A 58-year-old female patient presented to her general practitioner’s (GP) office accusing progressive thoracic pain and shortness of breath. The symptoms had debuted a few days prior to the consultation. Her past medical history revealed gastroesophageal reflux disease with regular proton-pump inhibitor medicamentous treatment and a previous birth through cesarean delivery, which she had undergone 18 years prior in a foreign country.\nAt the moment of consultation, her general status was mildly altered and she estimated the level of pain to be around 8/10. The physical examination conducted by the GP was marked by an episode of vomiting. On auscultation, all heart sounds were muffled. The patient’s blood pressure was 90/60 mmHg and her heart rate was 110 beats per minute. Electrocardiography (ECG) revealed sinus tachycardia, as well as Q waves and minimal acute ST segment elevation with concordant T waves in the inferior leads (Fig. ). Due to the electrocardiographic aspect being suggestive of an acute inferior myocardial infarction (MI), the patient was referred to our clinic for further investigations and possible therapeutic intervention.\nDuring the prehospital care the patient received 300 mg acetylsalicylic acid per os, 600 mg clopidogrel per os, and 5000 IU unfractionated heparin intravenously, in accordance to current STEMI guidelines [, ]. After admission, coronary angiography was promptly performed, but returned a negative result. However, it uncovered the silhouette of a long and thin metallic object (supposedly a needle) appearing to oscillate with the cardiac contractions (Fig. ). After further inquiry, it was discovered that after the patient’s cesarean delivery 18 years prior, two needles remained inside her pelvis. They were initially kept under observation for a period of time, until one of them was removed after perforating through the abdominal wall.\nThe patient was subsequently transferred to the cardiac intensive care unit (ICU), where she underwent bedside transthoracic echocardiography (TTE), which showed large pericardial effusion (Fig. ). Arterial blood gas analysis and laboratory test results were within normal range, with a high-sensitivity cardiac troponin T (hs-cTnT) level of 9 ng/l. The sustained accumulation of the intrapericardial fluid, the slowly increasing heart rate with pulsus paradoxus and the persistent hypotension, along with the progression of dyspnoea at rest sustained the diagnosis of cardiac tamponade. Considering the clinical findings and the apparent cause of PT, the patient was scheduled to undergo emergency open-heart surgery.\nFollowing preoperative preparation, the patient was taken into the operating room. Upon gaining access inside the pericardial cavity, 300 ml of fresh arterial blood were evacuated, ergo promptly improving the patient’s haemodynamic condition. The foreign body was found to be penetrating the anterior wall of the right ventricle (Fig. ). The source of the bleeding was identified to be an epicardial artery which was punctured by the needle. After the careful removal of the needle (Fig. ), the bleeding was controlled by suturing the puncture site using a 5–0 polypropylene suture. The otherwise uneventful intervention was completed successfully after 70 min and the patient was transferred to the ICU.\nPostoperatively, two units of red blood cells and eight units of platelet transfusion were administered. The patient was given analgesics, as well as ulcer prophylaxis. No pharmacological circulatory support was required. Extubation occurred at 3 h postoperatively, and the patient left the ICU the following morning. The postoperative ECG revealed no pathological findings. After an unremarkable postoperative period, she was discharged to a rehabilitation institution on the 7th day.\nAt the 1-year follow-up, the patient’s status was unaltered and TTE showed no recurrence.\nPericardial tamponade is a serious condition which may cause a wide spectrum of haemodynamic abnormalities, depending on its evolution (sudden or gradual). Most often, the rate with which the intrapericardial collection accumulates is more significant than its volume []. The accumulation of fluid or other contents inside the pericardial space may develop slowly in time, as it is the case of inflammatory or autoimmune diseases, infections or neoplasms, situations in which it may be well tolerated. However, a rapid increase in volume usually results in decreased cardiac output and severe circulatory distress [] and it is commonly seen in pericardial or heart wall injuries caused by iatrogenic maneuvers, ventricular wall rupture (post MI) or other penetrating or blunt lesions. A traumatic injury to the heart wall caused by a migrated foreign body is, however, an uncommon situation. Still, it should not be overlooked in patients with history of invasive interventions.