(Circulation. 1999;99:843-844.)
© 1999 American Heart Association, Inc.
Images in Cardiovascular Medicine |
Sewing Needle Transfixing the Posterior Wall of the Left Ventricle Causes Death
From the Departments of Pathology and Internal Medicine, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
Correspondence to Professor Marcos A. Rossi, Department of Pathology, Faculty of Medicine of Ribeirão Preto, University of São Paulo, 14049–900 Ribeirão Preto, SP, Brazil. E-mail marossi{at}fmrp.usp.br
Self-mutilation with a sewing needle and a fatal outcome due to a penetrating wound of the heart is exceedingly rare. To the best of our knowledge, the present image represents the best-illustrated case of such an occurrence.
A 64-year-old woman, a dressmaker, was admitted to the University Hospital because of intense dyspnea. On physical examination, the patient was pale, cyanotic, afebrile, and sweating profusely. The blood pressure was not obtainable. An ECG revealed ST-segment elevation >2 mV in inferior leads and >1 mV in lateral leads. A QRS pattern suggestive of myocardial necrosis was seen in lead V1. The chest film showed an indistinct aortic contour, opacification of the space between the aorta and pulmonary artery, mediastinal widening, and interstitial pulmonary edema. Under the assumption that she had diaphragmatic myocardial infarction, she was medicated accordingly. After transfusion of packed red cells, the blood pressure rose (60 mm Hg systolic, 50 mm Hg diastolic), and the patient presented little clinical improvement. Thereafter, her responsiveness gradually declined, terminating in cardiac arrest and death 15 hours after entry. Five days earlier, the patient had been admitted to a Basic Health Unit complaining of epigastric pain radiating to the precordium. The physical examination revealed pallor and hypotension. Transfusion of fresh whole blood was given, and she was discharged in an improved condition. The patient had a past history of depression.
At autopsy, a sewing needle was found transfixing the posterior wall of
the left cardiac ventricle (Figure
). The
tip of the needle could be seen extruding from the middle of a
subepicardial hemorrhage in the upper third of the
diaphragmatic surface of the heart, close to the
atrioventricular grooves. This was associated with
hemopericardium (
250 mL), a small laceration (3 to 4 mm in
diameter) of the posterior parietal pericardium close to the
inferior esophagus, and mediastinal hematoma. The
radiograph of the heart showed the sagittal position of the needle,
with the eye inside the left ventricular cavity. The
sagittal sectioning of the heart showed a roughly conical area of
myocardial hemorrhagic infiltration with the base outside around the
4-cm-long needle, which had its eye inside the left
ventricular cavity. Microscopically, the needle orifice was
surrounded by a collar of myocardial necrosis and degeneration,
hemorrhage, fibrin, edema, bacterial colonies, and an acute
neutrophilic inflammatory infiltrate. The shape of the myocardial
hemorrhagic infiltration clearly indicates that the perforation of the
heart occurred from outside inward. It is likely that the patient
swallowed the needle, which entered the heart from the lower
esophagus.
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It is difficult to understand why the patient failed to notice the needle injury, but self-mutilation may occur in depressive syndromes, usually in association with severely depressed sensibility to pain. In addition, it is well known that needles can easily and rapidly migrate through tissues.
Acknowledgments
Professor Rossi is Senior Investigator of the Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq).
Footnotes
The editor of Images in Cardiovascular Medicine is Hugh A. McAllister, Jr, MD, Chief, Department of Pathology, St Luke's Episcopal Hospital and Texas Heart Institute, and Clinical Professor of Pathology, University of Texas Medical School and Baylor College of Medicine.
Circulation encourages readers to submit cardiovascular images to Dr Hugh A. McAllister, Jr, St Luke's Episcopal Hospital and Texas Heart Institute, 6720 Bertner Ave, MC1-267, Houston, TX 77030.
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