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 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.