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Monday, January 19, 2015

Just a bit of innocent fun: putting lead in your pencil


In my last post, I described the case of a 76-year-old Australian who had inserted a steel dining fork into his penis. The bizarre practice of self-inserting foreign objects into the urethra during masturbation apparently appeals to some people, since an impressive variety of foreign objects gets stuck in urethras and bladders worldwide. A fairly strange case of this sort happened in London: a 62-year-old man was referred to the hospital from a nursing home by staff concerned that he had apparently passed a small household (AAA size) battery while urinating. The patient was in pain with difficulty in passing urine. Relevant in his past medical history was that one year previously a pen lid had been endoscopically removed from his bulbar urethra. He also had right-sided hemiplegia following a cerebrovascular accident 10 years earlier.

An X-ray of the patient's pelvis revealed what appeared to be two dense foreign bodies in his urethra:




Urethroscopy showed two AAA size household batteries lodged there. The surrounding mucosa was very inflamed with areas of necrosis and a rusty appearance suggesting that these batteries had been lodged within his body for a significant period of time. They were successfully removed using an endoscope with grasping forceps. Cystoscopy revealed inflamed-looking bladder mucosa that suggested recurrent urinary tract infections.

Here's an endoscopic view of the batteries, just before removal:

 Images from: Bedi et al. (2010)


The patient was catheterized postoperatively and discharged 48 hours later on a two-week course of broad spectrum antibiotics. On further questioning at discharge, he admitted to inserting three AAA sized batteries into his urethra for sexual gratification during masturbation four weeks earlier. Talk about having fun in a nursing home.


Source:

Bedi N, El-Husseiny T, Buchholz N, Masood J. (2010) ‘Putting lead in your pencil’: self-insertion of an unusual urethral foreign body for sexual gratification. JRSM Short Rep. 1(2): 18.




Thursday, January 15, 2015

Serious misuse of a fork


When it comes to sticking or shoving foreign bodies into the wrong places, the human mind shows boundless creativity. The motives are often difficult to comprehend. While inserting an object into the urethra is a fairly unusual practice, now and then an urological surgeon will be faced with this sort of emergency. The reason given by the patient is usually autoerotic stimulation. Males are 1.7 times more likely to insert something into the urethra than females. Almost all imaginable objects of suitable size have been pulled out of this small orifice: needles, pencils, pens, pen lids, various kinds of wire, safety pins, keys, wire-like objects (telephone cables, rubber tubes, feeding tubes, straws, string), toothbrushes, household batteries, light bulbs, marbles, cotton tip swabs, thermometers, plants and vegetables (carrot, cucumber, beans, hay, bamboo sticks, grass leaves), parts of animals (leeches, squirrel tail, snakes, bones), toys, pieces of latex gloves... The list goes on and on.


In one notable case, a 76-year-old man came to the Emergency Department of the Canberra Hospital in the Garran suburb of Canberra, the capital of Australia, complaining of blood in his urine. After questioning, he admitted that he had inserted a 10 cm steel dining fork into his urethra 12 hours earlier during masturbation. He had no history of psychiatric disorders. 

On examination, the dining utensil was not visible, but palpable within the penis. Pelvic radiography and computerised tomography confirmed the position of the fork, with the prongs pointed towards the urethral opening:


The urethra was not perforated. The fork was extracted with forceps under general anesthesia, with the aid of lignocaine gel. The patient had some mucosal abrasions, but was able to urinate without problems and was discharged home after the procedure. 

The following charming photo shows the fork being pulled out, with ample lubrication:

Images from: Naidu et al. (2013)


Source:

Naidu K, Chung A, Mulcahy M. (2013) An unusual urethral foreign body. Int J Surg Case Rep. 4(11): 1052–1054.

Monday, January 12, 2015

Chicken bone gets stuck in an awkward spot


Swallowing a chicken bone (or any other small bone) may cause choking, an esophageal injury or, sometimes, a serious intestinal obstruction that requires surgery. However, in some cases the bone will pass right through the digestive tract... only to get stuck in the rectum. This is precisely what happened to the 31-year-old man who walked into the Department of Accident and Emergency Medicine at the Royal Infirmary in Cardiff, UK, complaining of intense rectal pain. The pain had started suddenly nine hours earlier, while the subject was attempting to pass a stool.

