. 9
    

What is new?
In this report we sought to emphasize that a dorsal appendage may be considered as a cutaneous marker of the underlying spinal cord anomaly.


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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