REPETITION OF THERAPEUTIC PINNING BY A MENTALLY CHALLENGED : A CASE REPORT AND A MEDICO-LEGAL LESSON LEARNT FROM KATHMANDU MEDICAL COLLEGE AND TEACHING HOSPITAL , KATHMANDU , NEPAL

We present an unusual case of a 27 year-old-female with undiagnosed mental illness who presented with pricking type of tenderness in and around umbilicus and lower le quadrant of le breast. X-ray revealed the presence of sewing needles on those areas. The foreign body was inserted deliberately by the pa ent herself on trying to mimic the FNAC procedure performed on her a day before. Under C-arm guidance both the needles were located and extracted. Inser on of foreign body via abdominal wall is the first published report to our knowledge. Performing an invasive procedure in front of a mentally challenged individual requires precau on as a clinician, is an important lesson learned.


INTRODUCTION
Human body's best defense against penetra ng force is skin; subsequently lesser resistance is offered by subcutaneous fat, muscles and blood vessels.As any pointed object penetrates the skin, it con nues to slue further with even 1 less force applied, ll bone is reached.Any pointed objects like needles, pins etc when inserted accidentally or deliberately into the body causes prick injuries followed by various immediate and late complica ons.On the other hand; for centuries penetra ng events have been used by cer fied/trained medical prac oners, for remedial and diagnos c procedures like acupuncture, aspira on and injec on of drugs/fluids in and out of human body.We present a case report where one of such procedure performed in a mentally challenged pa ent presented a day later in emergency as complica ons of a deliberate selfpenetra ng injury.

CASE REPORT
A 27 year old female presented on ER with complaints of pricking type tenderness in and around umbilicus and lower quadrant of le breast for few hours.History as given by her father stated that she had undergone an invasive procedure (Fine Needle Aspira on Cytology) for a lump present around her umbilicus.He also added that the pa ent is only one in the family who has history of mul ple episodes of undiagnosed mental illness but failed to provide any medical documents/records about it for perusal by trea ng medical staffs of emergency department.
On admission her general condi ons were fair and vitals were stable.Local examina on of peri-umbilical area and le breast revealed no scars or any signs of inflamma on.However, on X-ray film, anterio-posterior view, taken in erected posi on, two thin opaque objects with pointed ps, each measuring around 5cm were found to be placed obliquely; one through into the le breast and other near the umbilicus.On lateral view the object in the breast was found to be near the pleural cavity.
Keeping in mind the urgency of the situa on, she was advised to undergo fluoroscopy with an aim to locate the needle with more accuracy.Coins were placed as a surface landmark for incision; just above the alleged site of foreign body inser on, over both sites, as revealed in Fig. 1.

Figure 1: X-ray films demonstra ng posi on between coin as a surface landmark and foreign objects
Incision was given in the previously marked area around le breast and under C-arm guidance, both the pointed objects were located and extracted.Both objects were noted to be sewing needles.Postopera ve recovery was uneven ul and she got discharged the next day.

DISCUSSION
Polyembolokoilamania, a term reported as inser on of foreign objects into natural body orifices mostly by pediatric pa ents, adults with compromised mental status and at mes deliberate inser on via body orifice done for other mo ves like ero c pleasures and malingering are not new to 2,3 literature.However, in the presented case, sewing needles were not inserted through the orifices, but penetrated through the skin.The chances of these objects sliding into the abdominal cavity or migra on and embolisa on to deeper body cavi es or organs causing lethal outcome cannot be 4,5 ignored.Minimizing intra-opera ve manipula on was itself a challenge faced by surgeons with fear of complica ons viz; pneumothorax, hemothorax or sepsis.
Was it pa ent's luck to have inserted needles confined to subcutaneous ssue, or doctor's fortune to abate medicolegal impediment for taking consent with a mentally challenged to perform invasive procedure ini ally, s ll remains unanswered.

CONCLUSION
Voluntary compliance to any act is consent and an informed wri en consent form is legal document valid in court of law.Hence, while filling or wri ng consent for any procedures, it must be clearly understood that the person consen ng for any act is in the state of Compos Men s and that he or she is free from any mental illness and is capable of understanding what is right or wrong for him/her.Any form of consent taken from individual undergoing invasive procedures; like FNAC in our case, must be free from mental ailment and that guardian or caregiver should provide the consent on behalf of a minor or pa ents with compromised mental status.Extra precau ons should be taken by the clinicians performing invasive procedures in mentally challenged, that the procedure is not mimicked by the pa ents in isolated circumstances.