On examination he was in acute distress, unable to sit because of the excruciating pain. Digital examination revealed a hard, sharp object in the rectum, lodged horizontally just above the anal margin. After sedation, a bone fragment 4 centimeters long was manually removed. Proctosigmoidoscopy showed no signs of a bowel perforation, so the patient was allowed to go home as soon as he recovered from the effects of the sedative. 

Further questioning revealed the cause of the problem - he had eaten chicken about 48 hours before the pain started. He denied being under the influence of alcohol at the time, but had a habit of eating quickly, without chewing food properly.

Here is a photo of the chicken bone after removal:




Source:

Davies DH (1991) A chicken bone in the rectum. Arch Emerg Med. 8(1): 62–64.

Friday, January 9, 2015

Strange cases of green urine


A variety of chemicals and metabolic abnormalities can cause the urine to change color. Normal human urine is the color of straw or amber due to the presence of urochrome, a yellow pigment (a degradation product of the heme in hemoglobin). Variations in color saturation result from differences in concentration: when a person drinks a lot of water, for example, the urine becomes so diluted that it is practically colorless. Certain ingested substances or metabolic disorders can lead to urine discoloration; anyone who has eaten a large amount of red beet salad or borscht (a delicious Polish beet soup) will soon notice a reddish tint in the toilet bowl after peeing. Red-colored urine can also be caused by drugs such as metronidazole, phenytoin and rifampicin. Green urine is somewhat more unusual, but not unheard of; it can be the result of certain medications or food dyes.

There have been numerous reports on the association of green-colored urine with the administration of propofol (2,6 diisopropylphenol) after surgery. Propofol is a short-acting intravenous hypnotic agent for anesthesia or sedation. Shioyo et al. describe the case of a 19-year-old man who was hospitalized for injuries sustained in a traffic accident (open fractures and a right axillary artery injury) and underwent surgery. When a continuous infusion of propofol was administered for postoperative sedation, the patient's urine became dark green:


Green urine after propofol infusion. Image from: Shioya et al. (2011)

The authors speculate that the appearance of green urine after propofol infusion was due to the drug being metabolized outside the liver, predominantly in the kidneys, because hepatic circulation was impaired as a result of diminished peristalsis.

In a similar case, a 16-year old boy was hospitalized with severe injuries after a motorcycle accident. He had fractured vertebrae, a spinal hematoma and a lung contusion, and needed surgery for the damage to his spine. After the operation, he developed respiratory failure and a lung infection. 10 days after the accident, he underwent surgery again for placement of a cerebrospinal fluid drain. His sensory and motor functions remained impaired downwards from the fracture site. One week after his accident, it was noted that his urine had assumed a very distinctive green color:


All the patient's laboratory tests were normal. There were no problems with kidney function and no signs of an urinary tract infection. The boy had been treated with a plethora of medications, including the muscle relaxants and sedatives midazolam, propofol and fentanyl. After stopping the propofol infusion the green colour of the urine disappeared within 2 days.

Other possible drugs that may lead to green discoloration of the urine are cimetidine, promethazine, amitriptyline, indomethacin or phenyl butazone. However, this effect can also be caused by harmful chemicals. Shim et al. describe a case of green urine caused by herbicide poisoning.

A 76-year-old woman was admitted to the hospital following the ingestion of approximately 150 cc of inorganic herbicide (proprietary name: Magma® ; mefenacet, imazosulfuron). (The article doesn't mention whether this poisoning was accidental - perhaps the result of drinking from the wrong container - or deliberate.) The patient presented to her local hospital with cyanosis of the lips and hands and her urine was noted to be a very distinctive green color. 1 day later, she was referred to a different hospital because methemoglobinemia was suspected due to the symptoms of cyanosis and green urine. (Methemoglobinemia is a disorder characterized by the presence of a higher than normal level of methemoglobin - a chemically altered form of hemoglobin - in the blood. This diminishes the ability of red blood cells to release oxygen to tissues.) There was no other drug history. The patient was treated in the intensive care unit. On examination, her vital signs were: blood pressure 140/70 mmHg; heart rate, 98 beats/min; respiratory rate, 18 breaths/min; body temperature 36.6℃. Clinical examination confirmed cyanotic discoloration of her lips, tongue, fingers and toes. Her urine was still green, as shown in the photo below:
\



Green urine after herbicide ingestion. Image from: Shim et al. (2008)


The patient was initially treated with methylene blue for possible methemoglobinemia; however, this diagnosis was not confirmed by laboratory findings, and the methylene blue was discontinued. There were also no signs of urinary tract infection and the urine culture was negative. After seven days in the hospital, the cyanosis of the fingers and toes improved and the urine color returned to normal.

