Self-inflicted intramyocardial injury with a sewing needle: a rare cause of pneumothorax

Unsuccessful suicidal attempts by sewing needle introducing to chest: Removing 17 ones from the right ventricle and breast tissue in two stages; case report and literature review

INTRODUCTION AND IMPORTANCE

Penetrating cardiac injuries among the whole injuries confronting the trauma surgeon is more alarming. The introduction of needles as an attempt to inflict self-injury has rarely been described, so we only found 34 reported cases reviewing the available English literature since 1967.

CASE PRESENTATION

We have reported a case of a 35-year-old depressed female who had introduced 17 sewing needles through her chest wall, causing myocardial puncture and mastitis; underwent exploratory sternotomy and mammoplasty in two stages and survived.

CLINICAL DISCUSSION

Penetrating cardiac trauma is rare enough for surgeons to deal with direct injuries by sewing needles. Penetrating wounds in the "cardiac box" anatomic area" should elicit the highest concern for potential cardiac injury. The mentioned region is demarcated superiorly by the clavicles, inferiorly by the xiphoid, and the nipples laterally in an area of the anterior thorax.

CONCLUSION

Anterior aspect penetrating traumas to the cardiac box myocardial injuries should be in mind, and immediate and proper intervention should be needed. Ventricles, for their anatomical condition, are exposed to be injured.

Postmortem Imaging of an Unusual Case of Fatal Heart and Lung Perforation Due to Self-Treatment

Intentional or accidental cardiothoracic injuries caused by needles and pins are rare and commonly reported in individuals with psychiatric conditions or intravenous drug users. Although rare, these cases could result in serious injury during the performance of an autopsy and highlight the importance of post-mortem radiology. Therapeutic complications with cardiac perforation have been reported due to pericardiocentesis and acupuncture. The majority of reported cases were not fatal and some had a prolonged asymptomatic period of weeks or even years after insertion. Needles or other sharp objects can reach the cardiovascular system directly through the chest wall, indirectly from any segment of the gastrointestinal tract after swallowing needles, or through migration of broken needles from distant injection sites in intravenous drug users. We report a case of rapidly fatal cardiopulmonary injuries following "self-treatment" to "pop" a cyst with a piercing needle. The scene, autopsy, computed tomography, and digital x-ray findings of this unique case are discussed with a review of selective literature. In this case, the right lung and heart showed multiple perforations, possibly resulting from heartbeats or respirations pushing the organs against the needle. To our knowledge, perforations in this setting of "self-treatment" have not been previously reported in the literature.

Teaching self-acupuncture survey report

BACKGROUND

People have been teaching self-acupuncture (SA) in the United Kingdom since 1977. More recently, a small body of research has been conducted on SA. However, detailed guidelines on teaching and delivery of SA have so far, to our knowledge, not been developed.

METHODS

Acupuncturists were invited to participate in an online survey about their experiences of teaching SA. Data from the survey were extracted, analysed using descriptive statistics and translated into SA teaching guidelines.

RESULTS

One hundred thirty-eight acupuncturists completed the survey. Nineteen percent of participants had taught SA. The most common symptoms for which acupuncturists taught SA were pain, nausea, anxiety, hot flushes, headaches/migraines and breathlessness. The six most commonly taught traditional acupuncture point locations were LI4, ST36, SP6, PC6, LR3 and TE5. No participants had received reports of adverse effects from their patients.

CONCLUSION

Acupuncturists who teach SA find it to be an acceptable and safe option for patients. The presented data have important implications for guiding the practice of SA.

Case report of a mysterious myocardial mass: an aetiological conundrum

Introduction

Atypical chest pain is frequently an aetiological conundrum, and missing a diagnosis of underlying cardiac disease can have detrimental consequences. The investigation of this may rule out cardiac disease but often provides no clear answers to the underlying pathology.

