Intracranial foreign metal body (sewing needle): A case report of infanticide attempt

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NTRODUCTION

Foreign metal bodies in the intracranial region are usually observed as the result of open craniocerebral trauma. There are mostly bone fragments and rarely pieces of glass or wood observed in general situations and metal things (shot, bullet, and splinter) during wars [1-3]. An intracranial foreign body is very dangerous because it is a potential nidus of infection. Specifically, bone fragments as foreign bodies are considered favorable environments for infection (meningitis, meningoencephalitis, abscess, granuloma, etc.) in the cerebrum [4, 5]. Foreign bodies of craniocerebral trauma can be asymptomatic, clinically showing themselves after a long period [6-8]. However, in many cases, symptoms depend on the location of the intracranial foreign body, its size, and number [9-11]. Pierced blind bullets, splinters, shots, nails, fountain pens, pieces of glass, wood, etc., were reported as intracranial foreign bodies that entered after the continuity of the cranial bones had closed. Studies have reported cases of cotton and pieces of gauze left in the intracranial region after surgical operations and foreign bodies introduced to the intracranial region from the orbit [12, 13].

Tuncer et al. (2007) reported the case of a 32-year-old man who came to the clinic of Marmora University with complaints of tonic and clinic spasms, and a sewing needle was found in his temporal region by computed tomography [14]. In Indian literature, Teegala et al. (2006) found two sewing needles in the intracranial region of a 4-year-old child by casual examination [15]. Sener (1997) found by X-ray examination three sewing needles in the frontal region of 20-year-old patient having headache complaints [16]. According to Hao et al. (2017), approximately 50 related cases have been reported worldwide so far. However, these data are only at the tip of the iceberg because many infants die as a result of crimes, and survivors are often overlooked for being asymptomatic [17].

However, nearly all cases of intracranial sewing needles encountered in practice were observed by neuropathologists, pediatricians, traumatologists, radiologists, surgeons, and mostly neurosurgeons [18-21]. In the literature, an intracranial sewing needle as a foreign body was not reported in the practice of psychiatrists. Accidental finding of foreign bodies such as sewing needles found in unclosed cranial bones is very common in psychiatric practice (Figures 1–3).

Fig. 1. Radiography in lateral (a, b) and direct (c) projections: Intracranial foreign metal body (sewing needle).

CASE PRESENTATION

Patient A. is a 25-year-old soldier and has been serving in the armed forces for 6 months.

Anamnestic information: He had no history of hereditary mental diseases. The first development period was unremarkable. He had been an umbrageous, touchy, crybaby, naughty, and impatient child since childhood. As he was the only son in the family, he became a person who always needed privileges. He went to secondary school in time, and his academic performance was satisfactory. His school attendance and behavior were satisfactory. He graduated from the tenth grade. He reported that at the age of 19, he cut his hand with an axe while hacking a tree and received treatment at the hospital. He had no pernicious habits and denied craniocerebral trauma. He was considered fit for service in the armed forces, was called to actual military service, and willingly went to military service. However, he presented as an undisciplined soldier from the first day of military service, negligently tended to his duties, did not promptly and appropriately fulfilled the orders and tasks of his commanders, and untidily kept his military uniform. He cannot guard military secrets. After receiving stationary treatment in the medical camp, with the diagnosis of “skin scar at the palmar surface of finger 1 of the right hand, muscle–tendon contracture of finger 1” and “hystero-neurotic condition,” he was admitted to a hospital for examination and treatment. After inpatient treatment in the psychiatric department for “hysterical reaction and folding contractures resulting from an old tendon injury and contractures of finger 1 of the right hand,” he was dismissed to the military unit with improvement. After having served approximately 6 months, he left the military unit. Criminal proceedings were started against him by the military procurator’s office related to his willfully leaving the military unit and criminal involvement. During the preliminary investigation, he was presented to the military medical board in the garrison hospital in an ambulatory state. He was examined and diagnosed with “pedomorphism and psychopathy” and recommended to be examined in the psychiatric department of the Central Military Clinical Hospital after 18 months following changes in his behavior.

Results of physical examination

His body structure was appropriate. A hypodermic layer of fat developed satisfactorily, and feeding was satisfactory. The skin color and mucous membranes are typical. A coarse scar measuring ≈7 cm was found on the palmar surface of finger 1 of the right hand. No bone–joint system pathologies were noted. Peripheric lymphatic and thyroid glands were not enlarged. Vesicular respiration was heard on lung auscultation. No crepitation was noted. Cardiac sounds are clear and rhythmic. His arterial pressure was 110/70 mmHg, and his pulse was 78 beats per minute. The stomach was soft and pain-free. The liver and spleen were not enlarged. No pain was noted on either side when punching the lumbar region. Urine and stool movements were normal. The diagnosis of the traumatologist was as follows: “stable opening contractures resulting from an old injury of tendons folding finger 1 of the right hand (1996) with slight dysfunction.”