Finally, food dyes can also cause odd and unwanted effects. In one case, a critically ill patient suffering from neutropenic sepsis developed dark green urine while in the intensive care unit. Review of his medications and infravenous infusions suggested the most likely cause was the food dye plaved in his enteral tube feedings - Food Dye and Color Blue Number 1 (FD&C No. 1). I was intrigued why blue dye, of all things, is placed in enteral tube feedings - turns out the purpose is to detect pulmonary aspiration (if respiratory secretions have a blue tint, the caregiver knows that the patient has aspired stomach contents...) However, the practice is now considered dangerous (in some severely ill persons, the dye can be absorbed and cause systemic toxicity).



Literature:


Carpenito G, Kurtz I. (2002) Green urine in a critically ill patient. Am J Kidney Dis. 39(4):E20.


Lepenies J, Toubekis E, Frei U, Schindler R. (2000) Green urine after motorcycle accident. Nephrol Dial Transplant. 15(5):725-6.

Shim YS, Gil HW, Yang JO, Lee EY, Kim SH, Hong SY. (2008) A Case of Green Urine after Ingestion of herbicides. Korean J Intern Med. 23(1): 42–44.


Shioya N, Ishibe Y, Shibata S, Makabe H, Kan S, Matsumoto N, Takahashi G, Yamada Y, Endo S. (2011) Green Urine Discoloration due to Propofol Infusion: A Case Report. Case Rep Emerg Med. 2011: 24514.




Monday, January 5, 2015

Abscesses being lanced (videos)


It's amazing, really, how much medical stuff finds its way onto YouTube, from cool educational videos on innocent topics like MRI scanning to 100% vintage gross-out material: pus, pus and more pus (I consider myself fairly hardened, but watching thick, yellow-gray goo ooze out of an incision makes me squeamish).

An abscess is a pus collection within the tissues of the body. The symptoms of an abscess include redness, warmth, swelling, significant pain and palpable fluid (fluctuation) under the skin. They're usually caused by a bacterial infection (Staphylococcus aureus is a frequent culprit, as are streptococci). Typing "abscess" into the search box brings up lots of hits - from infected sebaceous cysts to huge abscesses on dairy cows. If you feel like watching some purulent horrors, and possibly losing your lunch in the process, here are three interesting videos. The first two were shot by medical professionals and the third was filmed by the patient's wife.


1. "World's Largest" Arm Abscess (by Larry Mellick)




An overweight lady had a very large abscess on her arm. It was successfully lanced and drained. The video shows all the stages of the procedure: cleaning the skin with an antiseptic, injecting a local anesthetic (1% lidocaine), making the injection, squeezing the pus out, flushing the abscess cavity out with saline, using a hemostat to break up any remaining pockets of pus, packing the abscess cavity with sterile gauze and applying a dressing. Despite the anesthetic, the procedure was very painful for the patient. I can't help wondering why she let the infection get this bad - no insurance?


2. Large infected abscess/cyst drained in hospital (by Dave Darty)




This man had had a large sebaceous cyst on his back for many years. It finally became painful, and when the pain didn't go away for two weeks, he sought medical help. According to the doctor who treated him, the cyst was still in an early stage of infection, with only slight redness of the skin and not that much pain (8 ml of 2% lidocaine were enough to completely numb the area). The video shows the skin being cleaned with iodine before the procedure. After making the incision, the physician squeezes lots and lots of white material out of the cyst, uses a hemostat and a syringe of normal saline to loosen up the remainder, then squeezes again. At the end, the cavity is packed with sterile gauze and a dressing is applied.


3. HUGE ABSCESS STAPH INFECTION POPPED IN ARMPIT BIG PLUG REMOVED BEST ABSCESS DRAINAGE EVER!!!! (by elise morse)

Just what the title says. The patient had an enormous reddened abscess in his armpit - by the looks of it, the abscess cavity extended just about to his hip (I'm kidding of course). After lancing, some yellowish pus comes out; then the surgeon pulls out some thick material... and then a river of pus flows. And flows. And flows. Consider yourself warned.




