| Author | Affiliation |
|---|---|
| Abdullah Khan, MD, FAAD, FACEP |
ABSTRACT
Case Presentation
We present the case of a six-year-old child with autism who presented with persistent vomiting in the setting of a closed head injury (CHI). Computed tomography of the head was normal, but due to persistent vomiting a radiograph of the abdomen was done, which showed multiple, rare-earth magnets in the abdomen. There was no history of witnessed ingestion. These magnets had caused enteroenteric fistula formation leading to persistent vomiting.
Discussion
In the setting of CHI, vomiting can be a sign of concussion or intracranial hemorrhage. In cases of CHI where intracranial pathology is ruled out and vomiting still persists, it is important to explore intra-abdominal causes of vomiting, especially in developmentally challenged children as they have higher incidence of unwitnessed foreign body ingestions.
CASE PRESENTATION
A six-year-old autistic child presented to the emergency department with multiple episodes of non-bloody, non-bilious vomiting after sustaining a closed head injury (CHI). The patient had fallen face forward on the ground from a height of five to six stairsteps. No associated loss of consciousness, seizures, abdominal pain, difficulty breathing, ear, eye, or nasal discharges were reported. The physical examination revealed a two-centimeter contusion on the forehead. The rest of the ocular, auditory, abdominal, respiratory examinations including Glasgow Coma scale were normal. Initially the patient received ondansetron, but vomiting continued after the medication. Due to persistent vomiting, complete blood count, blood electrolytes, liver function tests, lipase level, and urinalysis were obtained from the laboratory, and CT of the head without contrast was performed. All lab tests and CT were normal. A radiograph of the abdomen incidentally showed a cluster of small round balls of rare-earth magnets with no signs of obstruction or pneumoperitoneum (Image 1).
There was no history of witnessed ingestion. General surgery was consulted, and the patient was admitted to the hospital. Initially, the patient was managed conservatively with antiemetics and laxatives; but due to persistent vomiting and lack of movement of the magnets, the patient was taken to the operating room. During the laparotomy, it was noticed that the magnets had caused formation of an enteroenteric fistula (Image 2). The fistula was divided, the magnets were extracted, and the edges of the fistula were closed. (Image 3). The patient recovered without any complications and was discharged from the hospital.
DISCUSSION
Rare-earth magnets (neodymium magnets) are commercially sold as 3–6 millimeters round recreational objects; they are five to 10 times more powerful than normal magnets. When more than one of these magnets are ingested, the bowel can get compressed between them, which leads to obstruction, necrosis, perforation, and fistula formation.1 Due to the small size of these magnets, patients can develop localized intestinal perforations and fistulas without significant symptoms and radiologic findings. Therefore, in patients with ingestion of multiple rare-earth magnets, surgical or endoscopic removal of the magnets should be performed even in asymptomatic patients.2 The incidence of foreign body ingestion is higher in toddlers and preschool children, whereas a higher incidence of ingestion is noticed at older age in children with neurological disabilities.3 Because foreign body ingestions in these children are often unwitnessed, it presents a challenge in diagnosis.1,3 In summary, foreign body ingestions should be in the differential diagnosis in children with neurological disability presenting with unexplained vomiting. Additionally, in cases with ingestion of multiple rare-earth magnets, conservative management may not be the appropriate choice.
Footnotes
Section Editor: Melanie Heniff, MD, JD
Full text available through open access at http://escholarship.org/uc/uciem_cpcem
Conflicts of Interest: By the CPC-EM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. The authors disclosed none.
Address for Correspondence: Abdullah Khan, MD, FAAD, FACEP, Sidra Medicine Department of Emergency Medicine, Al Gharrafa Street, Ar-Rayyan, Doha, Qatar, PO BOX 3050. Email: abdullahkhan120@gmail.com
8:171 – 173
Submission history: Revision received October 28, 2023; Submitted January 17, 2024; Accepted January 26, 2024
The author attest that their institution requires neither Institutional Review Board approval, nor patient consent for publication of this case report. Documentation on file.
REFERENCES
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