Discussion
Foreign body swallowing by children is common, especially in the toddler and early childhood stages, but cardiac tamponade caused by an ingested foreign body is rare and usually from chicken or fish bone fragments.1,2 Most metallic foreign bodies pass spontaneously through the gastrointestinal tract, but sharp, thin objects are more likely to cause gastrointestinal perforation which has been reported in 15 to 35% of cases.3 The precise sequence of events affecting our patient remain unknown; however, it seems most plausible that the patient accidentally swallowed a broken steel mesh strainer wire with food which then penetrated into the left ventricle from the gastric fundus and led to cardiac tamponade. Table 1 shows the demographics and clinical outcomes of five pediatric cases of ingested metallic foreign bodies with cardiac complications published since 2001, including the present case4,5,6,7. The age of the patients ranged from 9 months to 2 years and the perforation site of the gastrointestinal tract was the esophagus in four previously reported cases. The cardiac injury site was the pericardium in three of these cases, plus one case each of right atrium and left ventricle injury. All reported patients developed cardiac tamponade and hemodynamic instability that required early surgical intervention, but all also had good postoperative outcomes. In three of these cases, the cause was a safety pin, one case was a metallic needle, and, in this case, a metal wire fragment from kitchenware. In our case, the stomach was unusually penetrated and the perforation mechanism was thought to be initial impact, followed by necrosis due to local inflammation and direct pressure.8 To the best of our knowledge, there are no reports of pediatric cases of cardiac injury caused by accidental ingestion of metal wires since 2001 and only three adult cases have been reported9,10,11. Incidentally, in all reported adult cases, the symptoms and surgical interventions were the same as the pediatric cases. Although cases of pericardial tamponade secondary to accidental ingestion of a metallic foreign body are rare, pediatricians should be aware that delayed diagnosis of both gastrointestinal perforation and acute hemorrhagic pericardial effusion can have fatal consequences. It is important to remember that, even if symptoms are subclinical, prompt examination and rapid treatment are crucial for a favorable clinical outcome. Our report and the weight of the literature cases underscore the need for precise diagnosis and surgical intervention in the pediatric population since accidental ingestion of metal objects usually manifests as gastrointestinal injury and not cardiac tamponade with hemodynamic instability. In addition, tamponade in otherwise healthy children may warrant exploration for wire or other sharp, thin objects that could penetrate into the pericardium through the stomach or diaphragm.
Acknowledgements : No funding to declare.
Conflict of Interests : The authors declare that there are no conflicts of interest.