Case presentation

An 80-year-old man with a background of bilateral inguinal hernia repairs but no cardiac disease presented to his general practitioner with intermittent chest pain of approximately 15 min duration, felt inside his chest under his right nipple. His episodes of chest discomfort had increased in frequency, occurring both at rest and upon exertion. He was seen by the cardiology team at his local hospital and reassured following normal coronary angiography and outpatient echocardiography. The pain persisted, so cardiac magnetic resonance imaging (MRI) was arranged to exclude the underlying myocardial disease. This demonstrated a mass within the right ventricular free wall, which MRI was unable to characterize. Follow-up cardiac computed tomography showed this to be a metallic object within the right ventricular wall, but despite thorough examination of his medical and social history, there remains no obvious explanation to its aetiology other than potentially due to clip migration from his hernia repair.

Discussion

Metallic foreign bodies within the myocardium are described in case reports but almost entirely in the setting of intentional self-injury. There is no previous case evidence of migration of distal surgical clips to the heart, but there appears to be no other clear aetiology for this gentleman’s pathology, thus representing a novel description of iatrogenic injury.

An Unusual Case of Needle Embolus Presenting With Delayed Spontaneous Pneumothorax

We report the case of a 39-year-old man presenting with an acute right-sided traumatic pneumothorax secondary to migration of a hypodermic needle fractured during intravenous drug use. We discuss the unusual passage of this foreign body from the left groin to the right ventricular wall and into the mediastinum, ultimately presenting with a right pneumothorax 1 year later.

Self-Embedding Behavior in Adults: A Report of Two Cases and a Systematic Review

Self-embedding behavior (SEB) is the repeated insertion of sharp objects, such as needles or pins, into the soft tissues of abdomen, limbs, and other body parts. In this study, two cases of SEB were reported and the scientific worldwide literature reviewed. Thirty-two cases of SEB were identified through systematic searches in the main bibliographic databases. Mean age was 35 years (SD = 8.97). Just over two-thirds of the patients were female. Although the number of embedded objects could be as high as 200, major clinical and surgical complications were uncommon and mortality was null. Patients with SEB presented three major diagnoses: psychotic (25%), personality (21.9%), and factitious (28.1%) disorders. The practice of SEB largely went undetected as the patients themselves did not bring it to the attention of family members or physicians and usually denied they have engaged in SEB. A high level of suspicion is required to avoid a missed diagnosis.

Sewing Needle in the Heart

An unusual case of a sewing needle in the heart is reported for its rarity. The relevant literature is briefly reviewed.

Needle fragment embolism into the right ventricle: a rare cause of chest pain case report and literature review

Chest pain in young adults is usually self-limited and of benign etiology. However, rare causes of chest pain must be considered in patients for whom initial diagnostic tests are negative, particularly if unusual risk factors are identified. The authors present a rare case describing a 27-year-old male intravenous drug user who developed transient chest pain most likely secondary to pericardial irritation caused by a needle fragment that embolized from a peripheral vein to his right ventricle. The current literature on intracardiac needles and similar foreign bodies is discussed, providing insight to the epidemiology, complications, and treatment of such patients.

Metallic foreign body in heart mimicking moderator band

A foreign body in heart is rare, but it is more frequently encountered than the past as iatrogenic causes are increasing. Clinicians should be aware that foreign body could be mistaken for normal structure of heart. In order for accurate diagnosis, multi-imaging modalities should be used for information of exact location, mobility and hemodynamic effects. A decision to intervene should be made based on potential harms harbored by foreign bodies. Endovascular retrieval should be considered as an option. However, when fatal complications occur or when foreign bodies are embedded deeply, a surgical removal should be attempted.

Multiple self-inserted pins and nails in pericardium in a patient of schizophrenia: Case report and review

This report is the case of multiple self-inserted pins and nails in chest and pericardial cavity in a young male suffering from schizophrenia. This act of self-mutilation was done to get relief from burning sensation in chest and palpitations. Review of the relevant literature revealed that self-inflicted intra-cardiac needle injuries occur mainly in young and middle-aged adults suffering from psychiatric disorders, commonly depression, schizophrenia, and substance use disorders. In one-fourth of the patients, it is due to deliberate self-harm. About 70% use a single needle but 30% may use multiple needles. Second attempts are rare. Majority of the patients (85%) are managed by surgery and recover from the injury. The condition has a low mortality rate of 5%.

