Postmortem Imaging of an Unusual Case of Fatal Heart and Lung Perforation Due to Self-Treatment

Abstract

Intentional or accidental cardiothoracic injuries caused by needles and pins are rare and commonly reported in individuals with psychiatric conditions or intravenous drug users. Although rare, these cases could result in serious injury during the performance of an autopsy and highlight the importance of post-mortem radiology. Therapeutic complications with cardiac perforation have been reported due to pericardiocentesis and acupuncture. The majority of reported cases were not fatal and some had a prolonged asymptomatic period of weeks or even years after insertion. Needles or other sharp objects can reach the cardiovascular system directly through the chest wall, indirectly from any segment of the gastrointestinal tract after swallowing needles, or through migration of broken needles from distant injection sites in intravenous drug users. We report a case of rapidly fatal cardiopulmonary injuries following “self-treatment” to “pop” a cyst with a piercing needle. The scene, autopsy, computed tomography, and digital x-ray findings of this unique case are discussed with a review of selective literature. In this case, the right lung and heart showed multiple perforations, possibly resulting from heartbeats or respirations pushing the organs against the needle. To our knowledge, perforations in this setting of “self-treatment” have not been previously reported in the literature.

Introduction

Postmortem imaging has been well-documented as a critical adjunct to the autopsy procedure, especially in cases with potential safety hazards (1). Postmortem imaging, especially the computed tomography (CT) scan, can be of increased utility in documenting injuries and/or the depth of a penetrating injury to assist in performance of the autopsy. Needle perforations of the heart, lungs, and great vessels are uncommon; fatalities are rarely reported. Needles can potentially reach the heart and lungs resulting in hemothorax, cardiac tamponade, pneumothorax, or cardioembolic stroke (2,3). These injuries may be relatively asymptomatic for days or even years (4,5), but have the potential to result in death. The majority of reported cases of cardiovascular injuries due to needle perforation involved individuals with psychiatric disorders due to self-harm or self-mutilation (6). Additional reported cases in the literature were due to therapeutic complications, such as pericardiocentesis (7), acupuncture (8), needle embolization after intravenous drug use (9 -11), and swallowing of needles (12). Death still remains an uncommon outcome; in one study, it was reported in only 2 out of 40 individuals (6). In this report, using postmortem imaging and autopsy findings, we describe a rapidly fatal case of self-inflicted needle insertion into the chest wall, which resulted in perforations of the right lung and heart causing cardiac tamponade, hemothorax, and pneumothorax.

Case Report

A 33-year-old, obese, white male, with a history of pervasive developmental disorder and bipolar disorder was at home when he was heard screaming by his mother. He self-reported trying to “pop” a cyst on his chest, but the “needle went all the way in.” Soon after his mother went to assist him, he became unresponsive. There was minimal bleeding from the chest prior to his witnessed collapse. There was no needle visible externally. Despite resuscitative efforts, he was pronounced dead at the scene shortly after his collapse. According to his family, he “popped” cysts before. Scene investigation showed a packaged and sealed 14 gauge piercing needle and a second empty package. His computer screen was playing a video with instructions for “popping” cysts.

Prior to autopsy, a routine anterior–posterior full body digital X-ray was performed. A radio-opaque needle appeared superimposed on the right side of the chest ( Image 1 ). Body positioning and habitus precluded definitive identification of additional diagnostic findings (i.e., pneumothorax) on the conventional X-ray. The axial CT images acquired at 0.625 mm slice thickness further identified right hemothorax, hemopericardium, right pneumothorax, and a 5 cm needle embedded in the right third intercostal space. The tip of the needle projected in the right atrium of the heart ( Images 2 and 3 ). External examination was significant for a 14 × 10 cm abrasion, approximately 2 to 3 cm right of the sternal border (level of right nipple) with a 1.6 mm central perforation and multiple clustered superficial skin punctures, which were on the lateral and medial aspects of the central perforation ( Image 4 ). A definitive cyst was not identified. Internally, soft tissue hemorrhage was underlying the punctures. There was a right hemothorax (50 mL) and hemopericardium (250 mL). Within the soft tissues of the third intercostal space, the 5 cm needle ( Image 5 ) was recovered. At autopsy, CT findings were confirmed when the needle was observed to extend perpendicularly from the chest wall and enter the chest cavity with the tapered needle point puncturing the upper lobe of the right lung (at least three perforating defects [ Image 6 ]), the right side of the pericardium ( Image 7 ), the right atrial appendage ( Image 8 ), and the epicardial fat of the right ventricle (2.5 × 0.6 cm defect). The recovered needle is depicted in Image 9 .

Image 1.

Anterior–posterior chest X-ray showing the needle in the right side of the chest.

Image 2.

Axial maximum intensity projection (MIP) CT image showing the tip of the needle in the vicinity of the right atrium (arrow). CT indicates computed tomography; HT, hemothorax; HP, hemopericardium; PT, pneumothorax.

Image 3.

Sagittal MIP CT image showing the depth of needle penetration. CT indicates computed tomography; MIP, maximum intensity projection.

Image 4.

Photograph of the right side of chest showing needle puncture sites with surrounding abrasion.

Image 5.

Photograph of right side of the chest and upper abdomen with chest plate partially lifted showing the needle and right hemothorax.

Image 6.

Photograph of right chest showing two perforations of right lung.

Image 7.

Photograph of heart showing areas of perforations of pericardium.

Image 8.

Photograph of heart showing hemorrhage of epicardial fat and a perforation of the right atrium.

Image 9.

Photograph of the recovered piercing needle.

The cause of death was perforating injuries of right lung and heart; based on scene investigation and previous history of self-treatment of a cyst, the manner of death was classified as accident.

Discussion

Fatal injuries caused by bullets and knife blades are common occurrences, but injuries of the heart, lungs, or both due to needles are uncommon. In cases where a weapon is known, postmortem imaging is critical in identifying not only objects of evidentiary value but ones that may result in injury to persons performing the autopsy. In this case, imaging assisted in narrowing down the location of the needle tip and provided its course, especially when concern for autopsy injury was forefront. Through this case, we emphasize the importance of postmortem imaging as an adjunct to autopsy and highlight a rare case of a penetrating needle injury resulting in death. The majority of reported cases in the literature were not fatal and involved individuals with psychiatric disorders committing suicide or due to self-mutilation. However, foreign objects, such as needles or pins, can reach the heart and lungs either directly through the chest wall or indirectly through embolization, swallowing, or transabdominal penetration (13). To our knowledge, there are no previous reported cases of rapidly fatal self-inflicted needle perforations of the lung and heart from attempted “self-treatment” of a cyst. It is unclear whether the organ perforations were due to heartbeats or respirations pushing the organs against the needle or due to multiple insertions and manipulations by the decedent. Once again, postmortem imaging is critical in ensuring a thorough and safe autopsy is performed, especially in circumstances where fatal outcomes resulting from seemingly innocuous procedures are not always predicted.

Authors

Zabiullah Ali, MD, Office of the Chief Medical Examiner

Roles: A, B, C, D, E

Nikki Mourtzinos, DO, Office of the Chief Medical Examiner

Roles: A, C, D, E