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.