Interesting case of a sewing needle inside the heart: report of a case

Despite being rarely seen, penetrating cardiac injuries are clinically significant, as they are highly lethal. We herein present the case of a 3-year-old male who unintentionally injured himself by pricking his own chest with a sewing needle and introducing it through the left-lower margin of his sternum into his right ventricle. The needle was located anterior-posteriorly over the right ventricle. An anterior thoracotomy was performed, and the needle was safely removed. No hemorrhage or arrhythmia was seen, so the operation was ended. An early diagnosis and intervention proved to be life-saving for this penetrating cardiac injury.

Wires in the body: a case of factitious disorder

Factitious disorder can present with a wide variety of symptomatology. We present a case of a young girl presenting with spontaneous extrusion of wires from her limbs. These metallic wires were present in both her upper and lower limbs in the muscle bulk and were visible on X-ray. She sought repeated surgical removal of these wires, but the wires would invariably reappear. The patient could not be engaged in a therapeutic relationship and the family took premature discharge against medical advice, as they believed in supernatural causation for the phenomenon and were afraid that medical intervention might bring further ill fortune. The case highlights the importance of belief systems of family members as a barrier in managing such cases.

Management of metallic foreign bodies in the heart

Management of the metallic foreign body in the heart remains controversial. Evaluation of possible methods for this issue and its possible treatments are discussed, the results of which may lead to a more effective strategy for management of intracardiac foreign bodies.

Insertion of foreign bodies (polyembolokoilamania): underpinnings and management strategies

The Psychiatric Consultation Service at Massachusetts General Hospital sees medical and surgical inpatients with comorbid psychiatric symptoms and conditions. Such consultations require the integration of medical and psychiatric knowledge. During their twice-weekly rounds, Dr Stern and other members of the Consultation Service discuss the diagnosis and management of conditions confronted. These discussions have given rise to rounds reports that will prove useful for clinicians practicing at the interface of medicine and psychiatry.Dr Unruh is an attending psychiatrist at McLean Hospital, Belmont, Massachusetts, and an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts. Dr Nejad is an instructor in psychiatry at Harvard Medical School, Boston, Massachusetts, an attending physician on the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and the director of the Burns and Trauma Psychiatric Consultation Service at Massachusetts General Hospital, Boston. Mr Stern is a research assistant in the Department of Psychiatry at Massachusetts General Hospital, Boston. Dr Stern is chief of the Psychiatric Consultation Service at Massachusetts General Hospital, Boston, and a professor of psychiatry at Harvard Medical School, Boston, Massachusetts.Dr Stern is an employee of the Academy of Psychosomatic Medicine, has served on the speaker's board of Reed Elsevier, is a stock shareholder in WiFiMD (Tablet PC), and has received royalties from Mosby/Elsevier and McGraw Hill. Drs Unruh and Nejad and Mr Stern report no financial or other affiliations relevant to the subject of this article.

Self-embedding behavior: a new primary care challenge

OBJECTIVE

The goal of this study was to define self-embedding behavior (SEB), develop a clinical profile of adolescents who engage in SEB, and emphasize the importance of rapid, targeted, and effective identification and intervention.

METHODS

As part of a retrospective study with a database evaluating 600 patients percutaneously treated for soft-tissue foreign body removal, adolescents were identified with self-embedded soft-tissue foreign bodies. We describe patients' gender, age, and psychiatric diagnoses; SEB age of onset, frequency, and self-reported reasons; and the number, type, location of, and removal technique for objects.