Have I permanently ruined your appetite for mayonnaise? If you would like to learn more about diagnosing and treating abscesses, here is a 10-minute comprehensive educational video (by Ibnsina2006):





If you ever get an abscess, don't wait forever before going to the doctor, and don't try to cut it open yourself - there are videos of people doing this, too. Definitely NOT a good idea.


Thursday, January 1, 2015

Firework injuries (DRASTIC!)


Image courtesy of: satit_srihin at FreeDigitalPhotos.net


In the Gregorian calendar, New Year's Eve, the last day of the year is on December 31 (also known as Saint Sylvester's day). (Incidentally, it's also my birthday.) In many countries - including Poland, where I live - Saint Sylvester's day is a prime occasion for having fun. Celebrations start in the evening and evolve into a night of partying, with lots of laughter and alcohol (dancing is optional). At midnight, bottles of sparkling wine are opened and fireworks start to bloom in the sky. The flashes, bangs and multicolored stars are somehow mesmerizing even if you've already seen this sort of pyrotechnic display dozens of times. 

Unfortunately, while fireworks are spectacular and fascinating, they can also be extremely dangerous, especially in the hands of children or adolescents who underestimate the power of explosives. Every year, hundreds of unfortunate people spend the first days of January - and sometimes a much longer period - in hospital beds, recovering from injuries caused by a firework blast. Of course, this problem isn't limited to December 31. In different countries throughout the world, many holidays and festivities are celebrated with fireworks, always with similar consequences - a number of firework casualties land in hospital emergency rooms, or worse, end up dead. Common injuries include mangled hands, ruptured eyes, severe facial lacerations, fractures, and of course burns.

In Iran, the last Wednesday of the Persian year is known as “Charshanbeh Soori”. This traditional festival, dating back to ancient times, begins on the last Tuesday night of the year (based on the Persian calendar). During previous centuries, this celebration was mostly peaceful and only a simple bonfire was lit during festivities. However, nowadays the advent of new firework devices and dangerous hand-made grenades has changed this calm festival into a disastrous event. Below is a photo of an Iranian youth who lost his right hand to an exploding firework in 2006.


Another young Iranian male suffered numerous burns and contusions to his trunk and arms, also in 2006.




In the United States, Independence Day celebrations on July 4 (the Fourth of July) invariably involve fireworks - and the toll is high. In just one short case series, published in 2014, 4 adult men, all suffering from severe firework injuries to the face, were brought to one urban trauma center on July 4 within 5 hours of each other. The average age of these patients was 26.7 years. Two died from their injuries and two recovered; one required reconstructive surgery later on. Be warned - the photos are anything but pretty.


Image from: Tadisina et al. (2014)


This 23-year-old man was transferred from an outside hospital after being hit in the face from a firework blast. He had extensive facial fractures and a large wound on his forehead. His face was covered with abrasions and lacerations, his right cornea was burned, and the left eye was ruptured (it had to be removed surgically). Compuded tomography images show multiple broken facial bones (yellow arrows), mostly involving the sinuses. He survived.

The following case is rather more drastic. If your children are fascinated with fireworks and explosives, it might be a good idea to frighten them with this photo:



Image from: Tadisina et al. (2014)

The 30-year-old patient was brought to the emergency department with an extensive facial blast injury - most of his forehead and nose had been literally blown away. Both of the eyes were clinically ruptured. He had also sustained a severe head injury; computed tomography revealed diffuse cerebral edema (swelling of the brain), as well as multiple skull fractures and bone defects. The orbital bones, the hard palate and both jaws were all broken. He soon developed a persistent high fever, and was treated with antibiotics. He was unconscious, but able to move his arms and legs when stimulated. After seven days, his fever rose, while his responsiveness diminished, and it was thought that he progressed to brain death. He was in the middle of a brain death workup when he went into cardiac arrest, and after 3 cycles of cardiopulmonary resuscitation, he was pronounced dead.
To some degree, the type of injuries incurred depends on the kind of firework that caused them. A publication from 1961 describes that until 1956, the commonest cause of firework-related injuries in the United Kingdom was "bangers" held in the hand. They could cause blast or burn injuries, or a mixture of both; not infrequently, young patients would lose a finger or two. Towards the end of 1956, manufacturers voluntarily agreed to reduce the amount of explosives in "bangers". Another common cause of injury was bending over a firework to light it, or puffing at a smoldering fuse to make it burn. The subsequent explosion would cause flash burns and, often, severe eye injuries including perforation of the eyeball by fragments. Carrying fireworks around in one's pockets was also extremely risky, as this case shows:


