Diagnosis dilemma: The knife broke in a man’s chest, unaware for eight years

Patient: 44-year-old man from Tanzania

Symptoms: For 10 days, pus soaked through the opening of the man’s breast under the right nipple, urging him to visit the emergency room. He told the doctor he had no pain or difficulty breathing. He had no fever and his vital signs were normal.

What happened next: When the doctor examined the man, they discovered that the rib cage on the right side of the chest was flattened in front of the chest, and that the chest did not fully expand on that side when he inhaled. They confirmed that “dirty” pus was leaking out of the cavity beneath the nipple, they wrote in their report of the incident.

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During the examination, the man reported that he had been repeatedly stabbed in the chest, back, abdomen and face eight years ago during a “violent altercation.” No imaging tests were performed at that time, and only superficial emergency treatment was received for multiple knife wounds. For eight years, he said he had no health problems arising from those injuries.

Diagnosis: X-rays revealed a large metallic knife blade trapped inside the male’s chest cavity. This hollow chamber, also known as the thoracic cavity, resides above the abdomen and contains the heart and lungs. The blade, which extended from behind the thorax forward, entered the man’s back, near the right or scapula.

The knife blade was clogged there after sliding between the fifth and sixth ribs on the patient’s back, and the tip of the knife was placed between the third and fourth ribs on the front of the thoracic cage. CT scans showed healed fractures in the shoulder blades and several ribs. A layer of pus and dead or dying tissue surrounded the knife blade.

One way the body can protect itself from foreign objects is by using a process called fibrous capsule formation. In this process, the immune system cocots collagen and other fiber objects, limiting damage and inflammation of surrounding tissues. Such knife encapsulation, according to reports, is likely to have allowed men to spend the next eight years without knowing that there is a blade inside their chest.

Treatment: The hospital surgeon performed a thoracotomy where he cut into the man’s chest wall to remove the blade. They drained the accumulated pus, washed away the thoracic cavity with a solution of sodium chloride, set up a drain, and eventually sutured the wound. Patients were given broad-spectrum antibiotics for 7 days and closely monitored for signs of infection after surgery.

The doctor removed the drain after the eighth day, and two days later the man was discharged from the hospital. He returned to the hospital for two follow-up appointments: two weeks after his surgery, one week after a week. On both visits he was not infected and experienced no further complications.

What makes the case unique: It is not uncommon for some or all of the penetrating objects to remain in the thoracic cavity after a traumatic chest injury. However, in most cases, these foreign bodies are small ballistic projectiles, such as bullets, and are often difficult to find and remove.

In comparison, it is not much documented in the medical literature that large pieces, such as the entire knife blade or the entire other stab weapon, are broken and staying in their chest. And in most cases, these objects are not detected for years. Reports usually identify and remove within weeks or months.