\nThe timely diagnosis of any pericardial effusion is critical, as it may rapidly evolve towards circulatory disturbances and even cardiogenic shock. A reliable and widely available imaging technique is bedside echocardiography, which allows the quick non-invasive evaluation of pericardial collections even in emergency situations, aiding in the efficient assessment of the patient’s status and providing therapeutic guidance []. In our case, due to fast-track examinations and prompt intervention, the patient’s status had not reached low cardiac output syndrome and the haemodynamic changes were well tolerated throughout the acute period, ultimately allowing the optimal postoperative recovery.\nConsidering that thoracic pain is a common manifestation in PT, the differential diagnosis should include all other acute disorders manifesting with chest pain, such as MI, pulmonary embolism or aortic dissection, but tension pneumothorax, peptic ulcer disease, gastritis or esophagitis should also not be omitted. The differential diagnosis should be based on other diagnostic methods as well, namely ECG and echocardiography, as well as chest radiography or computed tomography scans. As shown in our case report, PT can clinically resemble a MI. Therefore, ECG alone is not sensitive enough for a PT diagnosis. Echocardiography allows easy recognition of the presence and severity of PT, being the gold standard examination.\nForeign bodies are a more frequent occurrence in the spheres of gastroenterology and otolaryngology. Cases of ingested foreign bodies causing esophageal or gastric perforation and leading to PT, such as sewing needles, fish bones, or even pens, have been previously reported, in both children and adults [–]. Similarly, accidental or iatrogenic foreign body injuries to the heart have also been described as a possible cause of PT, among the incriminated objects being projectile fragments, catheter fragments, Kirschner wires, or acupuncture needles [–]. However, when aiming to identify the cause of intrapericardial bleeding in a patient with a history of previous surgical interventions, the possibility of a migrating foreign body should be taken into account. In uncommon cases, foreign bodies have been reported to migrate through tissues []. A possible explanation of this phenomenon is that suppuration causes the foreign bodies to dislodge and change position. This same mechanism also explains how such foreign bodies are sometimes eliminated through the skin or inside various cavities []. The loss of tissue elasticity which occurs in elderly patients as a result of loss of collagen may also be a predisposing factor []. Still, reports of foreign bodies that have migrated over long distances through the human body (e.g. pacemakers), are scarce []. Moreover, in contrast to the case we presented, the migration appears to occur most frequently downwards through the human body, presumably as a result of gravity. We theorize that the needle traveled in the opposite direction due to its reduced mass, but more detailed studies on the subject need to be conducted.
A 16-year-old girl presented to the emergency room of pediatrics department in our hospital with complaints of abdominal pain, nausea and vomiting. Physical examination revealed tenderness on the right upper quadrant of the abdomen. Blood analysis showed increased white blood count (15, 91/μl) with left shift, an erythrocyte sedimentation rate of 78 mm/h, and C-reactive protein (CRP) 279 mg/l. The other laboratory examinations revealed increased levels of Aspartate transaminase (AST): 57 U/L, Alanine aminotransferase (ALT): 104.91 U/L, Lactate dehydrogenase (LDH): 599 U/L, and Alcalene phosphatase (ALP): 575 U/L.\nOn abdominal X-ray, a metallic lineer radio opaque image compatible with a foreign body was seen on right hepatic lobe localization (). Abdominal ultrasonography (US) examination revealed a 3cm long lineer echogeneity in segment 5 surrounded by an irregularly contoured heterogeneous hyper echoic area of 10×7cm in size (), and made us think about migration of a swallowed foreign body into the liver accompanied by an abscess formation. The patient was unaware of having swallowed any foreign body, but when we insisted on any possibility of such a condition, she remembered that she could have swallowed a sewing needle approximately a month ago while drinking water. She told that she saw a number of sewing needles in the water glass which she noticed after drinking some water. On further examination with abdominal computed tomography (CT), the metallic foreign body and surrounding inflammation were better demonstrated (Figs. , ).\nThe patient underwent surgical operation for the excision of the foreign body, but it could not be reached, and it was failed to get the foreign body due to patient's condition change during the operation. The patient went home with antibiotherapy for the surrounding inflammation. Two and a half months later the patient presented again with abdominal pain, and control CT examination demonstrated the migration of the foreign body inferomedially near to the gallbladder (Figs. , ). The surrounding inflammatory changes were disappeared. On reoperation with open abdominal surgery, the sewing needle was found easily due to its migration nearby the gallbladder, and it was removed from the liver. The patient recovered successfully after the operation.