The most clinically accepted term for what was inside the baby is "fetus in fetu" to describe the bone and tissue structures arranged so systematically as to resemble a human cranium with brain tissues, vertebrae, and even the beginnings of a limb. These features, noted Llanes, categorizes Eljie's tumor a step above a mere teratoma, a form of tumor that is known to harbor the buds of human body parts as well. On close inspection, the baby's tumor even presented with fine hair strands growing on a surface that had the consistency of human skin.

    There are fewer than 90 such cases in all of recorded medical history, and this is the first case documented in the Philippines. "Fetus in fetu" actually refers to a situation where one of twin fetuses engulfs the other during development in the womb and becomes the host to "a parasitic twin" within its body.

    Llanes said that the evolution of Eljie's absorbed twin appeared to have been cut short only weeks after conception, as it was only able to reach what is known in embryology as the "primitive streak" stage, marked by the presence of vertebrae and the spinal axis.

    "Evolution of fetus in fetu is usually arrested during the first trimester and what can happen after that is evolution by mass accretion rather than development, meaning, there is an increase in cells but no specialization," he said, noting that the mass inside the Millapes baby's belly continued to grow while the incipient twin inside it had stopped evolving.

    He observed that compared with other documented cases, baby Eljie's parasitic twin was even less evolved, not having the rudiments of a gastrointestinal tract, liver, and pancreas found in others. But the dumb assertion of its parasitic existence seemed to be stronger nevertheless, unlike in other cases where discovery took years, especially before the advent of medical imaging. In one instance, it took an autopsy of an adult host who had died from a totally unrelated cause to discover what was in his stomach.

Interest and controversy

    The grotesque circumstances so closely resembling the trappings of human pregnancy in this and other "fetus in fetu" cases have always attracted popular attention and fanciful conjectures.

    Among those recently documented were a baby boy from Chile and a male farmer from India in his mid-30s whose suppressed twin was only discovered when the bulge in his stomach, which had always been so out of proportion with the rest of him, suddenly became too much to bear one day. They still survive, having to field only perhaps the odd joke about being in the wrong gender for pregnancy.

     Baby Eljie's death stirred a different kind of controversy that almost overshadowed the novelty of his case. From a story about a local scientific phenomenon, it also became an indictment of a medical establishment's handling of a charity patient's case, resulting in at least one lawsuit for libel filed by an attending physician against a journalist from a leading daily.

    Even the excised tumor sitting innocently in the BGH pathology lab became an object of a mini-custody battle, with the baby's family claiming that the hospital is keeping them from having it, an allegation the hospital explained as only a temporary requirement for them to fully document the case.

    Llanes also disputed reports that the hospital was experimenting on the specimen, another claim that stoked the feelings of the baby's kin. He explained: "Because of its rarity, we were preserving it, keeping it intact as much as possible. We were also considering the rights of the parents."

     But months after the death of their child, the parents seem far from appeased. In a recent telephone interview with MEDICAL OBSERVER, the baby's father Edsel Millapes staunchly maintained that there was an element of medical neglect involved in his infant son's death. Eking out a living with wife Lorna and their firstborn in a mountainous village that even Bolinao town residents deem remote, Edsel had to seek the services of a midwife for a home-based delivery of the baby.

    Lorna was said to have gone for prenatal checkups, but none seemed to have involved an ultrasound or any other diagnostic procedures to alarm her of any abnormality. The parents and the BGH doctors were thus equally surprised by what the X-ray images showed them.

    It was decided nevertheless that the fetus in fetu had to be excised to save the host twin's life. According to the surgeon in charge, Dr. Alfredo Igama, it was to be a straightforward tumor operation, despite the unusual circumstances.

    He explained: "It was a dead fetus with no heart and no other internal organs functioning that's why we considered it as just a tumor. If it has a functioning heart, then morally it should be considered as having a soul."

    Llanes added that although pathologists tend to make finer distinctions in defining tumors, the identifying marks of an evolving fetus found in the baby's tumor were nowhere near normal and there was no possibility of independent survival for the parasitic twin.

More complications

    What really complicated things was that the baby, born with Down's syndrome, was in extremely poor health. "When I first saw the baby, I thought he wouldn't be able to withstand the surgery so I was not keen to do it," recalled Igama. "But the pediatrician was able to improve the condition of the baby after a week so the go-signal was given to do the operation."

    Reacting to criticisms about the hospital's handling of the case, he added that the BGH pediatrics department even helped the parents cover some of the expenses, like the laboratory tests, due to the interest ignited by the rare case.

    After the surgery, the team attending to the baby thought they had the situation well in hand, until postoperative complications cropped up four days after. Abdominal distension was noted again, arising from gangrene in the baby's small intestine and a blockage of the blood supply to the intestines.

    This led to an emergency second surgery which again seemed to bode well as it allowed the baby to feed for a short while after. But severe infection reared its ugly head again and this time. The baby eventually succumbed to sepsis he had acquired in his immunocompromised state.

    Igama said that an earlier detection of the fetus in fetu, when there would have been fewer complications to deal with, could have improved the baby's chances of survival.

    Indeed, Llanes pointed out that there are fewer surgical deaths among cases documented in recent literature compared with those from the past century, when preemptive measures like medical-imaging tools and fetal surgery were still in the realm of science fiction.

    And despite controversy and the lack of advanced facilities to study the specimen, he said he still plalsn to present his full report about the bizarre case, which is estimated to occur only in one out of every 500,000 births, to the local and international pathology community. M

 

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