RESULTS

Eleven patients (9 females) who engaged in SEB were identified. Ten of the 11 patients were members of a group home or psychiatric facility at the time they engaged in SEB. All patients had previous and multiple psychiatric diagnoses. SEB mean age-of-onset was 16 years, and mean number of SEB episodes per patient was 1.9. The most common self-reported purpose for SEB was suicidal ideation (6 of 8 [75%]) versus nonsuicidal ideation (2 of 8 [25%]), with 3 cases lacking this documentation. The mean number of objects embedded in a single episode was 2.4, usually composed of metal and embedded in the arm. Seventy-six foreign bodies were percutaneously removed (using ultrasound or fluoroscopic guidance), including metal, glass, wood, plastic, graphite, and crayon.

CONCLUSIONS

SEB is an extreme form of self-injury requiring aggressive and timely interdisciplinary assessment and treatment. An understanding of SEB allows medical professionals to pursue rapid, targeted, and effective intervention to interrupt the cycle of self-harm and institute appropriate long-term therapy.

Self-embedding behavior: radiologic management of self-inserted soft-tissue foreign bodies

PURPOSE

To report on a series of self-embedding behavior (SEB), demonstrate the effectiveness and clinical effect of image-guided foreign body removal (IGFBR) in the treatment of embedded soft-tissue foreign bodies (STFBs), and evaluate the role of the radiologist in the clinical management of SEB.

MATERIALS AND METHODS

This retrospective study was approved by the institutional review board. From a database of 600 patients treated with IGFBR with ultrasonographic (US) and/or fluoroscopic guidance, self-injury was identified in 11 (1.8%) mainly adolescent patients with a mean age of 16 years (age range, 14-18 years). Evaluated data included number of foreign bodies; number of repeat episodes of foreign body insertion; location, type, and size of foreign body; incision size; imaging modality; and success or failure of foreign body removal.

RESULTS

Seventy-six foreign bodies were inserted into the arm (n = 69), neck (n = 4), ankle (n = 1), foot (n = 1), or hand (n = 1) in the 11 patients. The number of STFBs per case ranged from one to 15. Foreign body types included metal (n = 40), plastic (n = 15), graphite (n = 12), glass (n = 4), wood (n = 3), crayon (n = 1), and stone (n = 1). STFB dimensions were 2.5-160.0 mm in length by 0.25-3.0 mm in thickness. Sixty-eight of the 76 STFBs were removed in the interventional radiology section. Incision lengths ranged from 4 to 8 mm (mean, 6 mm). The STFBs were removed with US guidance (n = 43), fluoroscopic guidance (n = 15), or a combination of the two modalities (n = 10). IGFBR was successful in all 68 cases, without complications.

CONCLUSION

Greater awareness of SEB may result in radiologists being the first physicians to identify SEB and rapidly mobilize an interdisciplinary team for early and effective intervention and treatment. Percutaneous radiologic treatment of self-imbedded STFBs is safe, precise, and effective for radiopaque and nonradiopaque foreign bodies.

A remnant sewing needle in the right ventricle as a cause of chest pain

Sewing needles, albeit a rare case of penetrating cardiac injury, are potentially life-threatening. We report a case of a self-inflicted remnant intracardiac sewing needle which is diagnosed with nonspecific chest pain and successfully extracted 23 months after its insertion.

The needle and the damage done: pericardial effusion with tamponade after needle ingestion in an infant

OBJECTIVE

Paediatric foreign bodies may present with vague and nonspecific symptoms. It is important to have a high index of suspicion when managing such cases.

METHOD

We report the case of a nine-month-old infant who presented with a wheeze, cough and fever following ingestion of a needle.

RESULTS

This patient developed pericardial tamponade as a consequence of the needle ingestion, and required a thoracotomy for retrieval. We discuss the pathophysiology involved and the surgery required.

CONCLUSION

Pericardial tamponade is a rare but potentially fatal manifestation of an ingested foreign body.

An unusual penetrating injury in an infant: straight-pin migration from the back to the stomach

Sharp foreign bodies reach into the abdomen frequently by ingestion and may lead to various complications including perforation. An 11-month-old infant is presented for straight-pin migration into the abdomen with penetration from the back and through the left diaphragm, spleen, and stomach. The infant was treated successfully with a well-organized diagnostic and therapeutic algorithm.

