SAEM Clinical Images Series: When Needles Go Beyond Sewing and Acupuncture
A 64-year-old male with a history of bipolar 1 disorder, PTSD, anxiety, depression, obsessive-compulsive disorder, GERD, and HTN presented to the ED with the chief complaint of foreign body and self-injury. He reported years of sticking sewing needles into his right arm, most recently yesterday. He explained that inserting needles makes him feel better with mild associated pain. He endorsed suicidal ideas, elaborating that he did not want to stop injuring himself. He also reported depression and wished that he was not alive. He stated that he had told his therapist that he didn’t want to present to the ED today and added that he wanted to leave the ED and did not want to be seen by the psych team. He denied homicidal ideation.
Extremities: When palpating the right forearm, multiple linear hard objects are felt in the subcutaneous tissue. The patient can flex/extend the wrist, supinate and pronate, and flex/extend the elbow without issue. No erythema or fluctuance. No obvious insertion site noted.
None
Numerous linear metallic foreign bodies are present throughout the right forearm; several new foreign bodies are noted. Bony exam is significantly limited due to the presence of numerous (greater than 50) linear metallic densities throughout the forearm. Mild to moderate degenerative changes of the wrist and elbow are noted.
Take-Home Points
- Removal of metallic foreign bodies is an individualized risk vs benefit decision based on the following: signs of infection, suspected level of contamination, type of metal, cooperativeness of the patient, location nearby vital structures, cosmetic deformity, and pain. When the risk of removal outweighs the benefits or if the patient does not desire removal, foreign body removal is not always needed.
- Regarding prophylaxis, antibiotics need not be routinely administered if the wound is clean. Tetanus vaccination status should be reviewed, and the vaccine (Tdap) and/or potentially tetanus immune globulin should be administered if indicated.
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