Disastrous Complication Caused Indirectly by the Success of Battlefield Acupuncture

Abstract

Background: Battlefield acupuncture (BFA) is an easy-to-learn type of auricular acupuncture that is being used increasingly and that has been shown to be effective for short-term reduction of pain. Many patients return for repeated applications of the semipermanent needles and ask if permanent earrings inserted in these points would lead to longer-lasting reduction in their pain.

Case: A patient sought to have permanent earrings placed at his BFA auricular points. This 47-year-old man was referred for BFA for his chronic pain. He had several underlying health conditions. The BFA gave this patient good pain relief, but he had difficulty traveling to the VA center; this was why he wished to have the permanent earrings.

Results: This patient had earrings implanted on his own where he thought the correct BFA points were. Hence, he developed a serious infection and inflammation that were difficult to treat.

Conclusions: The patient tried to have permanent earrings, but they produced very deleterious effects. No recommendation for such implantations can be made at this time.

Introduction

Various forms of acupuncture are being promoted to relieve pain, especially during the current opioid epidemic. Battlefield Acupuncture (BFA) is an easy-to-learn type of auricular acupuncture that is being promoted by the U.S. Department of Defense and Department of Veterans Affairs, and has been shown to be effective for short-term pain reduction.¹ Many patients return for repeated applications of the semipermanent needles used for BFA. These needles tend to fall out by day 7, and patients inquire if permanent earrings inserted in these points would lead to longer-lasting reduction in pain. This article reports on a case of a patient who sought to have permanent earrings where he thought BFA points should be and had very deleterious effects.

Case

A 47-year-old man was referred for BFA for his chronic pain. His medical history was significant for Chondrodermatitis nodularis helicis, long-standing diabetes mellitus with painful peripheral neuropathy, coronary-artery disease, previous cerebrovascular accident, chronic lower-back pain, hypertension, dyslipidemia, and depression. He derived immediate and marked diminution in his self-reported pain lasting several days after each treatment, but he found it difficult to travel the 72 miles each way between his home and the Veterans Administration facility where he received BFA weekly. After 4 months of weekly BFA administered by a physician without medical approval, he opted to have a local piercing establishment place permanent earrings into locations he thought were comparable to the sites of BFA placement (Cingulate Gyrus, Thalamus, Omega Two, Point Zero, and Shen Men; Fig. 1). Approximately 3 weeks later, his ears became tender, red, and edematous bilaterally and he noted decreased hearing (Fig. 2), although he was happy with his level of pain control. He was seen by the dermatology department and was noted to have erythematous, firm, bilateral superior helical rims with tender nodules (some with mild yellow drainage), and swollen cartilaginous structures of both ears.

FIG. 1.

Earrings inserted at sites the patient thought corresponded to Battlefield Acupuncture points.

FIG. 2.

Indurated, edematous, and tender ear partially occluding auditory canal. The other ear was similar in appearance.

Laboratory studies revealed a slight leukocytosis (12.9 K/cmm) and thrombocytosis (410 K/cmm). Serum electrolytes, transaminases, alkaline phosphatase, antinuclear antibody (ANA), antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor, C-reactive protein, thyroid-stimulating hormone, and urinalysis were normal. Collagen Type II antibodies were 19.4 EU/mL (normal is <20 EU/mL).

He was initially treated with gentamycin drops and mupirocin without much improvement. He was seen 3 weeks later by the otolaryngology department, was prescribed amoxicillin/clavulanic acid for a presumed auricular infection with chondritis, and was instructed to remove his piercings. Three weeks later, he completed a 2-week course of oral clindamycin and then presented to the emergency department with increasing pain. He was believed to have an abscess in his right ear and underwent incision and drainage; 3 cc of purulent material was expressed, which grew out to be Actinomyces neuii, Finegoldia magna, and Prevotella bergensis.

Additionally, since there was some diagnostic uncertainty, a punch biopsy initially revealed lymphocytic inflammation around vessels in the deep dermis and lining in an area of slightly degenerated collagen associated with a vascular proliferation. Some plasma cells, but not neutrophils, were detected. It was believed that these findings could be consistent with a phase of relapsing polychondritis or sequelae of perichondritis. A repeat biopsy 1 month later revealed normal cartilage and chronic inflammation, but was negative for fungal organisms or acid-fast bacilli.

The patient completed an additional 5 months of minocycline, and given that Actinomyces is a slow-growing organism, he also completed 12 months of amoxicillin/clavulanic acid. While his redness and swelling ultimately subsided, he was left with misshapen ears, an occluded external auditory canal, and decreased hearing thought to be secondary to this occlusion (Fig. 3).

FIG. 3.

Permanent sequelae after long-term antibiotic therapy.

Discussion

Unlike traditional acupuncture, BFA is relatively new, having been developed in the beginning of the twenty-first century by Niemtzow.² Patients often ask questions, many of which cannot be answered by using current published evidence. One of those questions is if permanent earrings in the appropriate points would be more beneficial than semipermanent needles that fall out after relatively short time periods. This article reported a case of a patient independently pursuing this option due to the efficacy he derived from traditional BFA and the hardships and inconvenience of travel for weekly applications.

Initially, there was diagnostic uncertainty concerning whether he might have been suffering from a forme fruste of relapsing polychondritis, a rare autoimmune disease characterized by inflammation of cartilaginous structures and other tissues, such as the ears, nose, respiratory tract, eyes, joints, and heart valves. ANA can be positive in roughly one-quarter to two-thirds of patients³ and anti-Type II collagen antibodies, while nonspecific, are found in fewer than half of patients.⁴ The lack of other cartilaginous or other organ involvements, positive culture results, and response to antibiotic therapy without long-term immunosuppressive therapy rendered this diagnosis unlikely.

It is interesting that this patient had a prior history of Chondrodermatitis nodularis helicis, another uncommon disorder that presents with painful nodules in the external ear, usually the helix, but occasionally the antihelix.⁵ While the etiology is not known, the condition's clinical appearance and histopathology⁶ were not consistent with this diagnosis. Whether he was more susceptible to the complications he experienced based on this history is unknown and purely speculative.

Conclusions

BFA is being used more widely to relieve pain. As this modality becomes adopted, new patient-generated clinical questions arise, such as what would happen if permanent earrings were inserted in the locations where BFA needles are inserted. The current case showed how a patient experienced a disastrous infectious complication when he had permanent earrings implanted where he thought the BFA sites were. Without any supporting evidence, the current author cannot recommend implanting permanent earrings as BFA substitutes at this time.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.