A 36-year-old single unemployed man who was first diagnosed with schizophrenia by a psychiatrist about 12 years ago is described here.\nHe remained in school until the eighth grade, when his abnormal behaviors at school caused him to stop his education. Also, for the same reason, he was fired from his job 2 years ago. He has been smoking cigarettes since 12years ago, and he started to smoke opium 11 years ago.\nHe did not have any evidence of brain damage or any major medical illnesses. He was the second child in a family of 6 with low socio-economic status. His parents were consanguineous and had no physical or mental abnormalities, although one of his younger brothers suffered from mental retardation. During the 12 years of his disease, he has been treated in both outpatient and inpatient settings. Due to exacerbation of his symptoms, he was admitted to a psychiatric ward on 4 occasions, and the course of his illness shows a fluctuating clinical picture. Since his first disease symptoms, he was diagnosed with personality disorder (borderline type), bipolar disorder, and even factitious disorder. His compliance with taking the prescribed medications and attending follow-ups has been very poor.\nDuring the initial phase of his illness, he had prominent positive features, occasional violent outbursts, and delusions of persecution regarding his family and neighbors. All of his hospital admissions were due to psychotic exacerbations, which initially manifested as violent behavior and aggression towards others and then progressed to delusions of persecution, delusions of reference, and both auditory and visual hallucinations. During this phase of his disease, he was diagnosed with schizophrenia. He had a good appetite, but was suffering from early and terminal insomnia. He also had a history of self-mutilation from about ten years ago, but at the time of visit had no suicidal or homicidal thoughts or plans. His initial treatment plan included Valproic acid 200mg tablets TID (600 mg/day) and an Olanzapine tablet 5mg per day. Two years ago, this regimen was changed by his psychiatrist to Haloperidol 5 mg BID (10 mg/day), Biperiden 2 mg/day, Clonazepam 1 mg/day, Citalopram 20mg BID (40 mg/day), and Propranolol 10mg BID (20 mg/day) prescribed as oral medication. During his hospital admissions, he made steady recoveries, but his follow-ups and compliance were poor. All of his laboratory work-ups and brain computed tomography scans (CT scans) were normal and his electroencephalograms (EEG) showed no abnormalities.\nDuring his fourth and last admission, he was brought to the emergency department because of severe abdominal pain. He had abdominal tenderness in his physical examination and his vital signs were stable. His abdominal X-ray revealed the ingestion of a metallic skewer that was broken apart (). After surgical consultation, endoscopic removal of the objects was suggested, but about an hour later the patient became medically unstable and had a board-like abdomen in his examination. After a second evaluation by a surgical team, the patient was diagnosed with intestinal perforation and an emergency exploratory laparotomy with enterotomy was performed. The surgery was without complications, and metallic items were removed from the patient’s abdomen. He had an uneventful postoperative recovery.\nAfter his recovery, at the subsequent psychiatric follow-up visit, he explained his motive for ingesting the metallic skewer and revealed that a demon that had been living inside his body had been controlling him for the previous three months. He insisted that the demon wouldn’t let him tell the psychiatrists about its existence and wanted to control and use his soul to destroy the world. He believed that he could fight and kill the demon by ingesting the metallic skewer.\nTwo weeks after abdominal surgery, the patient attended our psychiatry outpatient clinic twice. He continued to have delusions of persecution and reference; however, he was convinced that because the surgery involved opening his abdomen, the demon had left his body and there was no need to fight with him anymore. Due to close monitoring by his family members, he did not ingest any further non-food items. Also, this close monitoring helped him have better compliance with his psychiatric visits and therapies.
A 62-year-old man visited our hospital emergency room with dizziness and diaphoresis. He received an acupuncture treatment on the subxyphoid area (lower 2 cm and left 1 cm point from the lower xyphoid process border) directly an hour ago because of facial numbness. He had a history of cerebral infarction and permanent atrial fibrillation on warfarinization (2 mg warfarin per day). Surprisingly, the acupuncture needle () was still sticking into his substernum. The initial vital signs were blood pressure of 80/50 mm Hg and heart rate of 110 beats/min. We instantly removed the needle, but he went into cardiac arrest and was rescued within 10 minutes after cardiopulmonary resuscitation. At that time his prothrombin time international normalized ratio was 1.99, therefore, we administered 2 pints of fresh frozen plasma and 5 mg of vitamin K. The transthoracic echocardiography revealed pericardial effusion with early diastolic collapse of the right ventricle. We performed emergent pericardiocentesis using a subcostal approach. After drainage of 500 mL of sanguineous effusion, the patient stabilized hemodynamically. Two hours later, however, the drainage of pericardial effusion persisted up to the total amount of 1000 mL, and the cardiac arrest redeveloped. After resuscitation, an emergent operation was performed under cardiopulmonary bypass (CPB). A median sternotomy allowed visualization of huge hematomas over right atrium and ventricle (). After we evacuated the hematomas, a pumping of acute marginal branch of the right coronary artery was identified. The vessel was torn into pieces, and it was ligated with 4-0 Prolene suture, thereby leading to termination of bleeding (). The aortic cross clamp time was 25 minutes and CPB time was 45 minutes. Thereafter, the patient showed hemodynamically stable vital signs and uneventful condition. Finally he was discharged without any complications.