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Is That a Sewing Needle in the Left Ventricle? A Rare and Complex Presentation of Self-embedding in a Patient with Schizophrenia

Seema Sannesy, MD – Psychiatrist, Eating Recovery Center

Kelly Harrington, MD, MS – PGY-2 psychiatry resident, University of New Mexico

Emiliano Valles, MD – Assistant Professor, University of New Mexico

Cynthia Geppert, MD, MA, MPH, MBE, DPS, MSJ, FACLP, DFAPA, FASAM, HEC-C – Ethics Consultant, VA National Center for Ethics in Health Care Psychiatric Consultant, New Mexico V, VA National Center for Ethics in Health Care

Abstract:



Background: Self-embedding behavior is a recently recognized form of foreign-body insertion which involves the repeated insertion of solid objects into the soft tissues of the limbs, abdomen, chest, neck, or groin. The small number of publications on embedding behaviors involve psychiatric patients inserting foreign objections through natural body orifices. Even fewer articles have reported mediastinal self-embedding and very rarely are cases in which cardiac surgical intervention is necessitated discussed.

Case: Mr. Z is a 32-year-old male with Schizophrenia, who was 2.5 weeks overdue for his Paliperdone Palmitate 234 mg injection, when he self-presented to the emergency department complaining of severe midsternal pain. He had a history of inserting sewing needles into the soft tissues of his abdomen, chest, neck, and extremities. Initial evaluation included electrocardiogram, cardiac enzymes, and chest x-ray. Mr. Z left the emergency room against medical advice. Emergency medical services brought him back after his troponin returned at 0.763 and the radiologist noted a “new foreign body projecting over the cardiac silhouette” suggesting a possible intracardiac foreign body. Bedside echo was concerning for migration of what was later established to be a needle in the left ventricle. During emergent cardiothoracic surgical consultation, the need for further imaging and likely surgical removal of the needle was explained to Mr. Z. However, he refused Psychiatric consultation the following day noted Mr. Z to be acutely agitated, delusional, and without capacity to refuse diagnostic evaluation or possible surgical intervention. Mr. Z’s father provided surrogate consent for the open-heart surgery which successfully removed the intraventricular sewing needle. After surgical stabilization, Mr. Z was transferred to the inpatient psychiatric unit for treatment before being discharged home.

Discussion: This case illustrates several key points in consultation-liaison psychiatry 1) the potential severe complications of self-embedding behaviors, here requiring open-heart surgery 2) the possibility for delayed diagnosis and intervention given the difficulty in coordinating the surgical and psychiatric care of patients with serious mental illness who self-embed 3) the importance of psychiatric consultation-liaison involvement in providing guidance to surgical teams treating adult patients with acutely psychotic symptoms lacking capacity to consent to invasive surgical interventions.

Conclusion: A high level of clinical investigation is required to obtain timely diagnosis and appropriate interventions in self-embedding behaviors. In this case a needle embedded in the ventricle was discovered for which the recommended intervention was emergent surgical removal. Obtaining the expertise of the psychiatric consult service to evaluate the patient’s decision-making capacity and to liaison with cardiac surgery were shown to be key components in the optimal management of cardiac injury due to a self-embedded needle in a patient with schizophrenia.

Mannarino et al (2016). Self-Embedding Behavior in Adults: A Report of Two Cases... Journal of Forensic Sciences,62(4), 953-961.


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