An amazing case of working wrist watch in the esophagus

Foreign bodies in the esophagus are commonly seen in otolaryngologic practice. We report the successful removal of a working wrist watch dial lodged for one month in the esophagus of an adult schizophrenic patient, which is a rare incident.

Intramyocardial foreign body: sewing needle with the uncommon clinical feature of constrictive pericarditis

A rare case of intracardiac injury with a sewing needle causing constrictive pericarditis is reported. A 72-year-old woman was admitted with edema of the face and legs. A chest radiogram showed a needle-shaped metallic image overlying the cardiac silhouette. Computed tomography revealed the needle was located in the left ventricular myocardium, and also showed a thickened pericardium. Surgical removal of the needle and pericardectomy were performed simultaneously.

Tricuspid Valve Incompetence Caused by an Intracardiac Needle-Like Foreign Body

We report a rare case of tricuspid valve incompetence caused by a needle-like foreign body with an unknown route of invasion. A 55-year-old woman who had suffered from chronic heart failure for more than 25 years was diagnosed as having Ebstein's anomaly after a transthoracic echocardiogram with Doppler imaging showed severe tricuspid regurgitation and displacement of the septal leaflet toward the right ventricle inlet. Surgery revealed a foreign body attached to the tricuspid valve, causing regurgitation. Valve replacement was performed and the patient's condition improved remarkably thereafter.

Kapalabhati pranayama: breath of fire or cause of pneumothorax? A case report

Spontaneous pneumothorax is the most common cause of pneumothorax. We report a case of a 29-year-old healthy woman who presented to the emergency department with a spontaneous pneumothorax caused by a yoga breathing technique called Kapalabhati pranayama, or breath of fire. Yoga breathing exercises are commonly practiced, and a limited number of studies have shown various physiologic benefits of yoga breathing. This is the only known report of spontaneous pneumothorax caused by pranayama, but some other rare causes are noted. This case should illustrate that adverse side effects can occur when one pushes the body to physiologic extremes.

Cardiac tamponade caused by migration of a swallowed sewing needle

The case of a 20-year-old female prisoner who died due to cardiac tamponade caused by a swallowed sewing needle migration is reported. According to the autopsy report and complete analysis of medical records, the migration of the swallowed needle was reconstructed: from esophagus and stomach, through diaphragm and pericardium up to the left heart ventricle, where the needle was found at the autopsy. The case is very interesting and unique: there has been no similar case described in medical literature so far.

Suicide by blunt force trauma

Suicide by self-inflicted blunt force injury is rare. The authors report a case of a 48-year-old man who initially appeared to have died of a homicidal beating. The pertinent autopsy findings consisted of blunt force closed head injury combined with numerous cutaneous abrasions and contusions of the entire body. Further inquiries confirmed a medical history of paranoid schizophrenia and a previous attempt at suicide. This case represents an extreme example of severe blunt trauma sustained during fatal self-mutilation and masquerading as a homicide. It also underscores the importance of correlating a thorough background investigation with autopsy findings in determining the appropriate manner of death.

Cutaneous foreign bodies: elusive presentation. Case report and review of the literature

Injuries by foreign bodies are a common problem in children, and sewing needles are not uncommonly found foreign bodies. Cutaneous foreign bodies are also occasionally seen, and these patients are referred to dermatologists because of skin findings resulting from body reactions. In this report we present an unusual case of a foreign body presenting as a linear skin eruption.

Foreign bodies in the chest: how come they are seen in adults?

The radiologic and clinical findings of foreign bodies in the chest of children are well recognized. Foreign bodies in adults are infrequent, however, and the radiologic findings of these unusual circumstances have rarely been described. We classified various thoracic foreign bodies into three types according to their cause: Type I, Aspiration, Type II, Trauma or Accident; Type III, Iatrogenic. This pictorial essay will illustrate the radiologic findings and consequences of thoracic foreign bodies in adults, which have rarely been described in the radiologic literature. The clinical significance of thoracic foreign bodies will be also be discussed.