Neurological condition. His consciousness was clear. His pupils were round, OD = OS, and reactive to light. Ocular movements are good, and no nystagmus was noted. The nasal and labial folds are asymmetric, and the right angle of the mouth was slightly hanging. The tongue was inclined toward the right. The periosteum and tendon reflexes (D = S) are active in the upper extremities, and knee and axil reflexes (D > S) were asymmetric. Marinesco–Rodovich syndrome was positive. Romberg’s condition was stable. Finger tremors on extension and eyelid tremors were observed. Distal hyperhidrosis was noted. His visual acuity was 1.0 D in both eyes. Hearing: whispering–6 m in both ears. The diagnosis of the neuropathologist was as follows: “separate sparsely organic neurological marks of initial injury of the central nervous system and residual features as vegetovascular unstableness, without dysfunction of the central nervous system.”

Mental condition. He was well oriented. He began conversations in a strained and dull appearance and unwillingly and confusedly gave sharp answers to questions. He said, “I always have headaches, when somebody shouts at me and gives instructions I feel as if he beats me. I feel nervous and do not want to see anybody!” He explained his willful leave of the military unit as follows: “My headache did not stop. I could not stand and went home!”

Perception disorders and delirium were not observed. His emotions were changeable. His memory was not impaired. Critical approaches to himself, his disease, and his circumstances were kept. His scope of interest was limited, and he had no actual plans for the near future. His demands decreased and were simplified. The level of his mental development corresponded to his age and mode of life. During the examination, he conducted himself anxiously, nervously, gloomily, lonely, and secludedly in the department. He kept interacted with other patients in his ward by sampling and tended toward discussions and conflicts. He unwillingly and reluctantly implemented instructions and tasks. He slightly participated in table games and daily tasks in the department. He was negligent toward events that happened around him. He spent most of his time lying down on his bed and explained that he had a headache. He slept by taking medicine, he was not getting deep sleep, and his feeding was satisfactory. His psychiatric diagnosis was as follows: “psychopath-like syndrome mildly emerged after initial organic injury of the cerebrum. Intracranial foreign metal body (sewing needle).”

Results of special examination

General analyses of the blood and urine, electrocardiography, and fluorography of thoracic organs were normal. Traumatic bone changes were not observed in the roentgenography of the right hand. Roentgenography of a skull: “One foreign body, a metal needle was found in the intracranial region.”

According to the decision of the military medical board, he was considered unfit for military service in the peace period and limited fit at war. As he had committed a military crime (willfully leaving the military unit), he was released from criminal responsibility.

DISCUSSION

The patient (25 years old) was from the southern region of the republic. The patient, his family, and parents were unaware of the intracranial foreign metal body (sewing needle) until the examination. His parents could not give any anamnestic information about the existence of the sewing needle in the intracranial region. Nevertheless, according to the mother, it was alleged that the patient’s aunt harbored feelings of envy toward him from an early age, raising the possibility of her involvement in the incident. Clearly, a sewing needle can be entered into an intracranial region only until the sinciput becomes firm. As the needle tip was pointing down, the needle was considered intentionally pricked (Figures 1–3). The accident can be unambiguously evaluated as the result of an unsuccessful crime. Cases of pricking sewing needles into the sinciput to incapacitate babies and murder them are mostly reported in eastern countries (Turkey, Iran, and India) [22-25]. Following further examination, the patient was found to be the only grandson in the family, and near relatives enviously entered a sewing needle into his intracranial region from the sinciput to murder him while he was a baby. Fortunately, the foreign body did not injure the cerebral hemispheres and the front branch of the cerebral artery, not causing infection; therefore, clinical neurological symptoms and complications were not observed. However, psychopathic features were observed in the personality of the patient as he grew older.

Unfortunately, as the was patient outside the republic at present, it is impossible to collect catamnesis about him and subject him to further instrumental examinations (computed tomography, nuclear magnetic resonance, electroencephalography, rheoencephalography, etc.).

Surgical extraction of intracranial sewing needles has been reported in the literature. Akinetic blindness was observed in the postsurgical period in 1 (51 years old) of 4 patients, and the patient died. Thus, surgical extraction of sewing needles, particularly in older people, is not practical.

CONCLUSION

The case presented indicated that diagnosis of intracranial foreign bodies based only on clinical presentations and symptomatology without instrumental examinations is very challenging. Although pathological changes and neurological symptomatology are not visually observed in the brain, instrumental examinations (roentgenography of a skull in two projections, computed tomography, nuclear magnetic resonance examination, etc.) of patients with psychiatric problems are necessary. Moreover, in forensic medicine, such cases must receive special attention when investigating sudden and early child deaths.

ADDITIONAL INFORMATION

Funding source. This article was not supported by any external sources of funding.

Competing interests. The author declare that he has no competing interests.

Consent for publication. Written consent was obtained from the patient’s legal representatives for publication of relevant medical information and all of accompanying images within the manuscript in Russian Journal оf Forensic Medicine.

About the authors

Elshad S. Mehdiyev

Author for correspondence.
Email: elshadmehdiyev@yahoo.com
ORCID iD: 0000-0001-8725-9143
SPIN-code: 4575-8393

MD, Cand. Sci. (Med.)

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2. Fig. 1. Radiography in lateral (a, b) and direct (c) projections: Intracranial foreign metal body (sewing needle).

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