Image from: Jackson (1961)

A 5-year-old boy was carrying a pocketful of rockets on November 5, 1956 and they exploded, causing deep burns to his abdomen and groin area. After primary excision and grafting, the wounds took two months to heal. A year later, the patient required additional surgery to correct contractures in his groin. The article doesn't specifically mention how severe the injury to his genitals had been. The final result after lots of treatment, in 1960, looked like this:

Image from: Jackson (1961)

So... The next time when you plan to set off some fireworks to celebrate a holiday, think twice! At the very least, read the safety instructions very carefully.Do not carry fireworks in your pockets, and never smoke while handling them! When lighting a firework, never lean over it, and never point or throw burning fireworks at other people. Also, never attempt to re-light a firework that has misfired (a dud).  Never set off fireworks under the influence of alcohol, and don't let children play with them! Have a good time, but stay safe!


Literature:


Jackson D. (1961) Injuries from Fireworks. Br Med J. Nov 4, 1961; 2(5261): 1184–1187.

Tadisina KK, Abcarian A, Omi E. (2014) Facial Firework Injury: A Case Series. West J Emerg Med. 15(4): 387–393.

Vaghardoost R, Ghavami Y, Sobouti B, Mobayen MR. (2013) Mortality and Morbidity of Fireworks-Related Burns on the Annual Last Wednesday of the Year Festival (Charshanbeh Soori) in Iran: An 11-Year Study. Trauma Mon. 18(2): 81–85.



Saturday, December 6, 2014

Deep neck infection and abscess in a 2-year-old girl


Today's case isn't bizarre in any way - actually it's quite typical - but I decided to post it because of the images. I'm not a doctor, so I don't get to see abscesses on radiographs on a regular basis.




For anyone with small children, this story might be a little scary. The 2-year-old girl in these photos has a deep neck infection and an abscess has already formed. She was admitted to hospital after two days of fever, and after five days of hospitalization, a mass began to be noticeable on the front of her chest despite antibiotic treatment. Chest radiography and computer tomography showed that pus had collected in the tissues above the sternum (see below). Antibiotic therapy was changed to stronger drugs - meropenem, clindamycin and vancomycin - and the abscess was surgically incised and drained, releasing twenty milliliters of pus. A culture of the exudate grew Streptococcus anginosus sensitive to vancomycin. The toddler recovered and was discharged home after spending 15 weeks in the hospital.



Chest radiography, which was normal on the referring day (a), shows air in the soft tissue (b) on the 5th day of admission (arrows). t: trachea. Contrast-enhanced computer tomography shows an inflammatory swelling of the soft-tissue (*) with large abnormal air collections (arrows) suggesting abscess formation (c), and spreading into the ianterior chest wall (d). There is also subcutaneous edema (+). Images from: Ozurekci et al. 2014


Deep neck infections often start as an isolated area of soft tissue inflammation adjacent to the primary source of infection: a carious tooth, the throat, salivary glands or middle ear. In the case described above, the child had recovered from an ear infection two weeks before the abscess began to form. There's no way of knowing whether this infection was the cause. In the hospital, the toddler was tested for immune disorders causing impaired immunity, but her immune system turned out to be normal.

All in all, this child had a lucky escape. In May 2013, I blogged about another little girl who, in a bizarre twist of fate, got hit by a soccer ball, came down with necrotizing fasciitis and didn't survive.

For non-queasy viewers - here's a very cool educational video showing the incision and drainage of a HUGE abscess under a patient's chin. Note that the patient is awake throughout the procedure. After squeezing out all the pus, the cavity is irrigated, then packed with sterile gauze. The cause of this purulent monstrosity was an infected carious tooth.


 


 
Literature:

Ozsurekci Y, Oncel KE, Oguz B, Ayvaci FN, Kara A. (2014) Pre-Sternal Abscess associated with Deep Neck Infection. APSP J Case Rep. 5(3): 35.