Looking for a polyp, we found a...crab!

Chronic endometritis (CE) is an infectious or reactive process with multiple etiologies. The lesion is reportedly often associated with pelvic inflammatory disease, inter-menstrual bleeding, and pelvic pain [1].

Recently, Cicinelli and coworkers [2, 3] identified the hysteroscopic appearance of CE as characterized by the presence of endometrial micropolyps (less than 1 mm of size) associated with stromal edema, endometrial thickening and peri-glandular hyperhemia. These subtle lesions may be sporadic or may cover most of the endometrial surface. The detection of plasma cells in the stromal tissue of micropolyps is considered a marker of CE [4].

The association between endometrial polyps and CE is still unclear. However, it is likely that in both cases, impaired endometrial proliferative processes are involved.

We report on a 33-year-old woman referred to our department for primary infertility, pelvic pain, and intermenstrual spotting. Transvaginal ultrasonography showed a focal thickened endometrium suggestive for endometrial polyp. Office hysteroscopy was performed during proliferative phase using a 4-mm hysteroscope (office operative continuous flow hysteroscope size 4; Karl Storz GmbH & Co., Tuttlingen, Germany) with a 30°-grade optic and an incorporated 5Fr working channel. Vaginoscopic approach and normal saline solution were used to identify external uterine ostium to distend uterine cavity. Intrauterine pressure was maintained at a constant 50–70 mmHg with an electronic pump for irrigation and aspiration (Endomat; Karl Storz GmbH & Co.). Neither analgesia nor anesthesia was administered to our patient. At the entrance within the uterine cavity, a “bizarre” hysteroscopic finding similar to a waterscape was detected. A brownish, 1.5 cm-sized polypoid lesion with two foothills was detected in the fundal area (Fig. 1a) giving the appearance of a small crab (Fig. 1b); the overall endometrial surface was non-homogeneously thickened and hyperhemic covered by multiple thin and elongated micropolyps (1–3 mm size; Fig. 1a) similar to seaweeds (Fig. 1b).

Fig. 1

A brownish, 1.5 cm-sized polypoid lesion with two foothills was detected in the fundal area (a) giving the appearance of a small crab (b); the overall endometrial surface was non-homogeneously thickened and hyperhemic covered by multiple thin and elongated micropolyps (a) similar to seaweeds (b)

Multiple endometrial biopsies were performed with grasping forceps with teeth and histology confirmed the hysteroscopically suspected diagnosis of CE

Antibiotic therapy (doxiciclin 100 mg twice a day) was administered to our patient for 15 days. An office hysteroscopy was performed 2 months later showing a normal pinkish endometrial mucosa with the polyp crab-like being completely removed by means of 5Fr bipolar electrode (Versapoint Twizzle electrode, Gynaecare, Ethicon) and grasping forceps.

The hysteroscospic findings are often out of the ordinary and difficult to be interpreted; images taken from every-day life can help the operator to better describe such uncommon findings. Endometrial biopsy is recommended mostly to rule out infective or neoplastic endometrial conditions.