Mr. S is a 31-year-old, single, unemployed gentleman from a low socioeconomic Tamil-speaking background, who first came to psychiatric hospital in 2003 at the age of 17 years within 10 days of onset of symptoms of psychosis and mania. He was treated with tablet risperidone up to 4 mg/day. He responded well and even went back to school. After 9 months of regular treatment, he stopped medicines. Two months after stopping of medicines he had relapse of psychotic symptoms including Schniderian first rank symptoms without any mood symptoms. His diagnosis was revised to paranoid schizophrenia. He failed trials of tablet risperidone 8 mg/day, tablet olanzepine 25 mg/day, a course of 10 sittings of electroconvulsive therapy, and injection fluphenazine decanoate depot 100 mg intramuscular every month. He did not show significant improvement. He was started on tablet clozapine and the dose was gradually built up to 450 mg/day by 2007. He was on regular follow-up for 9 years during which he had fluctuations in psychiatric symptoms but was managing well without any physical health issues.\nIn 2016, he developed pain in the left lumbar region following trivial trauma (while using a crowbar) and later developed a swelling in the region for which incision and drainage were done at a primary health center. When the ulcer did not heal for about 3 months, he was referred to a surgical department of a teaching hospital for further management. The non-healing ulcer in the incision site of left lumbar gradually had increased in size and was associated with passage of air through the ulcer while defecating or straining. There was no history of abdominal distension, vomiting, obstipation, hematemeis, malena, or fever. Physical examination revealed a soft non-tender abdomen.\nRoentgenogram of abdomen and ultrasonography investigations revealed a foreign body in the abdominal cavity just below the diaphragm without any other features of obstruction or perforation. Contrast-enhanced computer tomography and magnetic resonance imaging revealed a linear foreign body forming a fistula communicating with splenic flexure of the colon [].\nThe patient was posted for elective exploratory laparotomy. On laparotomy, an intact ball point pen of size about 11 cm in length was found to be the foreign body with its tip inside the lumen of splenic flexure and its rear end facing the external ulcer []. The pen was carefully delivered through the external wound and the sealed perforation of size 1 × 1 cm was closed primarily []. Postoperative period was uneventful and the patient was discharged on the 11th postoperative day.\nThe patient recollected that he had swallowed the very same pen in 2004 when he had been very psychotic []. He reported that he had vague abdomen pain on and off, which he did not feel serious enough to report. There was no record of abdomen pain in the patient's case notes over the previous 13 years.\nHe is doing physically well and is on regular follow-up. He is not regularly employed but helps his family in household chores. He is currently on clozapine 450 mg/day, on which he has a serum level was 933 ng/mL.
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.